Skin-sparing Techniques Research Articles

O050 A ten-year review of methodological trends and outcomes in riskreducing mastectomy and associated reconstruction at a tertiary referral centre

Abstract Introduction Risk-reducing mastectomy (RRM) is the removal of breast tissue to substantially decrease the risk of developing breast cancer in individuals with higher breast cancer susceptibility due to strong family history or genetic mutations. This retrospective study evaluates cases of RRM, and subsequent reconstruction performed at a tertiary referral centre over the last decade, with emphasis on mastectomy and reconstructive trends. Methods A retrospective review of all cases of RRM performed between January 2010 and January 2020, divided into two groups corresponding to the first half (group 1) and second half (group 2) of the decade was conducted. Data collected included demographics, genetic test results, family and personal history of breast cancer, co-morbidities, mastectomy type, reconstruction type, surgical histopathology findings and complications. Results A total of 167 patients (group 1=76, group 2=91) underwent RRM, with a significant increase in cases of RRM despite negative genetic test results (p=0.047). The proportion of nipple sparing techniques for RRM compared to more traditional skin-sparing techniques. Concomitantly, post-RRM reconstruction has progressively become solely implant-based, to coincide with a rise in ADM usage. This is consistent with national trends towards fewer complex autologous procedures. Take-home message Emergent trends in risk-reducing mastectomy and reconstructive techniques are occurring against a background of broadened indications for RRM and more frequent patient requests for RRM in the absence of any documented pathogenic gene mutation. As breast surgery continues to evolve, it is important to evaluate specific trends such as more conservative forms of mastectomy and novel techniques/devices for breast reconstruction to ensure optimal patient care and levels of satisfaction.

Comparison of treatment planning techniques in treatment of carcinoma of left breast: Second cancer perspective

AimTo compare the secondary cancer risk (SCR) between different planning techniques for treatment of Ca. Left-Breast patient. Materials and methodsFive treatment plans; 3DCRT tangential fields with physical wedge (PW), enhanced dynamic wedges (EDW), electronic compensator (EC), IMRT tangential fields (ITF) and Volumetric modulated arc (VMAT) plan (partial arcs) with 6MV photon beams were generated for a carcinoma of Left breast patient of age 40 to a prescription dose of 50Gy in 25 fractions. The SCR was estimated using the organ equivalent dose (OED) concept with a linear-exponential, a plateau, and a linear dose-response model for OARs. Also, the low dose-bath volume (5Gy) was calculated for all the plans. ResultsFor contra lateral breast the SCR relative to PW were (linear, plateau, linear-exponential) (−26.0%, −35.0%, −39.0%) for VMAT, (−50.0%,−50.0%,−51.0%) for ITF, (−48.0%, −49.0%,−49.0%) for EC and (−33.0%, −24% , −25.0%) for EDW respectively. The relative SCR (plateau) for heart and left lung were (−66.0% & −73.0%) for VMAT, (−20.0% & −6.0%) for ITF, (−24.0% & −18.0%) for EC and ( −17.0% & −14.0%)for EDW. In contrast, for skin the relative SCR (linear - exponential) were 78.0%, −8.0%, −13.0% and −10.0% for VMAT, ITF, EC and EDW respectively. The 5Gy low dose volume relative to PW for VMAT was 201.45%, whereas the same for ITF, EC and EDW were 17.0%, −7.33% and −4.3%. ConclusionCompared to all plans, VMAT plan showed high conformity for CTV and superior heart and left lung sparing. But SCR for skin and the low dose bath volume were significantly high in VMAT. ITF plan showed relatively better sparing for contra lateral breast and heart. EC plan shows moderately good sparing for OARs while scoring least SCR value for skin next to EDW. EDW and PW plans were similar but later had high SCR for contra lateral-breast. Planning techniques like ITF and VMAT can be strongly considered for left breast, provided better skin sparing techniques and less dose spillage can be achieved.

Predictors of radiation-induced skin toxicity in nasopharyngeal cancer patients treated by intensity-modulated radiation therapy: a prospective study

AbstractPurposesExposure of skin to high doses of radiation may lead to the development of erythematous skin changes. The aims of this study were to measure skin doses and to identify potential factors that may contribute to skin reactions in nasopharyngeal cancer patients undergoing intensity-modulated radiation therapy (IMRT).Material and methodsThis study was a prospective study with 21 nasopharyngeal cancer patients treated by IMRT. Personal data were collected and in vivo skin dose measurements were performed using Thermoluminescent dosimeters. All patients were monitored clinically and skin reactions were classified according to the Radiation Therapy Oncology Group criteria. Univariate and multivariate logistic regression was conducted using Statistical Package for Social Sciences Software to identify skin toxicity risk factors.ResultsGrade 1 toxicity was observed in eight patients, Grade 2 in 11 patients and Grade 3 in two patients towards the end of treatment. It was found that accumulative skin doses >7 Gy (p<0·05) was a risk factor for skin toxicity. However, previous or concomitant chemotherapy with radiotherapy and stage of cancer were not significant factors for the severity of skin reactions.ConclusionThe neck skin should be identified as a sensitive structure for dose optimisation. Skin dose measurement and skin-sparing techniques are highly recommended for head and neck patients treated with IMRT.

Partial Breast Radiation Therapy With Proton Beam: 5-Year Results With Cosmetic Outcomes

We updated our previous report of a phase 2 trial using proton beam radiation therapy to deliver partial breast irradiation (PBI) in patients with early stage breast cancer. Eligible subjects had invasive nonlobular carcinoma with a maximal dimension of 3 cm. Patients underwent partial mastectomy with negative margins; axillary lymph nodes were negative on sampling. Subjects received postoperative proton beam radiation therapy to the surgical bed. The dose delivered was 40 Gy in 10 fractions, once daily over 2 weeks. Multiple fields were treated daily, and skin-sparing techniques were used. Following treatment, patients were evaluated with clinical assessments and annual mammograms to monitor toxicity, tumor recurrence, and cosmesis. One hundred subjects were enrolled and treated. All patients completed the assigned treatment and were available for post-treatment analysis. The median follow-up was 60 months. Patients had a mean age of 63 years; 90% had ductal histology; the average tumor size was 1.3 cm. Actuarial data at 5 years included ipsilateral breast tumor recurrence-free survival of 97% (95% confidence interval: 100%-93%); disease-free survival of 94%; and overall survival of 95%. There were no cases of grade 3 or higher acute skin reactions, and late skin reactions included 7 cases of grade 1 telangiectasia. Patient- and physician-reported cosmesis was good to excellent in 90% of responses, was not changed from baseline measurements, and was well maintained throughout the entire 5-year follow-up period. Proton beam radiation therapy for PBI produced excellent ipsilateral breast recurrence-free survival with minimal toxicity. The treatment proved to be adaptable to all breast sizes and lumpectomy cavity configurations. Cosmetic results appear to be excellent and unchanged from baseline out to 5 years following treatment. Cosmetic results may be improved over those reported with photon-based techniques due to reduced breast tissue exposure with proton beam, skin-sparing techniques, and the dose fractionation schedule used in this trial.

Möglichkeiten der Onkoplastik und Rekonstruktion bei Patientinnen mit Mammakarzinom

Although systemic treatment strategies are improving continuously, breast surgery still plays a central role in the management of breast cancer. Because breast conserving therapy is feasible in more than two thirds of breast cancer patients, breast surgeons should be aware of the different oncoplastic techniques. The development of skin sparing techniques combined with immediate reconstruction provides good cosmetic results in many cases in which mastectomy is required. Therefore the reconstructive element should be offered and integrated in the therapy plan as soon as mastectomy is indicated.

Skin-Reducing Subcutaneous Mastectomy Using a Dermal Barrier Flap and Immediate Breast Reconstruction with an Implant: A New Surgical Design for Reconstruction of Early-Stage Breast Cancer

The development of skin-sparing mastectomy techniques for early-stage breast cancer has opened a new era in reconstructive breast surgery. Because of improved early diagnoses, the demand for skin-sparing techniques continues to increase more than ever. Between March 2006 and April 2008, skin-reducing subcutaneous mastectomy (SRSM) using the dermal barrier flap technique and simultaneous breast reconstruction with silicone implants was performed for 15 patients (a total of 26 breasts) who had either a diagnosis of early-stage breast cancer or indications for prophylactic mastectomy. Of the 15 patients, 11 underwent bilateral reconstruction. The remaining four patients underwent unilateral reconstruction using SRSM with the dermal barrier flap technique. The average age of the patients who underwent SRSM with the dermal barrier flap was 45.7 years. All the patients were discharged from the hospital on postoperative day 1. The mean follow-up period was 12 months, and the recovery time was 35 days. Excellent aesthetic results and uneventful healing were obtained for 23 breasts. Partial nipple-areola necrosis occurred in two breasts. Total skin necrosis in the bilateral nipple-areola and central breast region occurred for one patient who underwent bilateral SRSM. Prosthesis exposure was not observed for any of these patients. The authors present their early results with SRSM using the dermal barrier flap and silicone implants for early-stage breast cancer. The dermal barrier flap became a reliable procedure by providing a decreased breast envelope, eliminating the risk of implant exposure, and forming a double layer of dermal tissue at the incision line.

Hyperhidrosis—Causes and Treatment of Enhanced Sweating: Surgical Treatment of Focal Hyperhidrosis

The authors explain the risk of compensatory hyperhidrosis after endoscopic transthoracic sympathectomy (ETS) for palmar hyperhidrosis. Recent studies have shown that the rate and severity of compensatory hyperhidrosis seems to decrease notably if the ETS is performed from ganglion T3 and T2 is spared (1). Unfortunately, the authors do not differentiate between individual techniques in the section on local surgical techniques for axillary hyperhidrosis. Curettage and liposuction are mentioned, but the techniques that are accompanied by resection of axillary skin remain unmentioned (Shelley technique, Salfeld technique). Even though skin sparing techniques have been favored in recent years, there is no comparative study to date which shows a higher efficacy for a particular method. The authors explain that the aim of a technique without skin resection is complete—as far as possible—removal of the axillary sweat and cite a 1987 article by Bisbal et al in support. The Bisbal technique, however, is characterized by an S shaped removal of large parts of the axillary skin and has nothing in common with the named minimally invasive techniques. By contrast, a recent study has shown that 79.1% of all axillary sweat glands were removed when an aggressive method was used but no skin was resected (2). In conclusion, we wish to comment on the terminology used for the surgical techniques. Axillary liposuction is practically not used any more nowadays because the use of blunt cannulas has not been shown to be sufficiently effective (3). The term used should be that of liposuction curettage or sweat gland suction curettage, which clarifies that in addition to liposuction, a sharp ablation of the sweat glands is required with special sharp cannulas or, in a second operative step, by using a curette.

Algorithm for clinical evaluation and surgical treatment of gynaecomastia

Gynaecomastia can be classified on the basis of the main characterising factors, i.e. pathogenesis, histopathology and morphology. The morphological classifications of gynaecomastia currently made often use subjective parameters and qualifying adjectives. In this paper the authors propose a scheme for morphological classification of gynaecomastia which can serve as a guide for choosing the surgical technique, once the diagnosis of gynaecomastia as a benign pathology has been confirmed by preoperative examinations. A retrospective analysis was made of 121 cases of gynaecomastia operated on in the last 5 years. The extent of the clinical picture, the technique employed, the complications and the need to re-operate were observed and related. On the basis of this review the authors observed that when the nipple-areola complex is above the inframammary fold (grade I and grade II gynaecomastia), complete flattening of the thorax can be achieved by means of suction or ultrasound-assisted lipectomy and skin-sparing adenectomy. When the nipple-areola complex is at the same height as, or at most 1cm below the fold (grade III gynaecomastia), skin-sparing techniques are no longer sufficient to flatten the thorax, and it becomes necessary to remove the redundant skin by means of periareolar removal of epidermis. In cases of marked ptosis, when the nipple-areola complex is more than 1cm below the fold (grade IV gynaecomastia), reduction mastoplasty becomes necessary, with upper repositioning of the nipple-areola complex; in these cases central pedicle techniques make it possible to limit scarring in the periareolar areas. In the preoperative phase this simple classification may help in choosing the most suitable treatment, thus avoiding insufficient or invasive treatments and undesirable scars.

Reconstruction mammaire immédiate : les progrès apportés par la mastectomie avec conservation de l’étui cutané

Skin sparing mastectomy (SSM) and subcutaneous mastectomy (SCM) are recent techniques. They are always associated with immediate breast reconstruction (IBR). Their safety from an oncologic point of view and indications are of great concern. In early breast cancer, SSM and SCM are associated with the same risk of local recurrence as a modified radical mastectomy, when correctly indicated. This has been validated by numerous studies. In these non-randomised studies, overall survival cannot be evaluated. Such techniques can now be validated in the oncologic setting when correctly indicated and when decision-making is always concerted and multidisciplinary. Skin-sparing techniques are obviously associated with better cosmetic results than secondary reconstructions. Thus SSM with IBR are ideally indicated for ductal carcinoma in situ, pure infiltrating or mixed carcinomas requiring mastectomy without subsequent radiotherapy. The selection criterion of no postoperative radiotherapy allows the right candidates to be chosen for SSM. But often this criterion cannot be obtained preoperatively. In such cases, performing a two-step operation could be a good option. The interval between operations can be used by the patient to obtain more information and to make a mature decision regarding her choice of treatment. It seems essential to be able to offer every patient SSM with IBR which are validated standardised indications. Such is not the case everywhere in France today. The organisation of primary care through professional networks should provide us with an opportunity to fulfil these needs.

386 PUBLICATION Re-irradiation and hyperthermia after macroscopic complete resection for locoregional recurrent breast cancer in previously irradiated area

Gynaecomastia can be classified on the basis of the main characterising factors, i.e. pathogenesis, histopathology and morphology. The morphological classifications of gynaecomastia currently made often use subjective parameters and qualifying adjectives. In this paper the authors propose a scheme for morphological classification of gynaecomastia which can serve as a guide for choosing the surgical technique, once the diagnosis of gynaecomastia as a benign pathology has been confirmed by preoperative examinations.A retrospective analysis was made of 121 cases of gynaecomastia operated on in the last 5 years. The extent of the clinical picture, the technique employed, the complications and the need to re-operate were observed and related.On the basis of this review the authors observed that when the nipple-areola complex is above the inframammary fold (grade I and grade II gynaecomastia), complete flattening of the thorax can be achieved by means of suction or ultrasound-assisted lipectomy and skin-sparing adenectomy. When the nipple-areola complex is at the same height as, or at most 1 cm below the fold (grade III gynaecomastia), skin-sparing techniques are no longer sufficient to flatten the thorax, and it becomes necessary to remove the redundant skin by means of periareolar removal of epidermis. In cases of marked ptosis, when the nipple-areola complex is more than 1 cm below the fold (grade IV gynaecomastia), reduction mastoplasty becomes necessary, with upper repositioning of the nipple-areola complex; in these cases central pedicle techniques make it possible to limit scarring in the periareolar areas.In the preoperative phase this simple classification may help in choosing the most suitable treatment, thus avoiding insufficient or invasive treatments and undesirable scars.