Breast cancer recurrence after immediate reconstruction: patterns and significance

Breast MRI surveillance in women with prior curative-intent therapy for breast cancer

BACKGROUND

We sought to determine factors that predict the use of breast magnetic resonance imaging (MRI) surveillance in women previously treated for breast cancer and the incidence of in-breast recurrences and/or new cancers identified by MRI.

METHODS

We reviewed 141 patients who were treated between 2005 and 2008 who also underwent surveillance breast MRI following their treatment. Patient, tumor, treatment characteristics, and MRI findings were collected. Gail scores were calculated based on the patient's personal and family history prior to the breast cancer diagnosis. Data were compared using chi(2) and Fisher's exact test.

RESULTS

The average age of the study population was 51 (range 24-73). One hundred forty-one women underwent 202 surveillance breast MRIs during the study period. Sixteen of 141 (11%) required second look imaging, and six of 141 (4%) required biopsy of suspicious lesions. Two of the six were invasive breast cancers, while four were benign. Overall, the rate of new cancer detection on surveillance MRI during the study period was 0.9% (two of 202 imaging studies). Of the 71 women with evaluable Gail scores, the average lifetime risk score was 16.7%. Eight patients had BRCA mutations and three previously underwent irradiation for Hodgkin's lymphoma. Patient age, Gail score, tumor stage, grade, histology, receptor status, and surgical treatment were not predictive of MRI surveillance use.

CONCLUSION

Prospective studies are needed to determine which patients may potentially benefit from breast MRI surveillance following curative-intent treatment. The lack of standardized guidelines may result in excessive or inappropriate use, unnecessary follow-up procedures, and a concomitant low yield.

Preferences in choosing between breast reconstruction options: a survey of female plastic surgeons

BACKGROUND

Female plastic surgeons are well suited to make a personal choice regarding breast reconstruction options, based on their knowledge of the actual procedures and first-hand experience with results. The authors surveyed this group to elicit their personal views on various modalities of breast reconstruction and to ascertain which types of reconstruction they would choose if faced with such a decision.

METHODS

All board-certified female plastic surgeons in the United States and Canada were surveyed by means of e-mail. This survey included questions regarding basic demographic and practice data. Respondents were requested to rank desired methods of reconstruction for themselves and to cite reasons for these choices.

RESULTS

A total of 435 surveys were sent: 350 were delivered (85 had invalid e-mail addresses), and 143 were returned (response rate, 41 percent). Overall, 66 percent of respondents chose implant-based reconstruction, 25 percent chose autologous reconstruction, and 9 percent chose no reconstruction. Respondents selecting autologous reconstruction cited cosmetic outcome as the most important factor considered in 47 percent of cases, compared with 14 percent of those choosing implant-based breast reconstruction (p = 0.0001). Invasiveness of the procedure/recovery time was cited as the most important factor by 83 percent of those surgeons opting for no breast reconstruction and by 51 percent of those choosing implant-based breast reconstruction (p = 0.0175).

CONCLUSIONS

Board-certified female plastic surgeons exhibit a strong desire to pursue implant-based breast reconstruction over autologous reconstruction. When it was chosen, autologous reconstruction was felt to offer improved aesthetic outcomes. When making such a decision, patients can use female plastic surgeons as a resource for information, thus helping them to make an informed decision.

Application of Screening Principles to the Reconstructed Breast

A significant number of women choose mastectomy for the treatment of early and locally advanced breast cancer. Advances in reconstruction techniques and greater awareness of options have led to an increased use of immediate breast reconstruction, which has resulted in uncertainty for the management of surveillance for local recurrence. In this article, we review mastectomy and reconstruction trends and how these techniques affect the frequency and location of local recurrence. The data on surveillance imaging of the reconstructed breast are extremely limited. However, by assessing the potential role for imaging in this setting and applying the principles of screening, we have identified that there is a potential theoretic advantage of surveillance imaging in a very small subset of women: those with autologous tissue reconstructions and moderate to high risk of recurrence. A prospective registry study of surveillance imaging in this target population would be the appropriate way to determine its benefit and its impact on survival outcomes. In this review article, we will detail the reasons that should allow clinicians to forego routine surveillance imaging in the majority of women who undergo mastectomy and reconstruction.

Long-term outcome after mastectomy with immediate breast reconstruction

INTRODUCTION

The purpose of this study was to investigate long term outcome for women who had undergone mastectomy and immediate breast reconstruction.

MATERIAL AND METHODS

Patient files of 167 immediately reconstructed breast cancer patients were reviewed for late surgical complications. Furthermore, information of local recurrence rate, radiotherapy and death was obtained from the Danish Breast Cancer Cooperative Group register. Histopatological high and low risk patients were compared with respect to locoregional recurrence rate, recurrence free survival and death. Unpaired t-test and Fisher's exact test were used to test for significance.

RESULTS

The overall rate of revision surgery was 27%. Reconstruction with implants was associated with a significantly higher rate of revision surgery compared to reconstructions with transverse rectus abdominis myocutaneous flap or latissimus dorsi flap without implant (36 vs. 14%; p=0.004). The locoregional recurrence rate was 6%. Patients with histopathologically high risk disease had increased death rate (22 vs. 6%; p=0.03) and shorter disease free survival (89+/-43 months vs. 104+/-35 months; p=0.048) compared with low risk disease. We found no increase in the occurrence of capsular contracture in our study group in patients who received radiotherapy.

CONCLUSION

Immediate breast reconstruction seems to be oncologically safe. Breast reconstruction performed with implants was associated with a higher risk of late complications, as was histopathologically high risk disease with increased death rate and shorter disease free survival.

Mastectomy scars following breast reconstruction: should routine histologic analysis be performed?

BACKGROUND

There is some debate in the recent literature regarding the routine submission of mastectomy scars for histologic analysis when performing delayed breast reconstructions. The aim of this study was to review the relevant publications and evaluate the practice of routine histologic examination of mastectomy scars.

METHODS

The authors conducted a retrospective review, across three regional plastic and reconstructive surgery units, of 433 patients who had 455 scars routinely sent for histologic examination following delayed breast reconstruction between January of 2000 and December of 2006. Patients with clinical evidence of recurrent carcinoma were excluded.

RESULTS

Data from 433 patients revealed an average age at reconstruction of 49.9 years (range, 25 to 77 years). The mean interval from primary breast surgery to reconstruction was 3.9 years (range, 2 months to 32 years), and the average length of patient follow-up, from primary surgery, was 6.4 years (range, 1 to 40 years). The majority of the initial operations were carried out for invasive carcinoma (89 percent). Four mastectomy scars in three patients were positive for carcinoma recurrence.

CONCLUSIONS

The publications related to the practice of routine histologic analysis of mastectomy scars provide conflicting conclusions. As a proportion of patients may benefit from the early detection and treatment of locoregional recurrence, the authors suggest that the routine submission of mastectomy scars will allow for the earlier detection of soft-tissue recurrences that may affect long-term outcome. In keeping with cancer surgery principles, the authors recommend routine histologic examination of mastectomy scars following delayed breast reconstruction.

Defining the role for autologous breast reconstruction after mastectomy: social and oncologic implications

Breast reconstruction plays a significant role in the management of breast cancer. The removal of a breast has implications for the psychologic, social, and sexual well-being of the patient, establishing the need for discussion of postmastectomy breast reconstruction with suitable patients. However, operative morbidity and the potential for diminished oncologic safety are ongoing issues of contention. A Medline literature review was performed to evaluate the interplay between the psychosocial need for breast reconstruction in patients after mastectomy and the issues surrounding its oncologic safety. Immediate breast reconstruction does not impair the oncologic safety of breast cancer management, with no increase in local recurrence rates, and no delays in the initiation of adjuvant chemotherapy or radiation therapy (RT). Immediate breast reconstruction in the setting of chemotherapy is not associated with greater complication rates; however, there is some evidence for increased complications in the setting of adjuvant RT. Breast reconstruction has a positive effect on the psychosocial outcomes of mastectomy and is oncologically safe in the immediate and delayed settings. Ultimately, the decision-making process of whether to reconstruct, how to reconstruct, and when to reconstruct requires a multidisciplinary approach, with the patient, plastic surgeon, oncologic surgeon, medical oncologist, and radiation oncologist all contributing.

The impact of breast reconstruction on the oncologic efficacy of radiation therapy: a retrospective analysis

Current indications for radiation therapy in women with breast cancer are controversial and continue to be modified. Current indications for breast reconstruction in the setting of radiation therapy are also controversial and poorly defined. The purpose of this study is to analyze oncologic outcomes following various methods of breast reconstruction in the setting of radiation therapy. A retrospective review of 676 women who had breast reconstruction following mastectomy was completed. A total of 146 women had breast reconstruction either before or after radiation therapy and were analyzed. Response variables included tumor recurrence and patient demise for patients having autologous and prosthetic reconstruction. Explanatory variables included patient age, cancer stage, radiation therapy, diabetes mellitus, and tobacco use. Recurrence of tumor occurred in 29 of 146 women (19.8%), of which 27% was when radiation followed reconstruction and 14.9% was when radiation preceded reconstruction. Patient demise occurred in 8.9%, of which 11.9% was when radiation followed reconstruction and 6.9% was when radiation preceded reconstruction. The difference in tumor recurrence in the setting of radiation therapy before or after breast reconstruction was significant for autologous (P = 0.0146) and prosthetic (P = 0.0424) reconstruction. The difference in patient demise was significant for autologous reconstruction (P = 0.0380) but not for prosthetic reconstruction (P = 0.2827). These results imply that tumor recurrence and patient demise may be increased when radiation therapy is performed following breast reconstruction. The need for a prospective inquiry is validated.

The superficial margin of the skin-sparing mastectomy for breast carcinoma: factors predicting involvement and efficacy of additional margin sampling

BACKGROUND

No study has systematically evaluated the significance of involvement of the superficial specimen margin in skin-sparing mastectomies (SSMs).

METHODS

168 SSMs with a small, additional superficial margin (ASM) specimen taken directly over the tumor to the dermis intraoperatively were studied.

RESULTS

64 SSMs (38%) had a positive superficial specimen margin but only 13 (20%) of these had residual breast carcinoma in ASMs. Only 1 of 104 SSMs with a negative superficial specimen margin had residual breast carcinoma in its ASM (P < 0.05). ASM sampling rendered the final true margin directly over the tumor negative in 54 of 58 (93%) SSMs with a focally positive superficial specimen margin, but did not negate the nonfocally positive superficial specimen margin in six other cases. In SSMs with a positive superficial specimen margin, multivariate analysis revealed that the presence of extensive ductal carcinoma in situ (DCIS) in the SSM and a thicker ASM specimen were the only independent factors predictive of residual breast carcinoma in ASM. Eighty-nine (53%) ASMs contained benign breast tissue.

CONCLUSIONS

Superficial specimen margins in SSMs are often microscopically positive and approximately half of ASMs contain benign breast tissue, likely reflecting the difficulty in completely removing breast tissue near the skin flaps in SSMs. ASM sampling effectively decreases positive superficial specimen margins directly over the tumor in SSMs, but fails to account for positive superficial specimen margins in other quadrants in patients with multicentric disease, especially extensive DCIS. Patients whose superficial margins remain positive could potentially represent a subset of patients for whom postmastectomy radiation is beneficial.

MOC-PSSM CME article: Breast reconstruction

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Understand the various techniques available to reconstructive breast surgeons. 2. Perform a comprehensive assessment of the breast reconstruction candidate. 3. Gain knowledge about the indications and contraindications for different breast reconstructive procedures. 4. Understand the complications inherent to different reconstructive breast procedures.

SUMMARY

This article was prepared to accompany practice-based assessment with ongoing surgical education for the Maintenance of Certification for the American Board of Plastic Surgery. It is structured to outline the care of the patient with the postmastectomy breast deformity.

Local recurrence of stage 1 and 2 breast cancer after skin-sparing mastectomy and immediate breast reconstruction in a 15-year series

AIMS

Since the introduction of skin-sparing mastectomy (SSM) in 1991 concerns on local control and recurrence rates have been discussed in the literature. The aim of this study is to examine in particular incidence of local recurrence in a 15-year consecutive series of breast cancer patients having undergone SSM and immediate breast reconstruction (IBR) at a single population-based institution.

METHODS

One hundred and forty-six consecutive patients with either stage 1 or 2 breast cancer who underwent SSM followed by IBR from 1992 to 2006 were included in this study. A retrospective review of patient records was conducted.

RESULTS

During a mean follow-up time of 51 months, four local recurrences of the native breast skin were accounted for. In addition, three regional lymph node recurrences and four systemic recurrences took place. All of the local and regional recurrences were handled by salvage surgery followed by adjuvant oncological therapies. During a mean follow-up of 35 months after the detection and treatment of the locoregional recurrences none of the patients developed new recurrences.

CONCLUSIONS

Our present study concludes that SSM followed by IBR seems oncologically sound procedure for stage 1 and 2 breast cancer patients. In addition, local recurrences and regional lymph node recurrences are not always associated with systemic relapse.

Oncological and aesthetic considerations of skin-sparing mastectomy

AIM

To review the oncological safety and aesthetic value of skin-sparing mastectomy (SSM) for invasive breast cancer (IBC) and ductal carcinoma in-situ (DCIS). Controversies including the impact of radiotherapy (RT) on immediate breast reconstruction (IBR), preservation of the nipple-areola complex (NAC) and the role of endoscopic mastectomy are also considered.

METHODS

Literature review facilitated by Medline and PubMed databases.

RESULTS

SSM is an oncologically safe technique in selected cases, including IBC <5 cm, multi-centric tumours, DCIS and prophylactic risk-reduction surgery. The high risk of local recurrence (LR) excludes inflammatory breast cancers and tumours with extensive involvement of the skin. SSM can facilitate IBR and is associated with an excellent aesthetic result. Prior breast irradiation or the need for post-mastectomy radiotherapy (PMR) do not preclude SSM, however the cosmetic outcome may be affected. Nipple/areola preservation is possible for remote tumours, employing a frozen section protocol for the retro-areolar tissue. There is limited data available for endoscopic mastectomy and superiority over conventional SSM has not been established.

CONCLUSION

In appropriately selected cases SSM is oncologically adequate. There are several patient centred advantages over conventional mastectomy, including aesthetic outcome and the avoidance of multiple staged procedures. Despite widespread uptake into surgical practice, validation of these techniques from randomised controlled trials is lacking.

Scientific Presentation Award. Patterns of local breast cancer recurrence after skin-sparing mastectomy and immediate breast reconstruction

BACKGROUND

Local recurrence rates after skin-sparing mastectomy and immediate reconstruction are similar to recurrence rates after conventional mastectomy. We investigated the pattern of local recurrences and risk factors associated with them.

METHODS

We identified 206 patients who underwent 210 skin-sparing mastectomies with immediate reconstruction from 1998 to 2006 in our database.

RESULTS

Eleven patients had local recurrences (5.3%). Nine developed in the quadrant of the corresponding primary tumor. There were no significant differences between patients who recurred and those who did not with respect to tumor size/stage, margin status, estrogen receptor/progesterone receptor/Her2neu status, lymph node metastases, or radiation therapy (P > .05). Patients with grade 3 invasive tumors or high-grade ductal carcinoma in situ were more likely to recur than patients with grade 1 or 2 invasive tumors or low- or intermediate-grade ductal carcinoma in situ (P = .0035). Those patients who recurred had a significantly decreased overall survival compared to patients who did not recur (P = .0006).

CONCLUSIONS

Skin-sparing mastectomy and immediate reconstruction has a low local recurrence rate. Recurrences occur most commonly in the same quadrant as the primary tumor and treatment approaches include surgery, chemotherapy, and radiation therapy. Local recurrence portends a poorer overall survival.

Surveillance Mammography following the Treatment of Primary Breast Cancer with Breast Reconstruction: A Systematic Review

BACKGROUND

Both the prevalence of breast cancer and the number of breast cancer patients seeking breast reconstruction are increasing, highlighting the importance for evidence to direct the clinician in the follow-up of these patients. Current practice guidelines recommend surveillance mammography of the contralateral breast in all breast cancer patients, and of the ipsilateral breast in women treated with breast-conserving surgery. However, there are no guidelines specifically addressing the role of surveillance mammography for women who have undergone mastectomy and breast reconstruction.

METHODS

A systematic review was conducted to identify studies specifically addressing the issue of surveillance mammography among women with breast reconstruction following treatment for primary breast cancer.

RESULTS

This systematic review identified eight articles, consisting of case reports and case series, that address the issue of surveillance mammography of the ipsilateral breast in women with breast reconstruction. The articles demonstrated that certain local recurrences are able to be detected by surveillance mammography.

CONCLUSION

This study has demonstrated the paucity of evidence and highlighted the need for further research to evaluate this issue.

Late results of skin-sparing mastectomy followed by immediate breast reconstruction

Background

Skin-sparing mastectomy (SSM) facilitates optimal immediate breast reconstruction (IBR) by preserving the inframammary fold and most of the breast skin. Concerns persist that SSM might increase the rate of local recurrence as the surgical approach is less extensive. Patients who had SSM and IBR over 10 years at a single institution were reviewed.

Methods

A total of 207 consecutive women who underwent SSM and IBR from 1992 to 2001 were included in the study. The patient records were analysed retrospectively and follow-up data were included.

Results

Postoperative complications included native skin flap necrosis (10·1 per cent), haematoma (10·6 per cent), infection (3·4 per cent), anastomotic thrombosis (5·3 per cent) and hernia (2·6 per cent). During a mean follow-up of 70 months, 5·8 per cent of patients with stage 0–2 disease developed a locoregional recurrence, although none of these later had a systemic recurrence. The rate of locoregional recurrence was 31 per cent (five of 16) in women with stage 3 breast cancer.

Conclusion

SSM followed by IBR was both surgically and oncologically safe, especially for early-stage breast cancer.

The Association between Breast Surgeonsʼ Attitudes toward Breast Reconstruction and Their Reconstruction-Related Information-Giving Behaviors: A Nationwide Survey in Japan

BACKGROUND

Breast reconstruction after breast cancer surgery has come to be regarded as an achievable treatment option to improve patients' quality of life. Although it has been pointed out that surgeons' information-giving behaviors affect women's decision to undergo breast reconstruction surgery, little is known about the factors that influence these behaviors. This study investigated Japanese surgeons' reconstruction-related information giving to patients and the factors that affect these behaviors.

METHODS

A nationwide postal survey of 1313 board-certified Japanese breast surgeons was conducted. In the questionnaire, surgeons were asked about their reconstruction-related information-giving behaviors and their attitudes toward six hypothetical critical statements regarding breast reconstruction.

RESULTS

Among 635 responding surgeons, 199 (31.3 percent) answered that they did not give reconstruction-related information at all when explaining breast cancer treatment options, and 291 (45.8 percent) stated that they selectively choose patients with whom they provide information based on patients' backgrounds such as age and marital status. Results from the multiple logistic regression analysis indicated that respondents who agreed to the statements "Breast reconstruction may delay the detection of local recurrence," "The aesthetic results of reconstructed breasts are not worth the cost and effort involved," "Breast reconstruction is a luxury," and "Surgeons should pursue breast conserving surgery rather than breast reconstruction" showed significantly decreased likelihood to give reconstruction-related information to patients.

CONCLUSION

Surgeons need to be aware of the adverse effect that their own attitudes and values with regard to breast reconstruction may have on a patient's ability to choose treatment options.

Comparison of Local Recurrence and Distant Metastases between Breast Cancer Patients after Postmastectomy Radiotherapy with and without Immediate TRAM Flap Reconstruction

BACKGROUND

The purpose of this study was to compare the local recurrence and distant metastasis of postmastectomy radiotherapy for breast cancer patients with and without immediate transverse rectus abdominis musculocutaneous (TRAM) flap reconstruction.

METHODS

Between March of 1997 and October of 2001, 191 breast cancer patients received postmastectomy radiotherapy: 82 patients had TRAM flap reconstruction (TRAM flap group) and 109 patients did not (non-TRAM flap group). The mean radiation dose to the chest wall or entire TRAM flap, axillary area, and lower neck was 50 Gy (range, 48 to 54 Gy). The median follow-up period was 40 months.

RESULTS

The percentages of chest wall recurrence were 3.7 percent (three of 82) in the TRAM flap group and 1.8 percent (two of 109) in the non-TRAM flap group (p = 0.653). The percentages of distant metastases were 12.2 percent (10 of 82) in the TRAM group and 15.6 percent (17 of 109) for the non-TRAM group (p = 0.67). The percentages of acute radiation dermatitis according to Radiation Therapy Oncology Group scoring criteria (TRAM flap group versus non-TRAM flap group) were as follows: grade I, 74 of 82 (90 percent) versus 93 of 109 (85 percent); grade II, seven of 82 (9 percent) versus 13 of 109 (12 percent); grade III, one of 82 (1 percent) versus three of 109 (3 percent) (p = 0.558). In the TRAM flap group, the increased percentage of fat necrosis was 8 percent. No flap loss was detected.

CONCLUSIONS

There were no significant differences in the incidences of complication, locoregional recurrence, and distant metastasis between the TRAM flap and non-TRAM flap patients. The authors' results suggest that immediate TRAM flap reconstruction can be considered a feasible treatment for breast cancer patients requiring postmastectomy radiotherapy.

Comparisons of Resource Costs and Success Rates between Immediate and Delayed Breast Reconstruction Using DIEP or SIEA Flaps under a Well-Controlled Clinical Trial

BACKGROUND

Every year many patients diagnosed with breast cancer are subjected to mastectomy. Some of them choose to undergo breast reconstruction to restore their body image. Immediate or delayed reconstruction is possible, depending on medical, financial, and emotional considerations. High success rate and cost-effectiveness are two important factors that may guide decision making in the management plan. The objective of this study was to compare the resource costs and success rates of immediate and delayed breast reconstructions using either deep inferior epigastric perforator (DIEP) or superficial inferior epigastric artery (SIEA) flaps. The resource cost is referred to as the cost of operation and hospitalization.

METHODS

From September of 2000 through August of 2001, 42 patients underwent immediate (n = 21) or delayed (n = 21) unilateral breast reconstruction using either a DIEP (n = 30) or SIEA (n = 12) flap by one surgeon.

RESULTS

There were no statistical differences in resource costs, success, and complication rates between DIEP and SIEA flaps in both the immediate and delayed breast reconstruction groups.

CONCLUSIONS

Using either a DIEP or SIEA flap as the autologous tissue, delayed breast reconstruction is as cost-effective as immediate reconstruction.

Issues related to choice of breast reconstruction in early-stage breast cancer

Reconstructive surgeons focus their efforts on refining and developing techniques that optimize oncologic outcome and recreate the most natural breast mound possible. The introduction of perforator flaps offers the potential for faster and more complete recovery, while increasing technical complexity and the risks associated with microsurgical reconstruction. Despite appealing long-lasting results, autologous reconstruction is not the ideal reconstructive choice for every patient. Tissue/expander reconstruction can produce a satisfactory aesthetic outcome and is the reconstruction of choice for most women undergoing breast reconstruction. Immediate autologous reconstruction at the time of mastectomy best resembles the lost breast and favorably withstands radiation, compared with other reconstructive methods. However, the best method for integrating reconstruction and radiation is being actively debated. Placing a tissue expander at the time of mastectomy allows a skin-sparing approach and gives the patient a chance to see how she will feel with an implant. This approach avoids radiation damage to tissue reconstruction flaps, saving them for use later if necessary. This approach, using a tissue expander as a first step, is growing in popularity.

Fat injection to correct contour deformities in the reconstructed breast

BACKGROUND

A ten-year, single-surgeon study of 37 patients from 1993 to 2003 who underwent fat injections to improve contour deformities in their reconstructed breasts was reviewed.

METHODS

Fat was harvested from elsewhere in the body using a low-pressure syringe lipoaspiration system, washed gently with saline, and injected into depressions along the margins of reconstructed breasts. Blinded physician observers judged preoperative and postoperative photographs of breasts injected with fat and categorized the degree of contour improvement as substantial, minimal to moderate, or none. Complications of fat injections were noted. A total of 43 breasts in 37 patients were injected with autologous fat during 47 discrete events; some patients had the procedure repeated and some were treated bilaterally. Of the 43 treated breasts, 25 (58 percent) were reconstructed with implants, 17 (40 percent) were reconstructed with a TRAM (transverse rectus abdominis muscle) flap, and one (2 percent) was reconstructed with a TRAM and an implant.

RESULTS

There were four complications (8.5 percent) in 47 treated breasts: one breast with cellulitis that resolved with antibiotics and three breasts with small, superficial lumps--two of which were biopsied and found to be liponecrotic cysts. Patient follow-up averaged 49 weeks, ranging from 3 weeks to 6 years. There was a substantial contour improvement in ten breasts (21 percent), minimal to moderate improvement in 30 breasts (64 percent), and no improvement in 7 breasts (15 percent).

CONCLUSIONS

Although fat injection in and around the reconstructed breast has limitations, such as fat necrosis and need for repeated injections, our experience indicates that overall it is a very safe technique that can improve or correct significant contour deformities that otherwise would require more complicated, riskier procedures to improve.

Changing patterns in diagnosis and treatment of ductal carcinoma in situ of the breast

BACKGROUND

The increased incidence of ductal carcinoma in situ (DCIS) of the breast and the emergence of new diagnostic and therapeutic tools like mammographic screening, stereotactic core biopsy and reconstructive surgery prompted us to investigate how these developments influenced diagnosis and treatment.

METHODS

Clinical and pathological characteristics of 403 patients with DCIS consecutively treated at The Netherlands Cancer Institute between 1986 and 2002 were evaluated and the effect of introduction of mammographic screening, stereotactic core biopsy and reconstruction on diagnosis and treatment was studied.

RESULTS

Following the nationwide introduction of mammographic screening the number of non-symptomatic DCIS increased from 47 to 77%. Introduction of stereotactic core biopsy resulted in a rise of one-step procedures from 26 to 52%. Mastectomy rate did not change over time: 59% overall. However, reconstruction rate increased from 17 to 39%.

CONCLUSION

This study shows a steep rise in diagnosis of non-symptomatic DCIS after introduction of screening. Further, the introduction of pre-operative diagnosis by stereotactic core biopsy resulted in a decrease of multiple surgical procedures. Mastectomy, with increasing application of breast reconstructions, remains an important treatment modality in the management of DCIS despite advancements in detection and diagnosis.

Immediate Breast Reconstruction can Impact Postmastectomy Irradiation

OBJECTIVE

Immediate breast reconstruction is an attractive option for patients who undergo mastectomy. The purpose of this study was to qualitatively assess the effect of immediate reconstruction on the design of postmastectomy radiotherapy fields at our institution.

METHODS

We retrospectively reviewed the records of 152 patients treated at our institution with postmastectomy radiotherapy over a 1-year period. We identified 18 postmastectomy radiotherapy plans in the setting of prior reconstruction. By consensus, 2 board-certified radiation oncologists scored the 18 plans in terms of 4 outcomes: coverage of the chest wall breadth, coverage of the ipsilateral internal mammary chain (IMC) region, minimization of lung exposure, and avoidance of the heart.

RESULTS

Only 4 of the 18 plans resulted in optimal treatment of the chest wall breadth and IMC region while well avoiding the heart and lung. Of the remaining 14 plans, 12 compromised coverage of the chest wall breadth medially and/or laterally, and 9 provided no IMC coverage.

CONCLUSION

Immediate breast reconstruction may impose limitations on the treatment planning of postmastectomy radiotherapy, particularly in regard to providing broad coverage of the chest wall and IMC region while avoiding excess exposure of the heart and lung.

Comparing the cost of delayed and immediate autologous breast reconstruction in Belgium

This study documents the cost of immediate and delayed DIEP flap breast reconstruction. Immediate reconstruction is more attractive from an economic perspective since it only requires one operation, one anaesthetic procedure and one recovery period in hospital. From the perspective of healthcare budget management, assessing the possible cost savings from immediate reconstruction yields interesting results. Since charges do not reflect the real costs of providing care, we calculated resource costs using the micro-costing method. About 95% of the initial mastectomy costs could be saved when performing an immediate breast reconstruction. This was about 35% of total standard direct and indirect costs due to mastectomy and delayed breast reconstruction. In a growing cost conscious environment of managed care, the economic evaluation should, therefore, encourage the trend towards more immediate reconstructions.

The Use of Calcium Hydroxylapatite for Nipple Projection After Failed Nipple-Areolar Reconstruction

Numerous studies have shown that the final stage in breast reconstruction, creation of the nipple-areolar complex, correlates highly with patient satisfaction and acceptance of body image. There are many different techniques, including nipple sharing, free-composite grafts, and local "pull-out" flaps, all of which are vulnerable to an unpredictable degree of loss of projection and possible need for reoperation. This leads to problems with symmetry and overbuilding the initial reconstruction with wider-based, larger flaps, which may cause breast-contour changes. We have used calcium hydroxylapatite (Radiesse, Bioform Inc., Franksville, WI) following nipple-areolar reconstruction to maintain or restore projection in selected breast-reconstruction patients. Approximately 0.4-1 mL of calcium hydroxylapatite was injected subdermally using a 27-gauge needle in 6 selected patients. All patients tolerated the office procedure well without the need for local anesthesia. We report initial short-term success, with 100% patient satisfaction, minimal loss of projection, and no complications. Semipermanent injectable soft-tissue fillers such as calcium hydroxylapatite may be useful in selected patients as a simple solution to the difficult problem of the lack of nipple projection following reconstruction.

Recurrences after immediate reconstruction in breast cancer

AIM

To determine the incidence of and reasons for recurrences after immediate breast reconstruction in breast cancer patients.

MATERIAL AND METHODS

The data of 79 patients undergoing immediate breast reconstruction between 1998 and 2001 in Kuopio University Hospital were re-examined from both the local cancer register and the patient charts at the end of year 2003.

RESULTS

There were five local recurrences (6.3%), one regional recurrence (1.2%), and three cases (3.8%) presented bone and/or visceral metastases. All recurrences except one (primary tumor noninvasive) appeared within the first two years after primary therapy. Young age and increasing size of the tumour were risk factors for distant or logoregional metastases.

CONCLUSION

Immediate breast reconstruction is a safe procedure in breast cancer patients, but a multidisciplinary team is needed for careful patient selection.

Recurrent Breast Carcinoma Arising in a Transverse Rectus Abdominis Myocutaneous Flap

Reconstruction after mastectomy for breast carcinoma with implants or myocutaneous flaps is a widely used surgical technique. Recurrence of breast carcinoma after these procedures is uncommon. Most recurrences occur in the skin or scar site of the mastectomy and are readily detectable by physical examination. There are rare reported cases of recurrent carcinoma occurring within the flaps that are usually diagnosed with the aid of imaging and subsequent pathologic examination. In most cases, these recurrences represent invasive or in situ ductal carcinoma. We report an additional 2 cases of breast carcinoma recurring within the myocutaneous flap, both of which exhibited uncommon histologic features not previously reported.

Skin-Sparing and Nipple-Sparing Mastectomy: Preoperative, Intraoperative, and Postoperative Considerations

The last several decades have witnessed significant advances in the surgical management of breast cancer. Although many have embraced breast conservation as the procedure of choice, some patients will still opt for mastectomy for a variety of reasons. Recently, the concept of skin sparing mastectomy and immediate breast reconstruction has emerged as an option that provides excellent cosmetic results while being oncologically safe. However, this surgical approach must be considered within a multidisciplinary context, and there are a number of perioperative issues that need to be considered. In addition, newer techniques, which spare the nipple and/or areola, warrant further examination.

Breast reconstruction in private practice

Comprehensive breast reconstruction can be performed in private practice. Our practice philosophy is that autogenous tissue provides the best substrate for breast reconstruction; the deep inferior epigastric perforator flap is our primary method of breast reconstruction. Microsurgical training and a group practice model permit routine use of all autogenous tissue techniques. Office, operating room, and hospital teams must be assembled; these teams follow clinical pathways, which make the execution of reconstructive procedures consistent and efficient. The practice must implement a plan for physician and patient education. The practice must review clinical outcomes, making adjustments in operative techniques and pre- and postoperative clinical pathways so that the best results can be achieved with a low complication rate. Breast reconstruction is a core service of our practice. We have accrued an economy of scale including these features: intraoperative and clinical efficiency, low practice overhead costs, and a high patient satisfaction rate.

Treatment and outcome of patients with chest wall recurrence after mastectomy and breast reconstruction

BACKGROUND

Chest wall recurrence (CWR) in the setting of previous mastectomy and breast reconstruction can pose complex management dilemmas for clinicians. We examined the impact of breast reconstruction on the treatment and outcomes of patients who subsequently developed a CWR.

METHODS

Between 1988 and 1998, 155 breast cancer patients with CWR after mastectomy were evaluated at our center. Of these patients, 27 had previously undergone breast reconstruction (immediate in 20; delayed in 7). Clinicopathologic features, treatment decisions, and outcomes were compared between the patients with and without previous breast reconstruction. Nonparametric statistics were used to analyse the data.

RESULTS

There were no significant differences between the reconstruction and no-reconstruction groups in time to CWR, size of the CWR, number of nodules, ulceration, erythema, and association of CWR with nodal metastases. In patients with previous breast reconstruction, surgical resection of the CWR and repair of the resulting defect tended to be more complex and was more likely to require chest wall reconstruction by the plastic surgery team rather than simple excision or resection with primary closure (26% [7 of 27] versus 8% [10 of 128], P = 0.013). Risk of a second CWR, risk of distant metastases, median overall survival after CWR, and distant-metastasis-free survival after CWR did not differ significantly between patients with and without previous breast reconstruction.

CONCLUSIONS

Breast reconstruction after mastectomy does not influence the clinical presentation or prognosis of women who subsequently develop a CWR. Collaboration with a plastic surgery team may be beneficial in the surgical management of these patients.

Effet radiosensibilisateur de l'acide linoléique conjugué chez les cellules cancéreuses du sein MCF-7 et MDA-MB-231

Apoptotic pathways in breast cancer cells are frequently altered, reducing the efficiency of radiotherapy. Conjugated linoleic acid (CLA), known to trigger apoptosis, was tested as radiosensitizer in breast cancer cells MCF-7 and MDA-MB-231. The CLA-mix, made up of the isomers CLA-9cis 11trans and CLA-10trans 12cis, was compared to three purified isomers, i.e., the CLA-9cis 11cis, CLA-9cis 11trans, and CLA-10trans 12cis. Using the apoptotic marker YO-PRO®-1, the CLA-9cis 11cis at 50 µmol/L turned out to be the best apoptotic inducer leading to a 10-fold increase in MCF-7 cells and a 2,5-fold increase in MDA-MB-231 cells, comparatively to the CLA-mix. Contrary to previous studies on colorectal and prostate cancer cells, CLA-10trans 12cis does not lead to an apoptotic response on breast cancer cell lines MCF-7 and MDA-MB-231. Our results also suggest that the main components of the CLA-mix (CLA-9cis 11trans and CLA-10trans 12cis) are not involved in the induction of apoptosis in the breast cancer cells studied. A dose of 5 Gy did not induce apoptosis in MCF-7 and MDA-MB-231 cells. The addition of CLA-9cis 11cis or CLA-mix has allowed us to observe a radiation-induced apoptosis, with the CLA-9cis 11cis being about 8-fold better than the CLA-mix. CLA-9cis 11cis turned out to be the best radiosensitizer, although the isomers CLA-9cis 11trans and CLA-10trans 12cis have also reduced the cell survival following irradiation, but using a mechanism not related to apoptosis. In conclusion, the radiosensitizing property of CLA-9cis 11cis supports its potential as an agent to improve radiotherapy against breast carcinoma.Key words: breast cancer, conjugated linoleic acid (CLA), radiotherapy, apoptosis.