Functional recovery after bilateral extended autologous latissimus dorsi breast reconstruction : a prospective observational study

Background: The impact of unilateral extended autologous latissimus dorsi (EALD) flap harvest and axillary surgery on shoulder function has been well described, but the impact of bilateral EALD flap harvest has not been clearly defined nor is it clear whether reconstructions should be synchronous or staged. Methods: In this prospective observational study, patients undergoing bilateral EALD breast reconstruction (February 2003–December 2009) completed the disability, arm, shoulder and hand (DASH) questionnaire preoperatively and at five post-operative timepoints. Intensive shoulder physiotherapy was offered to those whose DASH score was >30 at 6 weeks or >20 at 12 weeks post-operatively. Results: Sixty patients underwent bilateral EALD flap breast reconstruction (51 synchronous, 9 metachronous). Patients with pre-existing shoulder pathology (n = 1) and those who failed to return any post-operative DASH questionnaire (n = 10) were excluded from initial DASH analysis. However, these eleven patients were included in a separate analysis as an intention-to-treat analysis. Statistical analysis was performed using non-parametric, Friedman test and multiple comparison model. Forty-nine patients’ DASH scores were analysed. DASH score initially increased after surgery and then returned to functionally normal within 3–6 months (median DASH: preoperative = 1 vs 6 weeks post-operation = 26, p = <0.001; vs 3 months = 19, p = <0.001; vs 6 months = 13, p = <0.001); thereafter, the scores remained less than 12 (p = <0.001). Median DASH score after synchronous reconstruction was not higher than that after metachronous reconstructions, although the metachronous sample size was small. Conclusion: With appropriate patient selection and intensive physiotherapy, bilateral EALD breast reconstruction does not appear to cause significant long-term impairment of shoulder function, and patients can now be counselled about the likely timecourse of shoulder recovery. There seems no reason to stage bilateral reconstruction to reduce shoulder morbidity

Radiation-associated angiosarcoma after autologous breast reconstruction: report of two cases in a plastic surgery unit

Radiation-associated breast angiosarcoma is a rare diagnosis but is commonly reported. Angiosarcoma occurring in non-breast tissue in breasts that have been reconstructed with autologous tissue following mastectomy is extremely rare. In our unit, we have managed two patients with angiosarcoma arising in non-breast tissue autologous reconstructions. Our report emphasises that any tissue treated with radiotherapy—that is, the residual mastectomy skin flaps or non-breast tissue autologous reconstructions—are at a risk of secondary angiosarcoma. We also discuss recommended surgical management, surveillance and genetic testing. Level of Evidence is V, risk study

A population-based audit of surgical practice and outcomes of oncoplastic breast conservations in Scotland – an analysis of 589 patients

Introduction: Current evidence for oncoplastic breast conservation (OBC) is based on single institutional series. Therefore, we carried out a population-based audit of OBC practice and outcomes in Scotland. Methods: A predefined database of patients treated with OBC was completed retrospectively in all breast units practicing OBC in Scotland. Results: 589 patients were included from 11 units. Patients were diagnosed between September 2005 and March 2017. High volume units performed a mean of 19.3 OBCs per year vs. low volume units who did 11.1 (p = 0.012). 23 different surgical techniques were used. High volume units offered a wider range of techniques (8–14) than low volume units (3–6) (p = 0.004). OBC was carried out as a joint operation involving a breast and a plastic surgeon in 389 patients. Immediate contralateral symmetrisation rate was significantly higher when OBC was performed as a joint operation (70.7% vs. not joint operations: 29.8%; p &lt; 0.001). The incomplete excision rate was 10.4% and was significantly higher after surgery for invasive lobular carcinoma (18.9%; p = 0.0292), but was significantly lower after neoadjuvant chemotherapy (3%; p = 0.031). 9.2% of patients developed major complications requiring hospital admission. Overall the complication rate was significantly lower after neoadjuvant chemotherapy (p = 0.035). The 5 year local recurrence rate was 2.7%, which was higher after OBC for DCIS (8.3%) than invasive ductal cancer (1.6%; p = 0.026). 5-year disease-free survival was 91.7%, overall survival was 93.8%, and cancer-specific survival was 96.1%. Conclusion: This study demonstrated that measured outcomes of OBC in a population-based multi-centre setting can be comparable to the outcomes of large volume single centre series

The impact of immediate breast reconstruction on the time to delivery of adjuvant therapy: the iBRA-2 study

Background: Immediate breast reconstruction (IBR) is routinely offered to improve quality-of-life for women requiring mastectomy, but there are concerns that more complex surgery may delay adjuvant oncological treatments and compromise long-term outcomes. High-quality evidence is lacking. The iBRA-2 study aimed to investigate the impact of IBR on time to adjuvant therapy. Methods: Consecutive women undergoing mastectomy ± IBR for breast cancer July–December, 2016 were included. Patient demographics, operative, oncological and complication data were collected. Time from last definitive cancer surgery to first adjuvant treatment for patients undergoing mastectomy ± IBR were compared and risk factors associated with delays explored. Results: A total of 2540 patients were recruited from 76 centres; 1008 (39.7%) underwent IBR (implant-only [n = 675, 26.6%]; pedicled flaps [n = 105,4.1%] and free-flaps [n = 228, 8.9%]). Complications requiring re-admission or re-operation were significantly more common in patients undergoing IBR than those receiving mastectomy. Adjuvant chemotherapy or radiotherapy was required by 1235 (48.6%) patients. No clinically significant differences were seen in time to adjuvant therapy between patient groups but major complications irrespective of surgery received were significantly associated with treatment delays. Conclusions: IBR does not result in clinically significant delays to adjuvant therapy, but post-operative complications are associated with treatment delays. Strategies to minimise complications, including careful patient selection, are required to improve outcomes for patients

Bőrkímélő (skin-sparing) mastectomia és azonnali emlőrekonstrukció onkológiai biztonságossága a recidívaarány, recidívalokalizáció és a rekonstrukciós technika függvényében | Oncologic safety of skin-sparing mastectomy followed by immediate breast reconstruction: rate and localization of recurrences, and impact of reconstruction techniques

Bevezetés: A bőrkímélő mastectomia és az azonnali emlőrekonstrukció onkosebészeti biztonságossága megkérdőjelezhető. A rendelkezésre álló evidencia a legtöbb esetben szelektált betegcsoportok rövid távú utánkövetésén alapul. Cél: A szerzők tanulmányukban egy nem szelektált betegcsoport 10 éves onkológiai utánkövetésének adatait elemzik. Módszerek: 253, bőrkímélő mastectomiával és azonnali emlőrekonstrukcióval kezelt beteg utánkövetési adatainak retrospektív elemezését végezték. Minden, emlőcarcinomával diagnosztizált betegnek felajánlották az azonnali emlőrekonstrukciót a tumor stádiumától függetlenül („all-comers” módszer). Eredmények: Az „all-comers” módszer eredményeképp a betegek viszonylag nagy hányada előrehaladott emlőrákkal került műtétre. 119 hónapos átlagos utánkövetési idő alatt a lokoregionális recidíva aránya 8,2%, a distalis kiújulás 10,6% volt. A betegek emlőrák-specifikus túlélése 90,9% volt. Autológ szövettel végzett emlőrekonstrukciót gyakrabban alkalmaztak magasabb tumorstádium esetén, ezért a recidívák gyakorisága magasabb volt, mint implantátummal végzett emlőrekonstrukciók után. Következtetés: A hosszú távú utánkövetésen alapuló eredmények szerint a bőrkímélő mastectomia és az azonnali emlőrekonstrukció onkológiailag megbízható kezelési módszer. Mivel az „all-comers” módszer alkalmazása onkológiailag biztonságosnak bizonyult, ezért azonnali emlőrekonstrukció a tumorstádiumtól függetlenül felajánlható. Orv. Hetil., 2013, 154, 163–171. | Introduction: Oncological safety of skin-sparing mastectomy followed by immediate breast reconstruction is widely debated. Current evidence is relatively poor since it is based mostly on short-term follow-up data of highly selected patient populations. Aim: Recurrence rates of a large cohort of non-selected patients, i. e. “all-comers” were analyzed during a 10-year follow up. Methods: Patient records and follow-up data of 253 consecutive cases treated with of skin-sparing mastectomy and immediate breast reconstruction between 1995 and 2000 were studied. During this time period “all-comers” policy was applied, which meant that all patients treated with mastectomy were offered immediate breast reconstruction regardless of tumour stage. Results: “All-comers” approach resulted in a large proportion of patients with more advanced disease. During the 112 months mean follow-up 8.2% locoregional, 2.9% local, 10.6% distal and 18.8% overall recurrence rates were detected. Breast cancer specific survival rate was 90.9%. Autologous breast reconstruction was applied more frequently in patients with higher tumour stage; therefore recurrence rate was higher compared to patients undergoing implant-based reconstruction. Conclusion: Based on these long-term follow-up data skin-sparing mastectomy combined with immediate breast reconstruction is an oncologically safe treatment option. Therefore, application of “all-comers” policy for breast cancer patients treated with skin-sparing mastectomy followed by immediate breast reconstruction is feasible. Orv. Hetil., 2013, 154, 163–171

Terápiás emlőplasztika intraoperatív, közvetlen posztoperatív és hosszú távú onkosebészeti biztonsága | Intraoperative, postoperative and long-term oncosurgical safety of therapeutic mammaplasty

Bevezetés: Az onkoplasztikai emlősebészeti módszerek alkalmazásával a hagyományosan mastectomiával kezelt (pre)malignus emlőelváltozások is eltávolíthatók emlőmegtartó műtéttel (terápiás emlőplasztika). A módszer onkosebészeti megbízhatóságára ugyanakkor nincsenek megfelelő adatok. Célkitűzés: A szerzők célul tűzték ki a terápiás emlőplasztika onkosebészeti biztonságának meghatározását. Módszer: 99 beteget kezeltek terápiás emlőplasztikával és az eredményeket folyamatosan vezetett emlősebészeti adatbázis alapján elemezték. Az intraoperatív, a közvetlen posztoperatív, illetve a hosszú távú onkológiai biztonságot vizsgálták. Eredmények: A betegek 14,1%-ában voltak a reszekciós szélek inkomplettek, amelyek korreláltak a tumormérettel (p = 0,023) és a multifokális elváltozásokkal (p = 0,012). A terápiás emlőplasztika és a kemoterápia megkezdése közötti időintervallum hasonló volt a mastectomiával, egyszerű széles excisióval, vagy mastectomiával és azonnali rekonstrukcióval kezelt betegekéhez (átlagosan 29–31 nap; p<0,05). 27 hónapos (1–88) átlagos utánkövetési idő alatt a recidíva aránya 6,1%, ebből a lokális recidíva aránya 2% volt. Következtetések: Mivel az irodalmi adatok is hasonlóan rövid utánkövetési időszakon és alacsony betegszámon alapulnak, kulcsfontosságú, hogy minden emlőcentrum, ahol terápiás emlőplasztikát végeznek, folyamatosan vezetett adatbázist készítsen a hosszú távú recidívaarány meghatározása céljából. Orv. Hetil., 2013, 154, 1291–1296. | Introduction: (Pre)malignant lesion in the breast requiring mastectomy conventionally may be treated with breast conservation by using oncoplastic breast surgical techniques, which is called therapeutic mammaplasty. However, no reliable data has been published so far as regards the oncological safety of this method. Aim: The aim of the authors was to analyse the oncological safety of therapeutic mammaplasty in a series of patients. Method: 99 patients were treated with therapeutic mammaplasty and data were collected in a breast surgical database prospectively. Results were analysed with respect to intraoperative, postoperative and long-term oncological safety. Results: Incomplete resection rate was 14.1%, which correlated with tumour size (p = 0.023), and multifocality (p = 0.012). Time between surgery (therapeutic mammaplasty) and chemotherapy was similar to time between conventional breast surgeries (wide excision, mastectomy, mastectomy with immediate reconstruction) and chemotherapy (mean 29–31 days; p<0.05). Overall recurrence rate was 6.1%, locoregional recurrence rate was 2% during 27 month (1–88) mean follow-up. Conclusions: Since literature data are based on relatively short follow-up and low patient number, it is highly important that all data on therapeutic mammaplasty is collected in a prospectively maintained breast surgical database in order to determine true recurrence after long-follow-up. Orv. Hetil., 2013, 154, 1291–1296

Six-year follow-up of patients treated with oncoplastic reduction mammoplasty: a cohort study

Background: Current evidence for the oncological safety of oncoplastic breast conservation is poor as it is based mostly on short-term follow-up data. Hence, we report long-term recurrence rates in patients treated with oncoplastic reduction mammoplasty (ORM). Methods: A prospectively maintained database was searched to identify patients who underwent ORM between 2005 and 2010. A retrospective review of medical records was carried out, including patients with ductal carcinoma in situ and invasive breast cancer. Results: Follow-up data from 65 consecutive patients with ORM were reviewed, of which 50 patients were eligible to measure long-term recurrence rates. The average weight of the resected tissue was 272 g altogether. The mean preoperative tumour size was 2.95 cm on imaging. 64% of patients had stage II – III cancers. Incomplete excision rate after ORM was 16.1%, completion mastectomy rate was 10.7%. During a median follow-up of 72 months, 2% local, 6% distant recurrence rates were detected. The breast cancer-specific survival rate was 96% per cent. Conclusions: Based on these long-term follow-up data, ORM is an oncologically safe treatment option

Imaging results following oncoplastic and standard breast conserving surgery

Background: Oncoplastic breast-conserving surgery (OBCS) requires more complex surgical techniques than standard wide local excision (WLE) and the postoperative complication rate may be higher. Since these can have an impact on postoperative imaging, we compared imaging and biopsy results after OBCS and WLE. Methods: Findings for patients undergoing OBCS (n = 83) or standard WLE (n = 128) were compared. Numbers, indications and outcomes of mammograms, breast ultrasounds, magnetic resonance imaging scans and biopsies done within 2 years after surgery were analysed. Results: OBCS was applied for more advanced malignancy. Significantly more patients required breast ultrasound after OBCS than WLE (20/71 vs. 17/116; p = 0.024). Breast Imaging Reporting and Data System (BI-RADS) category 3 or 4 ultrasound results were found only in patients with OBCS (6/29 vs. 0/19; p = 0.034). Significantly more biopsies were required after OBCS (9/71 vs. 3/116; p = 0.006). New lumps or lumpiness were the commonest indications, and pathology confirmed fat necrosis in the majority (7/12). The rate of fat necrosis after OBCS was 18% on clinical examination (13/71), 15% with ultrasound (11/71) and 7% confirmed on pathology (5/71). Conclusion: Patients treated with OBCS require significantly more ultrasound scans and consequent biopsies than patients who underwent WLE. This is mainly due to fat necrosis developing after OBCS in the majority of cases