Oncoplastic Breast Consortium consensus conference on nipple-sparing mastectomy

Purpose Indications for nipple-sparing mastectomy (NSM) have broadened to include the risk reducing setting and locally advanced tumors, which resulted in a dramatic increase in the use of NSM. The Oncoplastic Breast Consortium consensus conference on NSM and immediate reconstruction was held to address a variety of questions in clinical practice and research based on published evidence and expert panel opinion. Methods The panel consisted of 44 breast surgeons from 14 countries across four continents with a background in gynecology, general or reconstructive surgery and a practice dedicated to breast cancer, as well as a patient advocate. Panelists presented evidence summaries relating to each topic for debate during the in-person consensus conference. The iterative process in question development, voting, and wording of the recommendations followed the modified Delphi methodology. Results Consensus recommendations were reached in 35, majority recommendations in 24, and no recommendations in the remaining 12 questions. The panel acknowledged the need for standardization of various aspects of NSM and immediate reconstruction. It endorsed several oncological contraindications to the preservation of the skin and nipple. Furthermore, it recommended inclusion of patients in prospective registries and routine assessment of patient-reported outcomes. Considerable heterogeneity in breast reconstruction practice became obvious during the conference. Conclusions In case of conflicting or missing evidence to guide treatment, the consensus conference revealed substantial disagreement in expert panel opinion, which, among others, supports the need for a randomized trial to evaluate the safest and most efficacious reconstruction techniques

European breast surgical oncology certification theoretical and practical knowledge curriculum 2020

The Breast Surgery theoretical and practical knowledge curriculum comprehensively describes the knowledge and skills expected of a fully trained surgeon practicing in the European Union and European Economic Area (EEA). It forms part of a range of factors that contribute to the delivery of high quality cancer care. It has been developed by a panel of experts from across Europe and has been validated by professional breast surgery societies in Europe. The curriculum maps closely to the syllabus of the Union of European Medical Specialists (UEMS) Breast Surgery Exam, the UK FRCS (breast specialist interest) curriculum and other professional standards across Europe and globally (USA Society of Surgical Oncology, SSO). It is envisioned that this will serve as the basis for breast surgery training, examination and accreditation across Europe to harmonise and raise standards as breast surgery develops as a separate discipline from its parent specialties (general surgery, gynaecology, surgical oncology and plastic surgery). The curriculum is not static but will be revised and updated by the curriculum development group of the European Breast Surgical Oncology Certification group (BRESO) every 2 years

Opportunities and priorities for breast surgical research

The Breast Cancer Campaign Gap analysis (2013) established breast cancer research priorities without specific focus on surgical research nor the role of surgeons. The majority of breast cancer patients encounter a surgeon at diagnosis or during treatment, thus surgical involvement in design and delivery of high-quality research to improve patient care is critical. This review aims to identify opportunities and priorities for breast surgical research to complement the previous gap analysis

AGO Recommendations for the surgical therapy of breast cancer: update 2022

The recommendations of the AGO Breast Committee on the surgical therapy of breast cancer were last updated in March 2022 (www.ago-online.de). Since surgical therapy is one of several partial steps in the treatment of breast cancer, extensive diagnostic and oncological expertise of a breast surgeon and good interdisciplinary cooperation with diagnostic radiologists is of great importance. The most important changes concern localization techniques, resection margins, axillary management in the neoadjuvant setting and the evaluation of the meshes in reconstructive surgery. Based on meta-analyses of randomized studies, the level of recommendation of an intraoperative breast ultrasound for the localization of non-palpable lesions was elevated to “++”. Thus, the technique is considered to be equivalent to wire localization, provided that it is a lesion which can be well represented by sonography, the surgeon has extensive experience in breast ultrasound and has access to a suitable ultrasound device during the operation. In invasive breast cancer, the aim is to reach negative resection margins (“no tumor on ink”), regardless of whether an extensive intraductal component is present or not. Oncoplastic operations can also replace a mastectomy in selected cases due to the large number of existing techniques, and are equivalent to segmental resection in terms of oncological safety at comparable rates of complications. Sentinel node excision is recommended for patients with cN0 status receiving neoadjuvant chemotherapy after completion of chemotherapy. Minimally invasive biopsy is recommended for initially suspect lymph nodes. After neoadjuvant chemotherapy, patients with initially 1 – 3 suspicious lymph nodes and a good response (ycN0) can receive the targeted axillary dissection and the axillary dissection as equivalent options

Immediate Breast Reconstruction with Free Autologous Tissue Transfer

Immediate breast reconstruction in the United States is increasing with the majority of patients undergoing implant-based reconstruction. The use of pedicled autologous tissues has also been used, but due to significant donor site morbidity, free autologous tissue transfer has largely replaced it. The gold standard currently for breast reconstruction is free autologous tissue transfer from the abdomen if no contraindications exist. However, not all hospitals have the expertise available to perform free autologous tissue transfers for breast reconstruction. Other donor sites available for free autologous tissue transfer include the thigh and gluteal areas. With advances in free tissue transfer techniques, the donor site morbidity and flap failure rates are minimal. The ultimate goal for any breast reconstruction patient is to achieve the appropriate size, shape, symmetry, softness, and sensation. The goal of this chapter is to assist in achieving these goals in the immediate breast reconstruction patient through the use of free autologous tissue transfers

Development and implementation of an evaluation framework for breast reconstruction decision support tool for women considering breast reconstruction following mastectomy

Breast cancer survival has improved significantly, with almost ninety percent of diagnosed women being cured (Australian Institute of Health and Welfare (AIHW) & Cancer Australia, 2012). Despite no survival advantage between breast conserving surgery and mastectomy, there has been an increasing trend back to mastectomy as primary treatment; in addition to an increase in bilateral prophylactic mastectomy in the absence of a breast cancer diagnosis (with or without BRCA mutation) (Dragun et al., 2013; Elmore, Ganschow & Geller, 2010; Jones et al., 2009; Tuttle, Abbott, Arrington & Rueth, 2010). Breast reconstruction has been shown to lessen psychological morbidity and facilitate adjustment to an altered body image resulting from mastectomy (Denford, Harcourt, Rubin & Pusic, 2011; Hill & White, 2008). Few women are prepared for the complexity in considering the personal, clinical and situational factors affecting breast reconstruction decision making. Given the limited research on breast reconstruction patient education or decision making tools, this study aimed to develop a decision support tool for women considering breast reconstruction. An evaluation framework was established to guide the development of a breast reconstruction decision support tool and was implemented over three phases: 1. Phase One undertook a needs analysis to explore the breast reconstruction decision making experiences and information needs of women who had undertaken breast reconstruction. 2. Phase Two developed a breast reconstruction decision support tool through the implementation of an evaluation framework driven by key stakeholders. 3. Phase Three completed implementation of the evaluation framework by conducting summative evaluation of the decision support tool’s value using survey and interview methods. The breast reconstruction decision support tool was found to meet women’s information needs, perceived to be useful throughout a woman’s breast reconstruction experience, and considered an acceptable and useful tool to assist women making decisions about breast reconstruction. This research culminated in a nationally endorsed and accessible source of breast reconstruction information to assist Australian women with their decision making (www.canceraustralia.gov.au/ breastreconstruction)

What is the impact of TRAM flap breast reconstruction on self-esteem and perceived body image for women with breast cancer?

Breast cancer is the most common of all cancers in women (26%) in Australia (Australian Institute Health Welfare AIHW, 1996; National Breast Cancer Centre NBCC, 1999). It is estimated that the lifetime incidence of one in eleven women in Australia will be diagnosed with breast cancer by the age of seventy-four (National Health and Medical Research Council NHMRC, 2000). Surgical resection continues to be the mainstay of treatment for early breast cancer, with approximately 50% of women diagnosed with breast cancer undergoing mastectomy (NBCC, 1999). Both the diagnosis of breast cancer and subsequent mastectomy raises a number of psychosocial issues for women. In addition to the diagnosis of a potentially life threatening illness, these women contend with the psychological consequences that accompany the loss of a breast. During the height of development of breast reconstructive techniques in the 1980\u27s, mastectomy became more commonly recognised as an important aspect of a woman\u27s experience with breast cancer. Breast cancer not only causes pain, suffering and the possibility of death, but also threatens a woman\u27s self-concept, self-esteem and feminine identity through its attack on her body (Derogatis, 1986). To reduce the psychological impact associated with removal of the breast, breast reconstruction is increasingly being offered. In the past five years there has been an increase in the number of women seeking breast reconstruction, with an increasing focus on quality of life issues and survivorship for women diagnosed with breast cancer (Wilkins et al., 1995). To date little is known about women\u27s experiences of undergoing breast reconstruction. Using a qualitative, exploratory descriptive approach this study investigated the impact of the transverse rectus abdominis musculocutaneous (TRAM) flap breast reconstruction, on self-esteem and perceived body image for women with breast cancer. In depth semi-structured interviews, using both individual and focus group methods, were undertaken with ten women who had undergone a TRAM flap breast reconstruction between January 1st 2001 and January 1st 2003. Data was analysed using the process of thematic analysis to determine key concepts and themes that described these women\u27s experiences. Three main themes emerged from the findings of this study: Loosing a breast matters , \u27\u27The process of adjusting to a changing body image , and Redefining normality . These themes and their sub-themes describe the experience of breast cancer survival and TRAM flap breast reconstruction for the women who participated in this study. These findings will further the current knowledge base on this topic and therefore assist nurses in providing sound information and psychosocially appropriate support to TRAM flap breast reconstruction patients and their significant others. Furthermore, this study\u27s findings will be a further resource for women considering breast reconstruction treatment options following mastectomy

Sentinel lymph node biopsy before mastectomy and immediate breast reconstruction may predict post-mastectomy radiotherapy, reduce delayed complications and improve the choice of reconstruction

AbstractBackgroundAdjuvant post-mastectomy radiotherapy (RT), which is often unpredicted, is known to increase complications following immediate breast reconstruction (IBR).AimTo investigate the role of sentinel lymph node biopsy (SLN) in predicting RT and improving the choice of IBR.Patients and methodsAll patients who had mastectomy and IBR between January 2004 and January 2007 were reviewed retrospectively. Axillary staging (clearance or SLN) was performed at the same time until October 2005 (Group 1), when the Unit’s protocol was updated to perform SLN initially prior to mastectomy and IBR (Group 2). Patients in Group 2 with positive SLN were offered either a delayed reconstruction or a temporary subpectoral immediate tissue expander, while all options were offered if SLN was negative and in Group 1 patients.ResultsOne hundred and thirty-nine patients were reviewed. 20 patients received unexpected RT in Group 1 (14 tissue expander, 4 Latissimus Dorsi flap with an implant and 2 DIEP flaps) compared to 11 patients in Group 2 who had a temporary tissue expander due to expected RT (P=0.03). Unexpected RT caused delayed complications in 14 patients (70%) compared to no delayed complications in patients who received expected RT in Group 2.ConclusionSLN biopsy before IBR helps to predict RT and avoids its complications on breast reconstruction. Patients with positive SLN biopsy are best offered a temporary subpectoral tissue expander for IBR