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Tellarini A, Bascialla E, Paganini F, Fasoli V, Buttarelli F, Marra EP, Tamborini F, Corno M, Di Giovanna D, Baraziol R, Flocchini M, Curic LM, Tuttolomondo A, Calabrese S, Valdatta L. Breast reconstruction with TiLOOP® Bra: Another arrow in plastic surgeons' quiver? J Plast Reconstr Aesthet Surg 2024; 97:89-114. [PMID: 39151289 DOI: 10.1016/j.bjps.2024.07.060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Revised: 06/25/2024] [Accepted: 07/22/2024] [Indexed: 08/19/2024]
Abstract
BACKGROUND The use of lower-pole sling products has made immediate breast reconstruction a feasible option in women undergoing skin-nipple sparing and skin-reducing mastectomies. To date, available data on the comparative efficacy of biological and synthetic meshes regarding postoperative complications are scattered and limited. METHODS A systematic literature search was performed to screen three different databases (PubMed, Web of Sciences, and Embase) using the following keywords: "breast reconstruction" AND "TiLOOP®" OR "Titanium-Coated Polypropylene Mesh" OR "TCPM". The perioperative and demographic characteristics of patients, complications profiles, and patient-reported outcomes were considered. RESULTS We initially identified 234 articles, of which only 41, including 3923 patients and 5042 reconstructed breasts, fully satisfied the inclusion criteria. CONCLUSION TiLOOP® Bra could be considered a safe and aesthetically valid alternative to Acellular Dermal Matrices (ADMs) in non-smokers patients undergoing skin-nipple sparing and skin-reducing mastectomies and immediate reconstruction. In such populations, complications are more likely to develop in patients with extreme body mass index values. The incidence of seroma with TiLOOP® Bra is comparable to that of ADMs as it is the beneficial effect in radiated patients, where TiLOOP® Bra seems superior to implant alone reconstruction. It has a good bio-integration with host tissues and resistance to infections in patients with a weakened immune system as a consequence of oncologic perioperative treatments.
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Affiliation(s)
- Annachiara Tellarini
- Division of Plastic and Reconstructive Surgery, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy.
| | - Elisa Bascialla
- Division of Plastic and Reconstructive Surgery, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
| | - Ferruccio Paganini
- Division of Plastic and Reconstructive Surgery, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
| | - Veronica Fasoli
- Division of Plastic and Reconstructive Surgery, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
| | - Francesco Buttarelli
- Division of Plastic and Reconstructive Surgery, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
| | - Eduardo Paolo Marra
- Division of Plastic and Reconstructive Surgery, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
| | - Federico Tamborini
- Division of Plastic and Reconstructive Surgery, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy; Microsurgery and Hand Surgery Unit, ASST Settelaghi Varese, Varese, Italy
| | - Martina Corno
- Division of Plastic and Reconstructive Surgery, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
| | - Danilo Di Giovanna
- Division of Plastic and Reconstructive Surgery, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
| | - Roberto Baraziol
- Department of Plastic Surgery, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Maria Flocchini
- Department of Plastic Surgery, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Laura Maria Curic
- Department of Plastic Surgery, ASST Spedali Civili di Brescia, Brescia, Italy
| | | | - Sarah Calabrese
- Department of Plastic Surgery, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Luigi Valdatta
- Division of Plastic and Reconstructive Surgery, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
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Hu Y, Diao W, Wen S, Kpegah JKSK, Xiao Z, Zhou X, Zhou J, Li P. The Usage of Mesh and Relevant Prognosis in Implant Breast Reconstruction Surgery: A Meta-analysis. Aesthetic Plast Surg 2024:10.1007/s00266-024-03879-5. [PMID: 38438762 DOI: 10.1007/s00266-024-03879-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 01/25/2024] [Indexed: 03/06/2024]
Abstract
BACKGROUND Although mesh-based implant breast reconstruction surgery is emerging as the primary surgical procedure for breast reconstruction, mesh use remains controversial in implant breast reconstruction surgery, especially in terms of how to select the ideal mesh. Our aim is to elaborate relevant prognosis in the mesh-based implant breast reconstruction surgery. METHODS Relevant studies were identified from PubMed, Web of Science, EMBASE, and Cochrane library searches. Extracted data included study type, basic characteristics, mesh information, complications, etc. We analyzed the included cohort studies and randomized controlled trials that reported mesh-related implant breast reconstruction complications and breast quality scale scores. RESULTS A total of 32 studies including 7475 subjects were included. The results showed that the overall complication rate was 2.07 times higher in the biological mesh group than in the synthetic mesh group (risk ratio [RR]: 2.07, 95% CI 1.14-3.78). The risk of seroma was 4.50 times higher in the biological mesh group than in the synthetic mesh group (RR: 4.50, 95% CI 2.27-8.95). In terms of comparing breast quality scale scores, the mesh group had scores that were 1.49 (95% CI 0.19-2.78) higher than the non-mesh group for "physical well-being" and 2.05 (95% CI 0.08-4.02) higher for "sexual well-being." CONCLUSIONS Our study found that the risk of total complications was higher with biological mesh than with synthetic mesh in implant breast reconstruction surgery. Based on short-term cost, healthcare burden, and healthcare benefits, synthetic meshes are superior to biological meshes. LEVEL OF EVIDENCE III This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
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Affiliation(s)
- Yang Hu
- Department of Plastic Surgery of Third Xiangya Hospital, Central South University, 138 Tongzipo Road, Changsha, 410013, Hunan, China
| | - Wuliang Diao
- Department of Plastic Surgery of Third Xiangya Hospital, Central South University, 138 Tongzipo Road, Changsha, 410013, Hunan, China
| | - Shiyi Wen
- Department of Plastic Surgery of Third Xiangya Hospital, Central South University, 138 Tongzipo Road, Changsha, 410013, Hunan, China
| | - Julius K S K Kpegah
- Department of Plastic Surgery of Third Xiangya Hospital, Central South University, 138 Tongzipo Road, Changsha, 410013, Hunan, China
| | - Zhenyang Xiao
- Department of Plastic Surgery of Third Xiangya Hospital, Central South University, 138 Tongzipo Road, Changsha, 410013, Hunan, China
| | - Xuan Zhou
- Center for Medical Research, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Jianda Zhou
- Department of Plastic Surgery of Third Xiangya Hospital, Central South University, 138 Tongzipo Road, Changsha, 410013, Hunan, China.
| | - Ping Li
- Department of Plastic Surgery of Third Xiangya Hospital, Central South University, 138 Tongzipo Road, Changsha, 410013, Hunan, China.
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Mathew J. Direct to implant reconstruction with adjustable permanent Becker implant expanders with ADM following de-epithelised skin reducing mastectomy in high-risk overweight and obese patients with severe ptosis. Surgeon 2023; 21:54-59. [PMID: 35248477 DOI: 10.1016/j.surge.2022.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 02/03/2022] [Accepted: 02/08/2022] [Indexed: 02/01/2023]
Abstract
Overweight and obese patients with severe ptosis undergoing mastectomy and reconstruction present a challenge to the oncoplastic breast surgeon. This paper investigates early-to medium-term outcome of high-risk overweight and obese women with severe ptosis undergoing de-epithelised skin reducing mastectomy and direct to implant reconstruction with Becker implant expanders. From Nov 2016 and April 2021, 20 Wise pattern skin reducing mastectomies (SRM) were performed, 18 with Adjustable Permanent Becker Implant expanders (APBI) and 2 with fixed volume implants. Median age was 48 years (27-73), and median FU was 21 months (4-49). There were 8 smokers and 7 patients needed radiation treatment. In the ABPI group, there was one infection, 3 patients had threatened wounds which needed revision, and one patient lost her implant. There was no locoregional recurrence or distant metastasis. There was 1 week delay in adjuvant chemotherapy for a patient with wound issues following reconstruction. One patient is awaiting autologous reconstruction following deformity subsequent to radiation treatment. In conclusion the use of APBI following de-epithelised skin reduction surgery in this high-risk group is an option with acceptable early-to medium-term outcome.
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Affiliation(s)
- John Mathew
- Peterborough City Hospital, North West Anglia NHS foundation trust, Edith Cavell Campus, Bretton Gate, Peterborough, PE3 9GZ, UK.
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Morgan JL, Cheng V, Barry PA, Copson E, Cutress RI, Dave R, Elsberger B, Fairbrother P, Hartup S, Hogan B, Horgan K, Kirwan CC, McIntosh SA, O'Connell RL, Patani N, Potter S, Rattay T, Sheehan L, Wyld L, Kim B. The MARECA (national study of management of breast cancer locoregional recurrence and oncological outcomes) study: National practice questionnaire of United Kingdom multi-disciplinary decision making. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2022; 48:1510-1519. [PMID: 35410760 DOI: 10.1016/j.ejso.2022.03.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 03/05/2022] [Accepted: 03/22/2022] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Evidence based guidelines for the optimal management of breast cancer locoregional recurrence (LRR) are limited, with potential for variation in clinical practice. This national practice questionnaire (NPQ) was designed to establish the current practice of UK breast multidisciplinary teams (MDTs) regarding LRR management. METHODS UK breast units were invited to take part in the MARECA study MDT NPQ. Scenario-based questions were used to elicit preference in pre-operative staging investigations, surgical management, and adjuvant therapy. RESULTS 822 MDT members across 42 breast units (out of 144; 29%) participated in the NPQ (February-August 2021). Most units (95%) routinely performed staging CT scan, but bone scan was selectively performed (31%). For patients previously treated with breast conserving surgery (BCS) and radiotherapy, few units (7%) always/usually offered repeat BCS. However, in the absence of radiotherapy, most units (90%) always/usually offered repeat BCS. For patients presenting with isolated local recurrence following previous BCS and SLNB (sentinel lymph node biopsy), most units (95%) advocated repeat SLNB. Where SLNs could not be identified, 86% proceeded to a four-node axillary sampling procedure. For ER positive, HER2 negative, node negative local recurrence, 10% of units always/usually offered chemotherapy. For ER positive, HER2 negative, node positive local recurrence, this recommendation increased to 64%. For triple negative breast cancer local recurrence, 90% of units always/usually offered chemotherapy. CONCLUSION This survey has highlighted where consistencies and variations exist in the multidisciplinary management of breast cancer LRR. However, further research is required to determine how these management patterns influence patient outcomes, which will further refine optimal treatment pathways.
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Affiliation(s)
- Jenna L Morgan
- Department of Oncology and Metabolism, University of Sheffield Medical School, Beech Hill Road, Sheffield, S10 2RX, UK.
| | - Vinton Cheng
- The Breast Unit at the Leeds Cancer Centre, St James's University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, LS9 7TF, UK
| | - Peter A Barry
- Department of Breast Surgery, The Royal Marsden NHS Foundation Trust, Downs Road, Sutton, Surrey, SM2 5PT, UK
| | - Ellen Copson
- Cancer Sciences Academic Unit, University of Southampton and University Hospital Southampton, Tremona Road, Southampton, SO16 6YD, UK
| | - Ramsey I Cutress
- Cancer Sciences Academic Unit, University of Southampton and University Hospital Southampton, Tremona Road, Southampton, SO16 6YD, UK
| | - Rajiv Dave
- The Nightingale Breast Cancer Centre, Wythenshawe Hospital, Manchester, M23 9LT, UK
| | - Beatrix Elsberger
- Aberdeen Breast Unit, Aberdeen Royal Infirmary, Foresterhill, Aberdeen, AB25 2ZN, UK
| | | | - Sue Hartup
- The Breast Unit at the Leeds Cancer Centre, St James's University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, LS9 7TF, UK
| | - Brian Hogan
- The Breast Unit at the Leeds Cancer Centre, St James's University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, LS9 7TF, UK
| | - Kieran Horgan
- The Breast Unit at the Leeds Cancer Centre, St James's University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, LS9 7TF, UK
| | - Cliona C Kirwan
- The Nightingale Breast Cancer Centre, Wythenshawe Hospital, Manchester, M23 9LT, UK; Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Oglesby Cancer Research Building, Manchester Cancer Research Centre, Wilmslow Road, Manchester, M20 4BX, UK
| | - Stuart A McIntosh
- Patrick G Johnston Centre for Cancer Research, Queen's University Belfast, 97 Lisburn Road, Belfast, BT9 7AE, UK
| | - Rachel L O'Connell
- Department of Breast Surgery, The Royal Marsden NHS Foundation Trust, Downs Road, Sutton, Surrey, SM2 5PT, UK
| | - Neill Patani
- Department of Breast Surgery, University College London Hospitals NHS Foundation Trust, London, NW1 2BU, UK
| | - Shelley Potter
- Translational Health Sciences, Bristol Medical School, Canynge Hall, Whatley Road, Bristol, BS8 2PS, UK
| | - Tim Rattay
- Leicester Cancer Research Centre, Clinical Sciences Building, University of Leicester, Leicester Royal Infirmary, Leicester, LE2 2LX, UK
| | - Lisa Sheehan
- Wessex Deanery, Southern House, Otterbourne, Winchester, SO21 2RU, UK
| | - Lynda Wyld
- Department of Oncology and Metabolism, University of Sheffield Medical School, Beech Hill Road, Sheffield, S10 2RX, UK
| | - Baek Kim
- The Breast Unit at the Leeds Cancer Centre, St James's University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, LS9 7TF, UK
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Harvey KL, Sinai P, Mills N, White P, Holcombe C, Potter S. Short-term safety outcomes of mastectomy and immediate prepectoral implant-based breast reconstruction: Pre-BRA prospective multicentre cohort study. Br J Surg 2022; 109:530-538. [PMID: 35576373 PMCID: PMC10364707 DOI: 10.1093/bjs/znac077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 01/18/2022] [Accepted: 02/22/2022] [Indexed: 11/14/2022]
Abstract
BACKGROUND Prepectoral breast reconstruction (PPBR) has recently been introduced to reduce postoperative pain and improve cosmetic outcomes in women having implant-based procedures. High-quality evidence to support the practice of PPBR, however, is lacking. Pre-BRA is an IDEAL stage 2a/2b study that aimed to establish the safety, effectiveness, and stability of PPBR before definitive evaluation in an RCT. The short-term safety endpoints at 3 months after surgery are reported here. METHODS Consecutive patients electing to undergo immediate PPBR at participating UK centres between July 2019 and December 2020 were invited to participate. Demographic, operative, oncology, and complication data were collected. The primary outcome was implant loss at 3 months. Other outcomes of interest included readmission, reoperation, and infection. RESULTS Some 347 women underwent 424 immediate implant-based reconstructions at 40 centres. Most were single-stage direct-to-implant (357, 84.2 per cent) biological mesh-assisted (341, 80.4 per cent) procedures. Conversion to subpectoral reconstruction was necessary in four patients (0.9 per cent) owing to poor skin-flap quality. Of the 343 women who underwent PPBR, 144 (42.0 per cent) experienced at least one postoperative complication. Implant loss occurred in 28 women (8.2 per cent), 67 (19.5 per cent) experienced an infection, 60 (17.5 per cent) were readmitted for a complication, and 55 (16.0 per cent) required reoperation within 3 months of reconstruction. CONCLUSION Complication rates following PPBR are high and implant loss is comparable to that associated with subpectoral mesh-assisted implant-based techniques. These findings support the need for a well-designed RCT comparing prepectoral and subpectoral reconstruction to establish best practice for implant-based breast reconstruction.
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Affiliation(s)
- Kate L Harvey
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK
| | - Parisa Sinai
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK
| | - Nicola Mills
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK
| | - Paul White
- Applied Statistics Group, University of the West of England, Bristol, UK
| | | | - Shelley Potter
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK
- Bristol Breast Care Centre, North Bristol NHS Trust, Bristol, UK
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Houvenaeghel G, Cohen M, Sabiani L, Van Troy A, Quilichini O, Charavil A, Buttarelli M, Rua S, Tallet A, de Nonneville A, Bannier M. Mastectomy and Immediate Breast Reconstruction with Pre-Pectoral or Sub-Pectoral Implant: Assessing Clinical Practice, Post-Surgical Outcomes, Patient's Satisfaction and Cost. JOURNAL OF SURGERY AND RESEARCH 2022; 5:500-510. [PMID: 36578374 PMCID: PMC9793874 DOI: 10.26502/jsr.10020250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Immediate breast reconstruction (IBR) rates increase during last years and implant-based reconstruction was the most commonly performed procedure. We examined data collected over 25 months to assess complication rate, duration of surgery, patient's satisfaction and cost, according to pre-pectoral or sub-pectoral implant-IBR. All patients who received an implant-IBR, from January 2020 to January 2022, were included. Results were compared between pre-pectoral and sub-pectoral implant-IBR in univariate and multivariate analysis. We performed 316 implant-IBR, 218 sub-pectoral and 98 (31%) pre-pectoral. Pre-pectoral implant-IBR was significantly associated with the year (2021: OR=12.08 and 2022: OR=76.6), the surgeons and type of mastectomy (SSM vs NSM: OR=0.377). Complications and complications Grade 2-3 rates were 12.9% and 10.1% for sub-pectoral implant-IBR respectively, without significant difference with pre-pectoral implant-IBR: 17.3% and 13.2%. Complications Grade 2-3 were significantly associated with age <50-years (OR=2.27), ASA-2 status (OR=3.63) and cup-size >C (OR=3.08), without difference between pre and sub-pectoral implant-IBR. Durations of surgery were significantly associated with cup-size C and >C (OR=1.72 and 2.80), with sentinel lymph-node biopsy and axillary dissection (OR=3.66 and 9.59) and with sub-pectoral implant-IBR (OR=2.088). Median hospitalization stay was 1 day, without difference between pre and sub-pectoral implant-IBR. Cost of surgery was significantly associated with cup-size > C (OR=2.216) and pre-pectoral implant-IBR (OR=8.02). Bad-medium satisfaction and IBR-failure were significantly associated with local recurrence (OR=8.820), post-mastectomy radiotherapy (OR=1.904) and sub-pectoral implant-IBR (OR=2.098). Conclusion Complications were not different between pre and sub-pectoral implant-IBR. Pre-pectoral implant-IBR seems a reliable and faster technique with better patient satisfaction but with higher cost.
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Affiliation(s)
- Gilles Houvenaeghel
- Aix-Marseille University, CNRS (National Center of Scientific Research), INSERM (National Institute of Health and Medical Research), Paoli-Calmettes Institute, Department of Surgical Oncology, CRCM (Research Cancer Centre of Marseille), 13009 Marseille, France
| | - Monique Cohen
- Paoli-Calmettes Institute, Department of Surgical Oncology, CRCM (Research Cancer Centre of Marseille), 13009 Marseille, France
| | - Laura Sabiani
- Paoli-Calmettes Institute, Department of Surgical Oncology, CRCM (Research Cancer Centre of Marseille), 13009 Marseille, France
| | - Aurore Van Troy
- Paoli-Calmettes Institute, Department of Surgical Oncology, CRCM (Research Cancer Centre of Marseille), 13009 Marseille, France
| | - Olivia Quilichini
- Paoli-Calmettes Institute, Department of Surgical Oncology, CRCM (Research Cancer Centre of Marseille), 13009 Marseille, France
| | - Axelle Charavil
- Paoli-Calmettes Institute, Department of Surgical Oncology, CRCM (Research Cancer Centre of Marseille), 13009 Marseille, France
| | - Max Buttarelli
- Paoli-Calmettes Institute, Department of Surgical Oncology, CRCM (Research Cancer Centre of Marseille), 13009 Marseille, France
| | - Sandrine Rua
- Paoli-Calmettes Institute, Department of Surgical Oncology, CRCM (Research Cancer Centre of Marseille), 13009 Marseille, France
| | - Agnès Tallet
- Paoli-Calmettes Institute, Department of Radiotherapy, CRCM (Research Cancer Centre of Marseille), 13009 Marseille, France
| | - Alexandre de Nonneville
- Aix-Marseille University, CNRS (National Center of Scientific Research), INSERM (National Institute of Health and Medical Research), Paoli-Calmettes Institute, Department of Medical Oncology, CRCM (Research Cancer Centre of Marseille), 13009 Marseille, France
| | - Marie Bannier
- Paoli-Calmettes Institute, Department of Surgical Oncology, CRCM (Research Cancer Centre of Marseille), 13009 Marseille, France
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Roberts K, Mills N, Metcalfe C, Lane A, Clement C, Hollingworth W, Taylor J, Holcombe C, Skillman J, Fairhurst K, Whisker L, Cutress R, Thrush S, Fairbrother P, Potter S. Best-BRA (Is subpectoral or prepectoral implant placement best in immediate breast reconstruction?): a protocol for a pilot randomised controlled trial of subpectoral versus prepectoral immediate implant-based breast reconstruction in women following mastectomy. BMJ Open 2021; 11:e050886. [PMID: 34848516 PMCID: PMC8634330 DOI: 10.1136/bmjopen-2021-050886] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Implant-based breast reconstruction (IBBR) is the most commonly performed reconstructive procedure following mastectomy. IBBR techniques are evolving rapidly, with mesh-assisted subpectoral reconstruction becoming the standard of care and more recently, prepectoral techniques being introduced. These muscle-sparing techniques may reduce postoperative pain, avoid implant animation and improve cosmetic outcomes and have been widely adopted into practice. Although small observational studies have failed to demonstrate any differences in the clinical or patient-reported outcomes of prepectoral or subpectoral reconstruction, high-quality comparative evidence of clinical or cost-effectiveness is lacking. A well-designed, adequately powered randomised controlled trial (RCT) is needed to compare the techniques, but breast reconstruction RCTs are challenging. We, therefore, aim to undertake an external pilot RCT (Best-BRA) with an embedded QuinteT Recruitment Intervention (QRI) to determine the feasibility of undertaking a trial comparing prepectoral and subpectoral techniques. METHODS AND ANALYSIS Best-BRA is a pragmatic, two-arm, external pilot RCT with an embedded QRI and economic scoping for resource use. Women who require a mastectomy for either breast cancer or risk reduction, elect to have an IBBR and are considered suitable for both prepectoral and subpectoral reconstruction will be recruited and randomised 1:1 between the techniques.The QRI will be implemented in two phases: phase 1, in which sources of recruitment difficulties are rapidly investigated to inform the delivery in phase 2 of tailored interventions to optimise recruitment of patients.Primary outcomes will be (1) recruitment of patients, (2) adherence to trial allocation and (3) outcome completion rates. Outcomes will be reviewed at 12 months to determine the feasibility of a definitive trial. ETHICS AND DISSEMINATION The study has been approved by the National Health Service (NHS) Wales REC 6 (20/WA/0338). Findings will be presented at conferences and in peer-reviewed journals. TRIAL REGISTRATION NUMBER ISRCTN10081873.
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Affiliation(s)
- Kirsty Roberts
- Population Health Sciences, University of Bristol Medical School, Bristol, UK
| | - Nicola Mills
- Population Health Sciences, University of Bristol Medical School, Bristol, UK
| | - Chris Metcalfe
- Population Health Sciences, University of Bristol Medical School, Bristol, UK
| | - Athene Lane
- Population Health Sciences, University of Bristol Medical School, Bristol, UK
| | - Clare Clement
- Population Health Sciences, University of Bristol Medical School, Bristol, UK
| | | | - Jodi Taylor
- Population Health Sciences, University of Bristol Medical School, Bristol, UK
| | - Chris Holcombe
- Linda McCartney Centre, Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
| | - Joanna Skillman
- Department of Plastic Surgery, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Katherine Fairhurst
- Population Health Sciences, University of Bristol Medical School, Bristol, UK
| | - Lisa Whisker
- Nottingham Breast Institute, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Ramsey Cutress
- Cancer Sciences Academic Unit, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Steven Thrush
- Breast Unit, Worcestershire Acute Hospitals NHS Trust, Worcester, Worcestershire, UK
| | | | - Shelley Potter
- Population Health Sciences, University of Bristol Medical School, Bristol, UK
- Bristol Breast Care Centre, North Bristol NHS Trust, Westbury on Trym, UK
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8
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Barber MD, Young O, Kulkarni D, Young I, Saleem TB, Fernandez T, Revie E, Dixon JM. No evidence of benefit for laminar flow in theatre for sling-assisted, implant-based breast reconstruction. Surgeon 2021; 19:e112-e116. [DOI: 10.1016/j.surge.2020.08.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 08/18/2020] [Accepted: 08/27/2020] [Indexed: 01/25/2023]
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9
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Haque S, Kanapathy M, Bollen E, Mosahebi A, Younis I. Patient-reported outcome and cost implication of acute salvage of infected implant-based breast reconstruction with negative pressure wound therapy with Instillation (NPWTi) compared to standard care. J Plast Reconstr Aesthet Surg 2021; 74:3300-3306. [PMID: 34217644 DOI: 10.1016/j.bjps.2021.05.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 03/04/2021] [Accepted: 05/24/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Implant loss due to infection is the most devastating complication of implant-based breast reconstruction. The use of negative pressure wound therapy with instillation(NPWTi) for salvage of infected implant-based breast reconstructions has shown promising results allowing early reinsertion of a new implant as an alternative to the current management with delayed reinsertion. This study compares the patient-reported outcome and cost implication of NPWTi to the current management. METHODS Twenty cases of infected breast implants treated with NPWTi(V.A.C. VERAFLO™ Therapy), followed by early reinsertion of new implants were compared to 20 cases that had delayed reinsertion(non-NPWTi). Patient satisfaction was evaluated using the BREAST-Q questionnaire. The average cost per patient was calculated using total operative expense, cost of inpatient stay, investigations, antibiotics, and outpatient visits. RESULTS Treatment with NPWTi allowed earlier reinsertion of a new implant (NPWTi: 10.3 ± 2.77days vs. non-NPWTi: 247.45±111.28days, p<0.001). Patients in the NPWTi group reported higher satisfaction. The average cost per patient for NPWTi and non-NPWTi was £14,343.13±£2,786.70 and £8,920.31±£3,005.73, respectively(p<0.001). All patients treated with NPWTi had one admission and spent 11.9 ± 4.1days as inpatients, while non-NPWTi patients had 2.1 ± 0.3 admissions(p<0.001) and spent 7.1 ± 5.8days(p<0.004) as inpatients. Patients treated with NPWTi had more procedures (NPWTi:3.35±0.81 Vs. non-NPWTi:2.2 ± 0.41, p = 0.006); however, three non-NPWTi cases required flap reconstruction. CONCLUSION Patients treated with NPWTi reported higher satisfaction, received a new and earlier implant, and had fewer admissions and outpatient visits; however, they incurred higher average costs, longer inpatient stays, and underwent more procedures. Early implant reinsertion preserves skin envelope; hence avoiding additional cost and stress related to further major autologous reconstruction.
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Affiliation(s)
- Shameem Haque
- Department of Plastic and Reconstructive Surgery, Royal Free NHS Foundation Trust Hospital, London NW3 2QG, United Kingdom
| | - Muholan Kanapathy
- Department of Plastic and Reconstructive Surgery, Royal Free NHS Foundation Trust Hospital, London NW3 2QG, United Kingdom; Division of Surgery & Interventional Science, University College London, London, United Kingdom.
| | - Edward Bollen
- UCL Medical School, University College London, London, United Kingdom
| | - Afshin Mosahebi
- Department of Plastic and Reconstructive Surgery, Royal Free NHS Foundation Trust Hospital, London NW3 2QG, United Kingdom; Division of Surgery & Interventional Science, University College London, London, United Kingdom
| | - Ibby Younis
- Department of Plastic and Reconstructive Surgery, Royal Free NHS Foundation Trust Hospital, London NW3 2QG, United Kingdom
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10
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Shaker H, Leena N, Mayers V, Koussa F, Deshpande A. Day-case approach to immediate breast reconstruction: pushing the boundaries of ambulatory breast surgery in the post-COVID-19 era. Ann R Coll Surg Engl 2021; 103:426-431. [PMID: 34058121 DOI: 10.1308/rcsann.2020.7152] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
INTRODUCTION Day-case surgery is safe and efficacious for most breast surgical procedures. Limited data exist on its use in immediate breast reconstruction. We present our experience of day-case management of mastectomy with immediate pre-pectoral implant-based reconstruction (IBR). METHODS Data were collected on 47 patients who underwent day-case skin-sparing (SSM) or nipple-sparing (NSM) mastectomy with pre-pectoral IBR between October 2017 and September 2019. Clinicopathological data were collected, including postoperative complications, re-admission and re-operation. The data were compared to published national standards. RESULTS Median age was 52 years (range 37-74). Thirty-two patients (68%) had an SSM and 15 (32%) had an NSM. Two patients (4%) had risk-reducing mastectomies and 45 had treatment for invasive cancer or ductal carcinoma in situ (DCIS). Mean tumour size was 33.3mm (range 7-85mm). Forty-two (89%) patients went home on the day of surgery. No patients required re-operation in the first 48 hours. The median postoperative follow-up time was 11.4 months (range 1.8-22.7 months). During the first 90-day postoperative period, eight patients (17%) developed superficial skin necrosis, five patients (10.6%) developed postoperative infections and five patients (10.6%) suffered an implant loss. Eight patients (17%) were readmitted for re-operation. Compared to UK national standards set in the iBRA study, our cohort has demonstrated comparable postoperative infection, implant loss and re-operation and re-admission rates. CONCLUSION We have demonstrated close to 90% day-case success rate for mastectomy with IBR. These early data suggest that immediate IBR can be carried out in a manner that is cost-efficient without impacting surgical outcomes.
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Affiliation(s)
- H Shaker
- Wrightington, Wigan and Leigh NHS Foundation Trust, UK
| | - Nar Leena
- Wrightington, Wigan and Leigh NHS Foundation Trust, UK
| | - V Mayers
- Wrightington, Wigan and Leigh NHS Foundation Trust, UK
| | - F Koussa
- Wrightington, Wigan and Leigh NHS Foundation Trust, UK
| | - A Deshpande
- Wrightington, Wigan and Leigh NHS Foundation Trust, UK
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11
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Meattini I, Becherini C, Bernini M, Bonzano E, Criscitiello C, De Rose F, De Santis MC, Fontana A, Franco P, Gentilini OD, Livi L, Meduri B, Parisi S, Pasinetti N, Prisco A, Rocco N. Breast reconstruction and radiation therapy: An Italian expert Delphi consensus statements and critical review. Cancer Treat Rev 2021; 99:102236. [PMID: 34126314 DOI: 10.1016/j.ctrv.2021.102236] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Revised: 05/21/2021] [Accepted: 05/24/2021] [Indexed: 02/06/2023]
Abstract
Breast conserving surgery (BCS) plus radiation therapy (RT) or mastectomy have shown comparable oncological outcomes in early-stage breast cancer and are considered standard of care treatments. Postmastectomy radiation therapy (PMRT) targeted to both the chest wall and regional lymph nodes is recommended in high-risk patients. Oncoplastic breast conserving surgery (OBCS) represents a significant recent improvement in breast surgery. Nevertheless, it represents a challenge for radiation oncologists as it triggers different decision-making strategies related to treatment volume definition and target delineation. Hence, the choice of the best combination and timing when offering RT to breast cancer patients who underwent or are planned to undergo reconstruction procedures should be carefully evaluated and based on individual considerations. We present an Italian expert Delphi Consensus statements and critical review, led by a core group of all the professional profiles involved in the management of breast cancer patients undergoing reconstructive procedures and RT. The report was structured as to consider the main recommendations on breast reconstruction and RT and analyse the current open issues deserving investigation and consensus. We used a three key-phases and a Delphi process. The final expert panel of 40 colleagues selected key topics as identified by the core group of the project. A final consensus on 26 key statements on RT and breast reconstruction after three rounds of the Delphi voting process and harmonisation was reached. An accompanying critical review of available literature was summarized. A clear communication and cooperation between surgeon and radiation oncologist is of paramount relevance both in the setting of breast reconstruction following mastectomy when PMRT is planned and when extensive glandular rearrangements as OBCS is performed. A shared-decision making, relying on outcome-based and patient-centred considerations, is essential, while waiting for higher level-of-evidence data.
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Affiliation(s)
- Icro Meattini
- Department of Experimental and Clinical Biomedical Sciences "M. Serio", University of Florence, Florence, Italy; Radiation Oncology Unit - Oncology Department, Azienda Ospedaliero Universitaria Careggi, Florence, Italy; Italian Association of Radiotherapy and Clinical Oncology (AIRO) Breast Cancer Group, Italy; Clinical Oncology Breast Cancer Group (COBCG), Italy.
| | - Carlotta Becherini
- Department of Experimental and Clinical Biomedical Sciences "M. Serio", University of Florence, Florence, Italy; Radiation Oncology Unit - Oncology Department, Azienda Ospedaliero Universitaria Careggi, Florence, Italy; Italian Association of Radiotherapy and Clinical Oncology (AIRO) Breast Cancer Group, Italy
| | - Marco Bernini
- Breast Surgery Unit - Oncology Department, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Elisabetta Bonzano
- Department of Radiation Oncology, IRCCS San Matteo Polyclinic Foundation & PhD School in Experimental Medicine, University of Pavia, Pavia, Italy; Italian Association of Radiotherapy and Clinical Oncology (AIRO) Breast Cancer Group, Italy; Clinical Oncology Breast Cancer Group (COBCG), Italy
| | - Carmen Criscitiello
- Department of Oncology and Haematology (DIPO), University of Milan & Division of Early Drug Development for Innovative Therapy, European Institute of Oncology, IRCCS, Milan, Italy
| | - Fiorenza De Rose
- Division of Radiation Oncology, Santa Chiara Hospital, Trento, Italy; Italian Association of Radiotherapy and Clinical Oncology (AIRO) Breast Cancer Group, Italy; Clinical Oncology Breast Cancer Group (COBCG), Italy
| | - Maria Carmen De Santis
- Radiation Oncology Unit 1, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy; Italian Association of Radiotherapy and Clinical Oncology (AIRO) Breast Cancer Group, Italy; Clinical Oncology Breast Cancer Group (COBCG), Italy
| | - Antonella Fontana
- Radiation Oncology Unit, Ospedale Santa Maria Goretti, Latina, Italy; Italian Association of Radiotherapy and Clinical Oncology (AIRO) Breast Cancer Group, Italy
| | - Pierfrancesco Franco
- Department of Translational Medicine, University of Eastern Piedmont & Radiation Oncology Unit, AOU "Maggiore della Carità", Novara, Italy; Italian Association of Radiotherapy and Clinical Oncology (AIRO) Breast Cancer Group, Italy; Clinical Oncology Breast Cancer Group (COBCG), Italy
| | | | - Lorenzo Livi
- Department of Experimental and Clinical Biomedical Sciences "M. Serio", University of Florence, Florence, Italy; Radiation Oncology Unit - Oncology Department, Azienda Ospedaliero Universitaria Careggi, Florence, Italy; Italian Association of Radiotherapy and Clinical Oncology (AIRO) Breast Cancer Group, Italy
| | - Bruno Meduri
- Radiation Oncology Unit, University Hospital of Modena, Modena, Italy; Italian Association of Radiotherapy and Clinical Oncology (AIRO) Breast Cancer Group, Italy; Clinical Oncology Breast Cancer Group (COBCG), Italy
| | - Silvana Parisi
- Radiation Oncology Unit, Department of Biomedical, Dental Science and Morphological and Functional Images, University of Messina, Messina, Italy; Italian Association of Radiotherapy and Clinical Oncology (AIRO) Breast Cancer Group, Italy
| | - Nadia Pasinetti
- Radiation Oncology Service, ASST Valcamonica, Esine, Italy; Italian Association of Radiotherapy and Clinical Oncology (AIRO) Breast Cancer Group, Italy; Clinical Oncology Breast Cancer Group (COBCG), Italy
| | - Agnese Prisco
- Department of Radiation Oncology, University Hospital of Udine, ASUFC, Udine, Italy; Italian Association of Radiotherapy and Clinical Oncology (AIRO) Breast Cancer Group, Italy
| | - Nicola Rocco
- Group for Reconstructive and Therapeutic Advancements (G.RE.T.A.), Milan, Naples, Catania, Italy
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12
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Whitehead I, Irwin GW, Bannon F, Coles CE, Copson E, Cutress RI, Dave RV, Gardiner MD, Grayson M, Holcombe C, Irshad S, O'Brien C, O'Connell RL, Palmieri C, Shaaban AM, Sharma N, Singh JK, Potter S, McIntosh SA. The NeST (Neoadjuvant systemic therapy in breast cancer) study: National Practice Questionnaire of United Kingdom multi-disciplinary decision making. BMC Cancer 2021; 21:90. [PMID: 33482770 PMCID: PMC7825231 DOI: 10.1186/s12885-020-07757-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 12/21/2020] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Neoadjuvant systemic therapy (NST) is increasingly used in the treatment of breast cancer, yet it is clear that there is significant geographical variation in its use in the UK. This study aimed to examine stated practice across UK breast units, in terms of indications for use, radiological monitoring, pathological reporting of treatment response, and post-treatment surgical management. METHODS Multidisciplinary teams (MDTs) from all UK breast units were invited to participate in the NeST study. A detailed questionnaire assessing current stated practice was distributed to all participating units in December 2017 and data collated securely usingREDCap. Descriptive statistics were calculated for each questionnaire item. RESULTS Thirty-nine MDTs from a diverse range of hospitals responded. All MDTs routinely offered neoadjuvant chemotherapy (NACT) to a median of 10% (range 5-60%) of patients. Neoadjuvant endocrine therapy (NET) was offered to a median of 4% (range 0-25%) of patients by 66% of MDTs. The principal indication given for use of neoadjuvant therapy was for surgical downstaging. There was no consensus on methods of radiological monitoring of response, and a wide variety of pathological reporting systems were used to assess tumour response. Twenty-five percent of centres reported resecting the original tumour footprint, irrespective of clinical/radiological response. Radiologically negative axillae at diagnosis routinely had post-NACT or post-NET sentinel lymph node biopsy (SLNB) in 73.0 and 84% of centres respectively, whereas 16% performed SLNB pre-NACT. Positive axillae at diagnosis would receive axillary node clearance at 60% of centres, regardless of response to NACT. DISCUSSION There is wide variation in the stated use of neoadjuvant systemic therapy across the UK, with general low usage of NET. Surgical downstaging remains the most common indication of the use of NAC, although not all centres leverage the benefits of NAC for de-escalating surgery to the breast and/or axilla. There is a need for agreed multidisciplinary guidance for optimising selection and management of patients for NST. These findings will be corroborated in phase II of the NeST study which is a national collaborative prospective audit of NST utilisation and clinical outcomes.
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Affiliation(s)
- I Whitehead
- Royal Liverpool University Hospital, Liverpool University Hospitals NHS Foundation Trust, Prescot Street, Liverpool, L7 8XP, UK
| | - G W Irwin
- Belfast Health and Social Care Trust, Belfast City Hospital, Lisburn Road, Belfast, BT9 7AB, UK
| | - F Bannon
- Centre for Public Health, Queen's University Belfast, Institute of Clinical Science, Block A, Royal Victoria Hospital, Belfast, BT12 6BA, UK
| | - C E Coles
- University of Cambridge, Cambridge, UK
| | - E Copson
- Cancer Sciences Academic Unit, Faculty of Medicine, University of Southampton, Southampton, SO16 6YD, UK
| | - R I Cutress
- Cancer Sciences Academic Unit, Faculty of Medicine, University of Southampton, Southampton, SO16 6YD, UK
| | - R V Dave
- The Nightingale Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, M23 9LT, UK
| | - M D Gardiner
- Department of Plastic Surgery, Wexham Park Hospital, Frimley Health NHS Foundation Trust, Slough, SL2 4HL, UK
| | - M Grayson
- NI Cancer Research Consumer Forum, c/o NI Cancer Trials Network, East Podium, C-Floor, Belfast City Hospital, Belfast, BT9 7AB, UK
| | - C Holcombe
- Liverpool University Hospitals Foundation Trust, Prescot Street, Liverpool, L7 8XP, UK
| | - S Irshad
- Guy's Cancer Centre, Guy's & St Thomas' NHS Trust, Great Maze Pond, London, SE1 9RT, UK
- School of Cancer & Pharmaceutical Sciences, King's College London, London, SE1 9RT, UK
| | - C O'Brien
- The Christie Hospital NHS Foundation Trust, Wilmslow Road, Manchester, M20 2BX, UK
- School of Medical Sciences Faculty of Biology, Medicine and Health University of Manchester, Manchester, M13 9PL, UK
| | - R L O'Connell
- Royal Marsden NHS Foundation Trust, Downs Road, Sutton, Surrey, SM2 5PT, UK
| | - C Palmieri
- University of Liverpool, Institute of Systems, Molecular and Integrative Biology, Department of Molecular and Clinical Cancer Medicine, Liverpool, UK
- The Clatterbridge Cancer Centre NHS Foundation Trust, Liverpool, UK
| | - A M Shaaban
- Queen Elizabeth Hospital Birmingham and University of Birmingham, Mindelsohn Way, Edgbaston, Birmingham, B15 2GW, UK
| | - N Sharma
- Breast Unit, Level 1 Chancellor wing, St James Hospital, Beckett Street, Leeds, LS97TF, UK
| | - J K Singh
- Queen Elizabeth Hospital Birmingham and University of Birmingham, Mindelsohn Way, Edgbaston, Birmingham, B15 2GW, UK
| | - S Potter
- Bristol Centre for Surgical Research, Population Health Sciences, Bristol Medical School, Canynge Hall, 39 Whatley Road, Clifton, Bristol, BS8 2PS, UK
- Bristol Breast Care Centre, North Bristol NHS Trust, Southmead Hospital, Southmead Road, Bristol, BS10 5NB, UK
| | - S A McIntosh
- Patrick G Johnston Centre for Cancer Research, Queen's University Belfast, 97 Lisburn Road, Belfast, BT9 7AE, UK.
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13
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Heeg E, Jensen MB, Mureau MAM, Ejlertsen B, Tollenaar RAEM, Christiansen PM, Vrancken Peeters MTFD. Breast-contour preserving procedures for early-stage breast cancer: a population-based study of the trends, variation in practice and predictive characteristics in Denmark and the Netherlands. Breast Cancer Res Treat 2020; 182:709-718. [PMID: 32524354 PMCID: PMC7320958 DOI: 10.1007/s10549-020-05725-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 06/02/2020] [Indexed: 12/01/2022]
Abstract
PURPOSE Breast-contour preservation (BCP) is possible for most women treated for early-stage breast cancer. BCP can be defined as primary breast-conserving treatment (BCT), neoadjuvant chemotherapy (NAC) followed by BCT and immediate postmastectomy breast reconstruction (IBR). This study provides insight in current BCP strategies in Denmark and the Netherlands and aims to identify opportunities for improvement within both countries. METHODS A total of 92,881 patients with early-stage breast cancer who were operated in Denmark and the Netherlands between 2012 and 2017 were selected from the Danish Breast Cancer Group and the Dutch National Breast Cancer Audit databases. BCP procedures and predictive factors were analyzed within and between both countries. RESULTS BCP was achieved in 76.7% (n = 16,355) of the Danish and in 74.5% (n = 53,328) of the Dutch patients. While BCP rate did not change significantly over time in Denmark (p = 0.250), a significant increase in BCP rate from 69.5% in 2012 to 78.5% in 2017 (p < 0.001) was observed in the Netherlands. In both countries, variation in BCP rates between hospitals decreased over time. NAC followed by BCT and postmastectomy IBR was substantially more often used in the Netherlands compared to Denmark, specifically in patients younger than 50 years. CONCLUSIONS In more than 75% of all Danish and Dutch patients, surgically treated for early-stage breast cancer, the breast-contour was preserved. The different use of BCP strategies within Denmark and the Netherlands and the differences observed between hospitals in both countries emphasize the need for more (inter)national consensus on treatment modalities.
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Affiliation(s)
- E Heeg
- Dutch Institute for Clinical Auditing, Leiden, The Netherlands. .,Department of Surgery, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands.
| | - M B Jensen
- Danish Breast Cancer Cooperative Group, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - M A M Mureau
- Department of Plastic and Reconstructive Surgery, Erasmus MC Cancer Institute, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - B Ejlertsen
- Danish Breast Cancer Cooperative Group, Department of Oncology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - R A E M Tollenaar
- Department of Surgery, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - P M Christiansen
- Department of Plastic and Breast Surgery, Aarhus University Hospital, Aarhus, Denmark
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Davies G, Mills N, Holcombe C, Potter S. Perceived barriers to randomised controlled trials in breast reconstruction: obstacle to trial initiation or opportunity to resolve? A qualitative study. Trials 2020; 21:316. [PMID: 32252788 PMCID: PMC7132957 DOI: 10.1186/s13063-020-4227-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Accepted: 03/03/2020] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Implant-based breast reconstruction (IBBR) is the most commonly performed breast reconstruction technique worldwide but the technique is evolving rapidly. High-quality evidence is needed to support practice. Randomised controlled trials (RCTs) provide the best evidence but can be challenging to conduct. iBRA is a four-phased study which aimed to inform the feasibility, design and conduct of an RCT in IBBR. In phase 3, the randomisation acceptability study, an electronic survey and qualitative interviews were conducted to explore professionals' perceptions of future trials in IBBR. Findings from the interviews are presented here. METHODS Semi-structured qualitative interviews were undertaken with a purposive sample of 31 health professionals (HPs) who completed the survey to explore their attitudes to the feasibility of potential RCTs in more detail. All interviews were transcribed verbatim and data were analysed thematically using constant comparative techniques. Sampling, data collection and analysis were undertaken iteratively and concurrently until data saturation was achieved. RESULTS Almost all HPs acknowledged the need for better evidence to support the practice of IBBR and most identified RCTs as generating the highest-quality evidence. Despite highlighting potential challenges, most participants supported the need for an RCT in IBBR. A minority, however, were strongly opposed to a future trial. The opposition and challenges identified centred around three key themes; (i) limited understanding of pragmatic study design and the value of randomisation in minimising bias; (ii) clinician and patient equipoise and (iii) aspects of surgical culture and training that were not supportive of RCTs. CONCLUSION There is a need for well-designed, large-scale RCTs to support the current practice of IBBR but barriers to their acceptability are evident. The perceived barriers to RCTs in breast reconstruction identified in this study are not insurmountable and have previously been overcome in other similar surgical trials. This may represent an opportunity, not only to establish the evidence base for IBBR, but also to improve engagement in RCTs in breast surgery in general to ultimately improve outcomes for patients. TRIAL REGISTRATION International Standard Randomised Controlled Trial Number ISRCTN37664281.
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Affiliation(s)
- Gareth Davies
- Bristol Centre for Surgical Research, Population Health Sciences, Bristol Medical School, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS UK
| | - Nicola Mills
- Bristol Centre for Surgical Research, Population Health Sciences, Bristol Medical School, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS UK
| | - Chris Holcombe
- Linda McCartney Centre, Royal Liverpool and Broadgreen University Hospital, Prescot Street, Liverpool, L7 8XP UK
| | - Shelley Potter
- Bristol Centre for Surgical Research, Population Health Sciences, Bristol Medical School, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS UK
- Bristol Breast Care Centre, North Bristol NHS Trust, Southmead Road, Bristol, BS10 5NB UK
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15
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Teoh V, Gui G. Direct to implant breast reconstruction with biological acellular dermal matrices. Br J Hosp Med (Lond) 2020; 81:1-7. [PMID: 32240004 DOI: 10.12968/hmed.2018.0428a] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Breast cancer is the most commonly diagnosed female cancer in the UK, with one in eight women receiving a cancer diagnosis during their lifetime. Forty per cent of women diagnosed with breast cancer undergo mastectomy as their primary therapeutic procedure. While a full range of choices is offered, breast reconstruction using implants is the patient-preferred method of reconstruction following mastectomy. This review discusses the evolution of implant-based reconstruction, focusing on the recent trend towards prepectoral breast reconstruction. Key quality indicators in the current literature are considered, including oncological outcomes, aesthetics and patient-related outcome measures, as are the health-care economics of this emerging surgical technique.
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Affiliation(s)
- Victoria Teoh
- Department of Breast Surgery, Royal Marsden NHS Foundation Trust, London, UK
| | - Gerald Gui
- Department of Breast Surgery, Royal Marsden NHS Foundation Trust, London, UK
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16
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Irwin G, Bannon F, Coles C, Copson E, Cutress R, Dave R, Grayson M, Holcombe C, Irshad S, O'Brien C, O'Connell R, Palmieri C, Shaaban A, Sharma N, Singh J, Whitehead I, Potter S, McIntosh S. The NeST (neoadjuvant systemic therapy in breast cancer) study - Protocol for a prospective multi-centre cohort study to assess the current utilization and short-term outcomes of neoadjuvant systemic therapies in breast cancer. Int J Surg Protoc 2019; 18:5-11. [PMID: 31897446 PMCID: PMC6921204 DOI: 10.1016/j.isjp.2019.10.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 10/17/2019] [Accepted: 10/19/2019] [Indexed: 01/31/2023] Open
Abstract
INTRODUCTION Neoadjuvant systemic therapy (NST) has several potential advantages in the treatment of breast cancer. However, there is currently considerable variation in NST use across the UK. The NeST study is a national, prospective, multicentre cohort study that will investigate current patterns of care with respect to NST in the UK. METHODS AND ANALYSIS Phase 1 - a national practice questionnaire (NPQ) to survey current practice.Phase 2 - a multi-centre prospective cohort study of breast cancer patients, undergoing NST.Women undergoing NST as their MDT recommended primary breast cancer treatment between December 2017 and May 2018 will be included. The breast surgery and oncological professional associations and the trainee research collaborative networks will encourage participation by all breast cancer centres.Patient demographics, radiological, oncological, surgical and pathological data will be collected, including complications and the need for further intervention/treatment. Data will be collated to establish current practice in the UK, regarding NST usage and variability of access and provision of these therapies. Prospective data on 600 patients from ~50 centres are anticipated.Trial registration: ISRCTN11160072. ETHICS AND DISSEMINATION Research ethics approval is not required for this study, as per the online Health Research Authority decision tool. The information obtained will provide valuable insights to help patients make informed decisions about their treatment. These data should establish current practice in the UK concerning NST, inform future service delivery as well as identifying further research questions.This protocol will be disseminated through the Mammary Fold Academic Research Collaborative (MFAC), the Reconstructive Surgery Trials Network and the Association of Breast Surgery. Participating units will have access to their own data and collective results will be presented at relevant conferences and published in appropriate peer-reviewed journals, as well as being made accessible to relevant patient groups.
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Affiliation(s)
- G.W. Irwin
- Belfast City Hospital, Belfast Health and Social Care Trust, 51 Lisburn Road, Belfast BT98 7AB, UK
| | - F. Bannon
- Centre for Public Health, Queen’s University, Belfast, UK
| | - C.E. Coles
- Oncology Centre, Box 193, University of Cambridge, Hills Road, Cambridge CB2 0QQ, UK
| | - E. Copson
- Cancer Sciences Academic Unit, University of Southampton, Southampton General Hospital, Tremona Road, Southampton SO16 6YD, UK
| | - R.I. Cutress
- Cancer Sciences Academic Unit, University of Southampton, Southampton General Hospital, Tremona Road, Southampton SO16 6YD, UK
| | - R.V. Dave
- Nightingale Breast Centre, Manchester University Foundation Trust, Southmoor Road, Wythenshawe, Manchester M23 9LT, UK
| | - M. Grayson
- Northern Ireland Cancer Research Consumer Forum, Belfast, Northern Ireland, UK
| | - C. Holcombe
- North West Cancer Research Centre, University of Liverpool, 200 London Road, Liverpool L3 9TA, UK
| | - S. Irshad
- Research Oncology, Kings College London, SE1 9RT, UK
- Guys & St Thomas’ NHS Trust, London SE1 9RT, UK
| | - C. O'Brien
- The Christie NHS Foundation Trust, Wilmslow Road, Manchester M20 2BX, UK
| | - R.L. O'Connell
- Department of Breast Surgery, Royal Marsden NHS Foundation Trust. Downs Road, Sutton, Surrey SM2 5PT, UK
| | - C. Palmieri
- Institute of Translational Medicine, University of Liverpool, Liverpool L69 3BX, UK
| | - A.M. Shaaban
- Queen Elizabeth Hospital Birmingham and University of Birmingham, Birmingham B15 2GW, UK
| | - N. Sharma
- Breast Unit, Level 1 Chancellor Wing, St James Hospital, Beckett Street, Leeds LS97TF, UK
| | - J. Singh
- University Hospitals Birmingham, Edgbaston, Birmingham B15 2GW, UK
| | - I. Whitehead
- Burney Breast Unit, St Helens & Knowsley Teaching Hospitals NHS Trust, Marshalls Cross Road, St Helens WA9 3DA, UK
| | - S. Potter
- Bristol Centre for Surgical Research, Population Health Sciences, Bristol Medical School, Canynge Hall, 39 Whatley Road, Bristol BS8 2PS, UK
- Bristol Breast Care Centre, North Bristol NHS Trust, Southmead Road, Bristol BS10 5NB, UK
| | - S.A. McIntosh
- Centre for Cancer Research and Cell Biology, Queen's University Belfast, 97 Lisburn Road, Belfast BT9 7AE, UK
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Guo R, Li L, Su Y, Xiu B, Zhang Q, Wang J, Chi W, Yang B, Zhang Y, Cao A, Shao Z, Wu J. Current practice and barriers of mesh-assisted implant-based breast reconstruction in China: A nationwide cross-sectional survey of 110 hospitals. Eur J Surg Oncol 2019; 46:65-70. [PMID: 31519428 DOI: 10.1016/j.ejso.2019.09.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 09/04/2019] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND The current National Practice Questionnaire of implant-based breast reconstruction (IBBR) (NPQi) was to assess the clinical practice of mesh-assisted IBBR in China. METHODS A questionnaire was mailed to 110 hospitals in China, which have more than 200 breast cancer operations performed in 2017. The survey mainly included questions on the type and timing of IBBR, questions about the use of TiLOOP® Bra and acellular dermal matrix (ADM) and the complications of IBBR. RESULTS IBBR was routinely carried out in 86.36% (95/110) hospitals. IBBR was the most frequently-used (65.7%, 4,296/6,534) BR after mastectomy with a median of 24 cases (IQR 7.5-65) in each hospital. TiLOOP® Bra and ADM were available in 49.5% and 33.7% hospitals, respectively. Hospitals with ADM offered were more likely to located in economically developed regions (65.6%), when compared with hospitals without any mesh offered (14/35, 40.0%, P = 0.036) and with only TiLOOP® Bra offered (16/28, 57.1%, P = 0.032). The surgery volume was largely variated from hospitals without any mesh offered (median 380 cases, IQR 304-550), with only TiLOOP® Bra offered (median 790 cases, IQR 439-1096, P = 0.001) and with ADM offered (median 797 cases, IQR 497-1528, P < 0.001). Higher proportion of one-stage mesh-augmented direct-to-implant BR and lower proportion of autologous BR were observed in hospitals with mesh offered. The reported major complications were similar between hospitals with or without mesh offered. CONCLUSIONS The NPQi has provided a valuable insight into the current practice of IBBR and mesh used in China. The introduction of mesh-assisted techniques has revolutionized the clinical practice.
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Affiliation(s)
- Rong Guo
- Department of Breast Surgery, Fudan University Shanghai Cancer Center, No. 270, Dongan Rd., Shanghai, 200032, China; Department of Oncology, Shanghai Medical College, Fudan University, China
| | - Lun Li
- Department of Breast Surgery, Fudan University Shanghai Cancer Center, No. 270, Dongan Rd., Shanghai, 200032, China; Department of Oncology, Shanghai Medical College, Fudan University, China
| | - Yonghui Su
- Department of Breast Surgery, Fudan University Shanghai Cancer Center, No. 270, Dongan Rd., Shanghai, 200032, China; Department of Oncology, Shanghai Medical College, Fudan University, China
| | - Bingqiu Xiu
- Department of Breast Surgery, Fudan University Shanghai Cancer Center, No. 270, Dongan Rd., Shanghai, 200032, China; Department of Oncology, Shanghai Medical College, Fudan University, China
| | - Qi Zhang
- Department of Breast Surgery, Fudan University Shanghai Cancer Center, No. 270, Dongan Rd., Shanghai, 200032, China; Department of Oncology, Shanghai Medical College, Fudan University, China
| | - Jia Wang
- Department of Breast Surgery, Fudan University Shanghai Cancer Center, No. 270, Dongan Rd., Shanghai, 200032, China; Department of Oncology, Shanghai Medical College, Fudan University, China
| | - Weiru Chi
- Department of Breast Surgery, Fudan University Shanghai Cancer Center, No. 270, Dongan Rd., Shanghai, 200032, China; Department of Oncology, Shanghai Medical College, Fudan University, China
| | - Benlong Yang
- Department of Breast Surgery, Fudan University Shanghai Cancer Center, No. 270, Dongan Rd., Shanghai, 200032, China; Department of Oncology, Shanghai Medical College, Fudan University, China
| | - Yingying Zhang
- Department of Breast Surgery, Fudan University Shanghai Cancer Center, No. 270, Dongan Rd., Shanghai, 200032, China; Department of Oncology, Shanghai Medical College, Fudan University, China
| | - Ayong Cao
- Department of Breast Surgery, Fudan University Shanghai Cancer Center, No. 270, Dongan Rd., Shanghai, 200032, China; Department of Oncology, Shanghai Medical College, Fudan University, China
| | - Zhimin Shao
- Department of Breast Surgery, Fudan University Shanghai Cancer Center, No. 270, Dongan Rd., Shanghai, 200032, China; Department of Oncology, Shanghai Medical College, Fudan University, China; Collaborative Innovation Center for Cancer Medicine, China
| | - Jiong Wu
- Department of Breast Surgery, Fudan University Shanghai Cancer Center, No. 270, Dongan Rd., Shanghai, 200032, China; Department of Oncology, Shanghai Medical College, Fudan University, China; Collaborative Innovation Center for Cancer Medicine, China.
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18
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Nava MB, Benson JR, Audretsch W, Blondeel P, Catanuto G, Clemens MW, Cordeiro PG, De Vita R, Hammond DC, Jassem J, Lozza L, Orecchia R, Pusic AL, Rancati A, Rezai M, Scaperrotta G, Spano A, Winters ZE, Rocco N. International multidisciplinary expert panel consensus on breast reconstruction and radiotherapy. Br J Surg 2019; 106:1327-1340. [PMID: 31318456 DOI: 10.1002/bjs.11256] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Revised: 12/11/2018] [Accepted: 05/06/2019] [Indexed: 11/06/2022]
Abstract
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.
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Affiliation(s)
- M B Nava
- Department of Plastic Surgery, University of Milan, Milan, Italy
| | - J R Benson
- Cambridge Breast Unit, Addenbrooke's Hospital, Cambridge, UK.,School of Medicine, Anglia Ruskin University, Cambridge and Chelmsford, UK
| | - W Audretsch
- Department of Senology and Breast Surgery, Heinrich Heine University, Dusseldorf, Germany
| | - P Blondeel
- Department of Plastic Surgery, University Hospital Ghent, Ghent, Belgium
| | - G Catanuto
- Multidisciplinary Breast Unit, Azienda Ospedaliera Cannizzaro, Catania, Italy
| | - M W Clemens
- Plastic and Reconstructive Surgery Unit, MD Anderson Cancer Center, Houston, Texas
| | - P G Cordeiro
- Department of Plastic and Reconstructive Surgery, Weill Cornell Medicine and.,Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, USA
| | - R De Vita
- Department of Plastic Surgery, National Cancer Institute 'Regina Elena', Rome, Italy
| | - D C Hammond
- Partners in Plastic Surgery of West Michigan, Grand Rapids, Michigan, USA
| | - J Jassem
- Department of Oncology and Radiotherapy, Medical University of Gdansk, Gdansk, Poland
| | - L Lozza
- Radiotherapy Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - R Orecchia
- Department of Radiotherapy, European Institute of Oncology, Milan, Italy
| | - A L Pusic
- Division of Plastic and Reconstructive Surgery, Brigham and Women's Hospital, Harvard University, Boston, Massachusetts, USA
| | - A Rancati
- Oncoplastic Surgery, Instituto Henry Moore, University of Buenos Aires, Buenos Aires, Argentina
| | - M Rezai
- European Breast Centre, Dusseldorf, Germany
| | - G Scaperrotta
- Radiology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - A Spano
- Plastic Surgery Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Z E Winters
- Division of Surgery and Interventional Science, Faculty of Medical Sciences, University College London, London, UK
| | - N Rocco
- Department of Clinical Medicine and Surgery, University of Naples 'Federico II', Naples, Italy
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19
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The impact of immediate breast reconstruction on the time to delivery of adjuvant therapy: the iBRA-2 study. Br J Cancer 2019; 120:883-895. [PMID: 30923359 PMCID: PMC6734656 DOI: 10.1038/s41416-019-0438-1] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2018] [Revised: 02/18/2019] [Accepted: 02/18/2019] [Indexed: 01/29/2023] Open
Abstract
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.
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20
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Potter S, Conroy EJ, Cutress RI, Williamson PR, Whisker L, Thrush S, Skillman J, Barnes NLP, Mylvaganam S, Teasdale E, Jain A, Gardiner MD, Blazeby JM, Holcombe C. Short-term safety outcomes of mastectomy and immediate implant-based breast reconstruction with and without mesh (iBRA): a multicentre, prospective cohort study. Lancet Oncol 2019; 20:254-266. [PMID: 30639093 PMCID: PMC6358590 DOI: 10.1016/s1470-2045(18)30781-2] [Citation(s) in RCA: 109] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Revised: 10/07/2018] [Accepted: 10/12/2018] [Indexed: 11/23/2022]
Abstract
BACKGROUND Use of biological or synthetic mesh might improve outcomes of immediate implant-based breast reconstruction-breast reconstruction with implants or expanders at the time of mastectomy-but there is a lack of high-quality evidence to support the safety or effectiveness of the technique. We aimed to establish the short-term safety of immediate implant-based breast reconstruction performed with and without mesh, to inform the feasibility of undertaking a future randomised clinical trial comparing different breast reconstruction techniques. METHODS In this prospective, multicentre cohort study, we consecutively recruited women aged 16 years or older who had any type of immediate implant-based breast reconstruction for malignancy or risk reduction, with any technique, at 81 participating breast and plastic surgical units in the UK. Data about patient demographics and operative, oncological, and complication details were collected before and after surgery. Outcomes of interest were implant loss (defined as unplanned removal of the expander or implant), infection requiring treatment with antibiotics or surgery, unplanned return to theatre, and unplanned re-admission to hospital for complications of reconstructive surgery, up to 3 months after reconstruction and assessed by clinical review or patient self-report. Follow-up is complete. The study is registered with the ISRCTN Registry, number ISRCTN37664281. FINDINGS Between Feb 1, 2014, and June 30, 2016, 2108 patients had 2655 mastectomies with immediate implant-based breast reconstruction at 81 units across the UK. 1650 (78%) patients had planned single-stage reconstructions (including 12 patients who had a different technique per breast). 1376 (65%) patients had reconstruction with biological (1133 [54%]) or synthetic (243 [12%]) mesh, 181 (9%) had non-mesh submuscular or subfascial implants, 440 (21%) had dermal sling implants, 42 (2%) had pre-pectoral implants, and 79 (4%) had other or a combination of implants. 3-month outcome data were available for 2081 (99%) patients. Of these patients, 182 (9%, 95% CI 8-10) experienced implant loss, 372 (18%, 16-20) required re-admission to hospital, and 370 (18%, 16-20) required return to theatre for complications within 3 months of their initial surgery. 522 (25%, 95% CI 23-27) patients required treatment for an infection. The rates of all of these complications are higher than those in the National Quality Standards (<5% for re-operation, re-admission, and implant loss, and <10% for infection). INTERPRETATION Complications after immediate implant-based breast reconstruction are higher than recommended by national standards. A randomised clinical trial is needed to establish the optimal approach to immediate implant-based breast reconstruction. FUNDING National Institute for Health Research, Association of Breast Surgery, and British Association of Plastic, Reconstructive and Aesthetic Surgeons.
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Affiliation(s)
- Shelley Potter
- Bristol Centre for Surgical Research, Population Health Sciences, Bristol Medical School, Bristol, UK; Bristol Breast Care Centre, North Bristol NHS Trust, Bristol, UK.
| | | | - Ramsey I Cutress
- Faculty of Medicine, Cancer Sciences Unit, University of Southampton, Somers Cancer Research Building, University Hospital Southampton, Southampton, UK
| | - Paula R Williamson
- North West Hub for Trials Methodology, University of Liverpool, Liverpool, UK
| | - Lisa Whisker
- Nottingham Breast Institute, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Steven Thrush
- Breast Unit, Worcester Royal Hospital, Worcester, UK
| | - Joanna Skillman
- Department of Plastic Surgery, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Nicola L P Barnes
- Nightingale Breast Unit, Manchester University NHS Foundation Trust, Manchester, UK
| | | | | | - Abhilash Jain
- Department of Plastic Surgery, Imperial College London NHS Trust, London, UK; Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Nuffield Orthopaedic Centre, Oxford, UK
| | - Matthew D Gardiner
- Department of Plastic Surgery, Imperial College London NHS Trust, London, UK; Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Nuffield Orthopaedic Centre, Oxford, UK
| | - Jane M Blazeby
- Bristol Centre for Surgical Research, Population Health Sciences, Bristol Medical School, Bristol, UK
| | - Chris Holcombe
- Linda McCartney Centre, Royal Liverpool and Broadgreen University Hospital, Liverpool, UK
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21
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Abstract
Breast cancer is the most common cancer diagnosed in the UK ( Cancer Research UK, 2018 ). Breast reconstruction following mastectomy can be performed with prosthetic devices or autologous tissue. In the UK implant-based breast reconstruction following mastectomy is the most common type of breast reconstruction, estimated to account for 70% of the reconstructive caseload in the UK. Since 2001 there has been a considerable increase in the number of prosthetic reconstructions performed with the use of mesh or matrix to augment the reconstructive pocket. This article introduces the main types of mesh and matrix used in implant-based breast reconstruction, reconstructive techniques and reviews the benefits and complications associated with their use.
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Affiliation(s)
- Rachel Rolph
- Honorary Research Fellow, Department of Plastic and Reconstructive Surgery, Guys and St Thomas' NHS Foundation Trust, London SE1 7EH
| | - Jian Farhadi
- Consultant Plastic Surgeon, Department of Plastic and Reconstructive Surgery, Guys and St Thomas' NHS Foundation Trust, London
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22
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Mylvaganam S, Conroy EJ, Williamson PR, Barnes NLP, Cutress RI, Gardiner MD, Jain A, Skillman JM, Thrush S, Whisker LJ, Blazeby JM, Potter S, Holcombe C. Adherence to best practice consensus guidelines for implant-based breast reconstruction: Results from the iBRA national practice questionnaire survey. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2018; 44:708-716. [PMID: 29472041 PMCID: PMC5937851 DOI: 10.1016/j.ejso.2018.01.098] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Accepted: 01/21/2018] [Indexed: 11/29/2022]
Abstract
INTRODUCTION The 2008 National Mastectomy and Breast Reconstruction Audit demonstrated marked variation in the practice and outcomes of breast reconstruction in the UK. To standardise practice and improve outcomes for patients, the British professional associations developed best-practice guidelines with specific guidance for newer mesh-assisted implant-based techniques. We explored the degree of uptake of best-practice guidelines within units performing implant-based reconstruction (IBBR) as the first phase of the implant Breast Reconstruction Evaluation (iBRA) study. METHODS A questionnaire developed by the iBRA Steering Group was completed by trainee and consultant leads at breast and plastic surgical units across the UK. Simple summary statistics were calculated for each survey item to assess compliance with current best-practice guidelines. RESULTS 81 units from 79 NHS Trusts completed the questionnaire. Marked variation was observed in adherence to guidelines, especially those relating to clinical governance and infection prevention strategies. Less than half (n = 28, 47%) of units obtained local clinical governance board approval prior to offering new mesh-based techniques and prospective audit of the clinical, cosmetic and patient-reported outcomes of surgery was infrequent. Most units screened for methicillin-resistant staphylococcus aureus prior to surgery but fewer than 1 in 3 screened for methicillin-sensitive strains. Laminar-flow theatres (recommended for IBBR) were not widely-available with less than 1 in 5 units having regular access. Peri-operative antibiotics were widely-used, but the type and duration were highly-variable. CONCLUSIONS The iBRA national practice questionnaire has demonstrated variation in reported practice and adherence to IBBR guidelines. High-quality evidence is urgently required to inform best practice.
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Affiliation(s)
- Senthurun Mylvaganam
- New Cross Hospital, Royal Wolverhampton Hospitals NHS Trust, Wednesfield Way, Wolverhampton, WV10 0QP, UK
| | - Elizabeth J Conroy
- Clinical Trials Research Centre (CTRC), North West Hub for Trials Methodology/University of Liverpool, Liverpool, L12 2AP, UK
| | - Paula R Williamson
- Clinical Trials Research Centre (CTRC), North West Hub for Trials Methodology/University of Liverpool, Liverpool, L12 2AP, UK
| | - Nicola L P Barnes
- Breast Unit, University Hospital of South Manchester NHS Foundation Trust, Southmoor Road, Manchester, M23 9LT, UK
| | - Ramsey I Cutress
- Breast Unit, University Hospital Southampton, Tremona Road, Southampton, Hampshire, SO16 6YD, UK; Faculty of Medicine, University of Southampton, University Road, Southampton, SO17 1BJ, UK
| | - Matthew D Gardiner
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Nuffield Orthopaedic Centre, Windmill Road, Headington, Oxford, OX3 7HE, UK; Department of Plastic Surgery, Imperial College London NHS Trust, London, SW7 2AZ, UK
| | - Abhilash Jain
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Nuffield Orthopaedic Centre, Windmill Road, Headington, Oxford, OX3 7HE, UK; Department of Plastic Surgery, Imperial College London NHS Trust, London, SW7 2AZ, UK
| | - Joanna M Skillman
- Department of Plastic Surgery, University Hospitals Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Coventry, CV2 2DX, UK
| | - Steven Thrush
- Breast Unit, Worcester Royal Hospital, Charles Hastings Way, Worcester, WR5 1DD, UK
| | - Lisa J Whisker
- Breast Institute, Nottingham University Hospitals NHS Trust, Hucknall Road, Nottingham, NG5 1PB, UK
| | - Jane M Blazeby
- Bristol Centre for Surgical Research, Population Health Sciences, Bristol Medical School, Canynge Hall 39 Whatley Road, Clifton, Bristol, BS8 2PS, UK
| | - Shelley Potter
- Bristol Centre for Surgical Research, Population Health Sciences, Bristol Medical School, Canynge Hall 39 Whatley Road, Clifton, Bristol, BS8 2PS, UK; Bristol Breast Cancer Centre, North Bristol NHS Trust, Southmead Hospital, Bristol, BS10 5NB, UK.
| | - Christopher Holcombe
- Linda McCartney Centre, Royal Liverpool and Broadgreen University Hospital, Prescot Street, Liverpool, L7 8XP, UK
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