Radiotherapy and nipple-areolar complex necrosis after nipple-sparing mastectomy: a systematic review and meta-analysis

Breast Cancer Patient Flap Management After Mastectomy: A Best Practice Implementation Project

BACKGROUND

Breast cancer is a prevalent malignancy in women, with mastectomy as the main surgery. Common postmastectomy complications are seroma (15%-81%), infections (2.9%-3.8%), and flap necrosis (10%-18%), severely impacting quality of life and costs. However, there's a lack of standardized flap care protocols and limited staff knowledge.

OBJECTIVES

This study aims to apply best evidence for flap management post-mastectomy to standardize practices, reduce complications, and enhance patient's quality of life.

METHODS

This project followed JBI PACES and GRiP principles, implementing evidence-based practices in a Chinese tertiary hospital between January and May 2023. It entailed evidence identification, integration into clinical context, protocol development, baseline audits, barrier/enabler analysis. The study compared pre- and post-evidence implementation rates of flap complications, healthcare staff's knowledge/skill scores on mastectomy flap management, and audit indicator adherence by both staff and patients.

RESULTS

After evidence application, flap ischemia/necrosis rates dropped from 8.57% to 5.56% (P < .001), wound infection rates after surgery reduced from 5.71% to 2.78% (P < .001), and seroma rates decreased from 17.14% to 2.78% (P < .001). Healthcare staff's knowledge and skill scores for flap management following mastectomy increased from 50.67 ±18.32 preimplementation to 98.33 ± 4.01 (t = -13.90, P < .001). Audit criterion compliance rates increased from 8.57% to 94.29% to between 91.67% and 100%, with statistically significant differences in all 15 criteria (P < .001).

CONCLUSIONS

Evidence-based management of flaps after mastectomy improves healthcare staff's knowledge and skills, enhances nursing quality, effectively reduces flap complications in patients, and boosts their quality of life.

Positive Nipple Margins in Nipple-Sparing Mastectomy: Management of Nipples Containing Cancer or Atypia

BACKGROUND

Nipple-sparing mastectomy (NSM) is an oncologically safe approach for breast cancer treatment and prevention; however, there are little long-term data to guide management for patients whose nipple margins contain tumor or atypia.

METHODS

NSM patients with tumor or atypia in their nipple margin were identified from a prospectively maintained, single-institution database of consecutive NSMs. Patient and tumor characteristics, treatment, recurrence, and survival data were assessed.

RESULTS

A total of 3158 NSMs were performed from June 2007 to August 2019. Nipple margins contained tumor in 117 (3.7%) NSMs and atypia only in 164 (5.2%) NSMs. Among 117 nipple margins that contained tumor, 34 (29%) margins contained invasive cancer, 80 (68%) contained ductal carcinoma in situ only, and 3 (3%) contained lymphatic vessel invasion only. Management included nipple-only excision in 67 (57%) breasts, nipple-areola complex excision in 35 (30%) breasts, and no excision in 15 (13%) breasts. Only 23 (24%) excised nipples contained residual tumor. At 67 months median follow-up, there were 2 (1.8%) recurrences in areolar or peri-areolar skin, both in patients with nipple-only excision. Among 164 nipple margins containing only atypia, 154 (94%) nipples were retained. At 60 months median follow-up, no patient with atypia alone had a nipple or areola recurrence.

CONCLUSIONS

Nipple excision is effective management for nipple margins containing tumor. No intervention is required for nipple margins containing only atypia. Our results support broad eligibility for NSM with careful nipple margin assessment.

Prepectoral Breast Reconstruction with Prosthesis and Acellular Dermal Matrix: A New Technique of ADM Implantation and Fixation

Background

Direct-to-implant (DTI) immediate breast reconstruction has proven to be an oncologically safe technique and linked to better overall results. The introduction of new surgical techniques has prompted us to develop an acellular dermal matrix fixation technique that reduces the rate of complications and implant loss.

Methods

We retrospectively analyzed data from patients who underwent DTI prepectoral breast reconstruction with two different techniques of acellular dermal matrix fixation to the chest wall. Descriptive statistics were reported using frequencies and percentages for categorical variables, and means and SDs for continuous variables. Pearson chi-square test was used to compare differences in categorical variables. Univariable and multivariable logistic regression models were fitted to investigate the predictors of complications.

Results

From October 2019 to March 2023, 90 DTI breast reconstructions were performed, 43 using the standard technique and 47 using the new technique. The new technique demonstrated a significant reduction of major complications (P = 0.010), namely seroma (13.9% versus 2.3%), skin necrosis (9.3% versus 2.3%), implant loss (7% versus 0%), wound dehiscence (9.3% versus 0%), and infection (4.7% versus 0%). Compared with the standard technique, the new one reduced the risk of complications by 76% (OR 0.24; 95% confidence interval 0.09-0.68; P = 0.007) and 73% (aOR 0.27; 95% confidence interval 0.08-0.92; P = 0.037), at univariable and multivariable regression models. No other significant predictor of complications was identified.

Conclusions

The procedure performed with the proposed modality proved to be advantageous. Careful fixation of the prosthetic implant and the placement of two drains, were the keys to a drastic reduction in complications.

"Toward Breast Reinnervation- What is our Endpoint" A systematic review of normal breast sensibility

BACKGROUND

To restore breast sensibility, some centers are offering nerve reconstruction as a component of implant and flap-based breast reconstruction. To interpret and contextualize the results of these procedures, it is necessary to understand the normal range of breast sensibility, the factors that affect it, and the best methods for its objective measurement.

METHODS

We conducted systematic and comprehensive searches across PubMed, Web of Science, and Cochrane Library databases using keywords and controlled vocabulary for the concepts of the breast, nipple, areola, and measurement. The search results were imported into Rayyan QCRI for a blinded screening of titles and abstracts. Studies were evaluated for bias using RevMan 5 software. The results of sensory measurements were pooled, and a quantitative summary of breast sensibility was generated.

RESULTS

A total of 36 articles were identified, including retrospective, cross-sectional, and prospective studies. Although there were some consistent findings across studies, such that breast sensibility is inversely related to breast volume, there was wide variability in the following parameters: population, breast condition, measurement modality, anatomic areas of measurement, and sensibility findings. This heterogeneity precluded the generation of normative breast sensibility measurements. Furthermore, we detected a high degree of bias in most studies, due to self-selection of participants and failure to record patient characteristics that may alter sensibility.

CONCLUSIONS

The literature lacks consistent data delineating normative values for breast sensibility. Standardized measurements of healthy volunteers with various breast characteristics are necessary to elucidate normative values and interpret efforts to restore sensibility in breast reconstruction.

Nipple-Sparing Mastectomy With Immediate Reconstruction After Breast-Conserving Therapy and Radiation: Complications and Oncologic Safety

INTRODUCTION

Nipple-sparing mastectomy (NSM) offers improved, patient-centered outcomes with demonstrated oncologic safety ( Ann Surg Oncol 2020;27:344-351). Indications for NSM continue to expand to patients outside of the traditional eligibility criteria, including those with prior breast-conserving therapy (BCT) with radiotherapy. Currently, limited data exist evaluating both short- and long-term outcomes in patients proceeding to NSM after prior BCT.

METHODS

All patients undergoing bilateral NSM in a single institution from 2002 through 2017 with history of prior BCT were included in the final cohort, without exclusions. A retrospective chart review was performed to identify patient demographics, operative details, and complications. Outcomes assessed included early complications (<30 days from NSM), late complications (>30 days), rates of prosthetic failure, unplanned reoperations, and reconstructive failures, as well as oncologic safety. Student t , χ 2 , and Fisher exact tests were used to analyze outcomes of paired (BCT vs non-BCT) breasts within each patient.

RESULTS

A total of 17 patients undergoing 34 NSMs were included. Each had a history of BCT and either ipsilateral breast recurrence (64.7%), risk-reducing NSM (23.5%), or a new contralateral primary cancer (11.8%). The cohort had a mean age of 51.1 years. With regard to acute complications (ischemia, infection, nipple-areolar complex or flap ischemia or necrosis, and wound dehiscence), there was no significant difference noted between breasts with prior BCT versus no prior BCT overall (41.2% vs 35.3%, respectively; P = 0.724). Complications occurring after 30 days postoperatively (capsular contracture, contour abnormality, animation deformity, bottoming out, rotation, and rippling) in prior BCT breasts versus no prior BCT had no significant differences overall (58.8% vs 41.2% respectively; P = 0.303). The mean follow-up was 5.5 years, during which no patients had a reported locoregional or distant recurrence in either breast.

CONCLUSIONS

No significant differences in early or late complications were identified between breasts in patients undergoing bilateral NSM with a history of unilateral BCT and XRT. In the 5.5 years of follow-up, there were no recurrences, lending support to NSM for management of recurrent disease in addition to National Comprehensive Cancer Network-recommended total mastectomy. We propose that NSM should not be contraindicated in patients exposed to radiation with BCT.

Short-term outcomes and safety of radiotherapy for immediate breast reconstruction with autologous flap transfer following breast-conserving surgery

BACKGROUND

The outcomes of immediate autologous breast reconstruction (IABR) after partial mastectomy followed by postoperative radiotherapy (RT) in terms of aesthetics, treatment-related complications, and local control are unclear. In this study, we evaluated the efficacy of IABR after partial mastectomy with or without breast RT, and thus the impact of radiation on autologous flap transfer.

METHOD

A retrospective cohort study involving consecutive breast cancer patients who underwent IABR after partial mastectomy between July 2011 and December 2017 at Shengjing Hospital was performed. Patients were divided into two groups based on whether or not they received RT after IABR. We compared aesthetic outcomes and changes in the flap size over the three-dimensional coordinates at various timepoints (pre-RT, 1, 6, and 12 months post-RT), as well as postoperative complications, survival, and recurrence rates between the two groups.

RESULTS

In total, 84 breast cancer patients were enrolled, with 32 patients in the RT group and 52 in the non-RT group. At a median follow-up time of 33.3 months, no significant difference was found in the rate of regional recurrence between the two groups (3.13% vs. 3.85%, P = 1.00), and no local recurrences occurred in either group. At the timepoints pre-RT, 1, and 6 months post-RT (approximately 4, 7, and 12 months after IABR, respectively), 77 (91.7%), 70 (83.3%), and 83 (98.8%) patients, respectively, had achieved very good or good cosmetic outcomes, and only changes in breast skin color at 1 month after RT significantly differed between the RT and non-RT groups, with very good or good cosmetic result rates of 62.5% vs. 96.2%, respectively (P < 0.001). No significant difference in the reduction of flap size was observed at any timepoint between the two groups. There were no significant differences between the two groups in the rates of postoperative complications including necrosis of the flap, infection, hematoma, or seroma (all P > 0.05). Additionally, no grade 3 or greater RT-associated adverse events occurred during or after RT.

CONCLUSION

RT following IABR provides aesthetically satisfactory results without intolerable adverse complications and may safely be performed in patients who underwent IABR after partial mastectomy.

Intraoperative central nipple biopsy in nipple-sparing mastectomy- A retrospective analysis of 211 patients

Subcutaneous nipple sparing mastectomies (NSM) are an important tool in modern oncoplastic surgery. Especially when an immediate implant-based reconstruction (IBR) is desired, clean margins are of the utmost importance. Central nipple biopsies during surgery serve two main purposes. Most importantly, it is hypothesized that intraoperative pathological evaluation of this biopsy may increase clean margin resection rates. In addition, a general recurrence risk reduction may occur due to the elimination of glandular and ductal components within the nipple. This analysis is a single center, multi-surgeon, retrospective, head to head analysis. Starting in March 2015, intraoperative central nipple biopsy in NSMs with IBR was introduced at the Municipal Breast Cancer Centre Cologne, Holweide, Germany. This trial retrospectively evaluates global complication rates, clean margin status and local recurrence rates for cohort 1 (NSM/no nipple biopsy, n = 103) vs. cohort 2 (NSM with nipple biopsy, n = 108) Median follow-up was 15 months. All implant-based reconstruction procedures used an epipectoral implant pocket. Cohorts were comparable. Global complication rates slightly favored the nipple biopsy cohort with respects to implant loss rate. An involved central nipple biopsy was found in 4.6% (n = 5/108) of the performed NSM procedures leading to the immediate removal of the nipple areola complex. All positive retro-areolar biopsies correlated with a positive nipple biopsy. However, in n = 1 case we found DCIS discontinual proliferation with an involved nipple biopsy, without a correlating positive retro-areolar biopsy (ie, 1 false-negative case was prevented). For the 15 month follow-up, there was no case of local recurrence within nipple areola complex for both cohorts. With this retrospective head to head analysis of 211 patients, it was shown that the central nipple biopsy correlates well with the retro-areolar biopsy. There may be a reduction in false negative rates. The procedure is safe to use and should be offered to NSM patients.

Long-Term Outcomes of Immediate Autologous Breast Reconstruction for Breast Cancer Patients

BACKGROUND

There is limited information on the oncological outcomes of immediate autologous breast reconstruction in the Asian population. This study aimed to evaluate the oncological outcomes of immediate one-stage autologous breast reconstruction using a free perforator flap for breast cancer patients at a single institution in Japan.

METHODS

We retrospectively reviewed 239 patients who underwent immediate one-stage autologous breast reconstruction using a free perforator flap after skin- or nipple-sparing mastectomy. The whole breast was pathologically analyzed in 5-mm sections. Clinical and pathological data were collected from medical records.

RESULTS

For tumor stage among the 239 patients, 101 (42.3%) had stage 0, 127 (53.1%) had stage I and II, and 11 (4.6%) had stage III. Twenty-three patients (9.6%) had margin involvement in the surgical specimen. Adjuvant chemotherapy was performed in 75 patients (30%), and endocrine therapy was administered in 153 patients (64%). Radiation therapy was performed in 15 patients (6.3%) because of multiple lymph node metastases or margin involvement. With a median follow-up time of 73 mo, local recurrence was found in 3.3%, distant metastases in 2.5%, and contralateral breast cancer in 3.7%. All patients with local recurrence did not receive radiation therapy as adjuvant treatment.

CONCLUSIONS

Among the patients who underwent immediate one-stage autologous reconstruction after breast surgery, 3.3% had local recurrence. For patients with margin involvement, radiation therapy is a promising option.

Preoperative loco-regional staging of invasive lobular carcinoma with contrast-enhanced digital mammography (CEDM)

The aim of our study was to assess the performance of contrast-enhanced digital mammography (CEDM) in the preoperative loco-regional staging of invasive lobular carcinoma (ILC) patients, about the valuation of the extension of disease and in measurement of lesions. Then, we selected retrospectively, among the 1500 patients underwent to CEDM at the Breast Diagnostics Department of the Careggi University Hospital of Florence and the National Cancer Institute of Milan from September 2016 to November 2018, 31 women (mean age 57.1 aa; range 41-78 aa) with a definitive histological diagnosis of ILC. CEDM has proved to be a promising imaging technique, being characterized by a sensitivity of 100% in the detection of the index lesion, and of 84.2% in identifying any adjunctive lesions: It was the presence of a non-mass enhancement (NME) to lower the sensitivity of the technique (25% vs. 100% for mass-like enhancements or a mass closely associated with a NME). Specificity in the characterization of additional lesions was 66.7%, and the diagnosis of the extension of disease was correct in 77.4% of cases: NME also led to a decrease in diagnostic accuracy in the evaluation of disease extension up to 40% versus 85% for masses and 80% for masses associated with NME (M/NME). Moreover, in 12/31 (38.7%), CEDM allowed to correctly identify lesions not shown by mammography + ultrasonography + tomosynthesis: In the half of these (6/12), there was a multicentricity, thus allowing an adequate surgical planning change. CEDM was also very accurate in analyzing the maximum diameter of the masses, while it was much less reliable in the case of the M/NME and pure NME. In conclusion, CEDM is a new promising imaging technique in the loco-regional preoperative staging and in the evaluation of disease extension for ILC, especially in case of mass enhancement lesions.

International multidisciplinary expert panel consensus on breast reconstruction and radiotherapy

BACKGROUND

Conflicting evidence challenges clinical decision-making when breast reconstruction is considered in the context of radiotherapy. Current literature was evaluated and key statements on topical issues were generated and discussed by an expert panel at the International Oncoplastic Breast Surgery Meeting in Milan 2017.

METHODS

Studies on radiotherapy and breast reconstruction (1985 to September 2017) were screened using MEDLINE, Embase and CENTRAL. The literature review yielded 30 controversial key questions. A set of key statements was derived and the highest levels of clinical evidence (LoE) for each of these were summarized. Nineteen panellists convened for dedicated discussions at the International Oncoplastic Breast Surgery Meeting to express agreement, disagreement or abstention for the generated key statements.

RESULTS

The literature review identified 1522 peer-reviewed publications. A list of 22 key statements was produced, with the highest LoE recorded for each statement. These ranged from II to IV, with most statements (11 of 22, 50 per cent) supported by LoE III. There was full consensus for nine (41 per cent) of the 22 key statements, and more than 75 per cent agreement was reached for half (11 of 22).

CONCLUSION

Poor evidence exists on which to base patient-informed consent. Low-quality studies are conflicting with wide-ranging treatment options, precluding expert consensus regarding optimal type and timing of breast reconstruction in the context of radiotherapy. There is a need for high-quality evidence from prospective registries and randomized trials in this field.

Nipple sparing mastectomy and the evolving direct to implant breast reconstruction

In this paper, we describe the evolving use of the nipple-sparing mastectomy (NSM) and direct to implant breast reconstruction according to existing literature and our own experience. The surgical method enables superior aesthetic results resembling that of a natural breast while maintaining oncologic safety. Acellular dermal matrix enables direct to implant breast reconstruction by serving as a hammock and can be used with acceptable rates of complications. A successful nipple-sparing mastectomy and direct to implant breast reconstruction approach with acceptable postoperative complication rates relies upon quality of the mastectomy skin flaps and correct patient selection. The surgical method has developed with a rapid pace and expected to evolve further in terms of technical modalities, safety measure and lasting results.