The Multi Centre Canadian Acellular Dermal Matrix Trial (MCCAT): study protocol for a randomized controlled trial in implant-based breast reconstruction

A systematic review of randomised controlled trials in breast reconstruction

BACKGROUND

For preference sensitive treatments, such as breast reconstructions, there are barriers to conducting randomised controlled trials (RCTs). The primary aims of this systematic review were to investigate what type of research questions are explored by RCTs in breast reconstruction, where have they been performed and where have they been published, and to thematise the research questions and thus create an overview of the state of the research field.

METHODS

Randomised controlled trials investigating any aspect of breast reconstructions were included. The PubMed database was searched with a pre-defined search string. Inclusion and data abstraction was performed in a pre-defined standardised fashion. For the purpose of this study, we defined key issues as comparison of categories of breast reconstruction and comparison of immediate and delayed breast reconstruction, when the thematisation was done.

RESULTS

A total of 419 abstracts were retrieved from the search. Of the 419, 310 were excluded as they were not RCTs concerning some aspect of breast reconstruction, which left us with 110 abstracts to be included in the study. The research questions of the included studies could more or less be divided into seven different themes inclusive of 2 key issues: Other issues - comparison of different categories of breast reconstruction, comparison of immediate and delayed breast reconstruction, surgical details within a category of breast reconstruction, surgical details valid for several categories of breast reconstruction, donor site management, anaesthetics, and non-surgical details. Only five studies compared key issues, and they all illustrate the challenges with RCTs in breast reconstruction.

CONCLUSIONS

A total of 110 publications based on RCTs in breast reconstruction have been published. Seven themes of research questions could be identified. Only five studies have explored the key issues. Better scientific evidence is needed for the key issues in breast reconstruction, for example by implementing a new study design in the field.

The new bioabsorbable sheet for the sling method in immediate breast reconstruction with expander-implant: a study protocol for interventional prospective study

The popularity of a sling method using biomaterial sheets for immediate breast reconstruction based on prosthesis has been increasing in western countries. However, acellular dermal matrix, which is representative of the biomaterial sheet, is not available and the sling method also has not been accepted in Japan. We focused on a new bioabsorbable sheet (NEOVEIL sheet) as a substitute for the sling method and report a prospective study protocol to assess the safety and effectiveness of this material. This was an ongoing, single center, open-label, single-arm study. Inclusion criteria and exclusion criteria are defined restrictively. If the surgeon determined that the perfusion of skin envelope after mastectomy is poor, the surgical procedure can be modified and that patient was excluded from the study. The primary outcome was the incidence of tissue expansion or implant explantation occurring within 1 month after surgery. The secondary outcomes are as follows: (1) aesthetic outcome using a rating scale; (2) symmetry of the nipple areolar complex position; (3) patient reported outcomes using BREAST-Q; (4) pain intensity using the Visual Analog Scale; (5) histology of the capsule around the tissue expander; (6) inflation volume at the first stage and overall inflation time of expansion; and (7) other adverse events regarding the surgery. This study will determine the safety and effectiveness of the sling method using a NEOVEIL sheet in Japanese women.

Comparisons of Therapeutic and Aesthetic Effects of One-Stage Implant-Based Breast Reconstruction with and without Biological Matrix

Background

Biological matrix can provide coverage of compromised muscle and augment the subpectoral pocket in the one-stage reconstruction. However, few studies compared one stage implant-based breast reconstruction with and without biological matrix. The primary endpoint of our study was to assess the patient-reported outcomes (PROs) based on BREAST-Q version 2.0 and analyze complications between SIS matrix-assisted implant-based breast reconstruction (IBBR) and no-matrix-assisted IBBR.

Methods

This retrospective single-center study was conducted from May 2015 to April 2019, and we analyzed 155 patients who underwent one-stage IBBR with at least 1 year of follow-up. Seventy-nine patients underwent one-stage IBBR with SIS matrix group and 76 patients underwent one-stage IBBR without SIS matrix group were evaluated of PROs with BREAST-Q version 2.0 (from 3 different domains) and compared with complications. Complications occurred in patients were divided into major complications and minor complications.

Results

In the satisfaction domain, the mean score for satisfaction with breasts was 60.27 (17.71) in the SIS matrix group and 54.49 (14.76) in the no-matrix group, p=0.045. The multivariate logistic regression for postoperative complications in the whole series pointed out a statistical significance for age>40 years old (odds ratio 3.314, 95% CI 1.012–10.854, p=0.048) and patients with endocrine therapy (odds ratio 0.260, 95% CI 0.092–0.736, p=0.011).

Conclusion

Patients who underwent SIS matrix-assisted one-stage IBBR yield better results in PROs of satisfaction with breasts. Other domains and complications between the two groups had no significant difference.

Current practice and barriers of mesh-assisted implant-based breast reconstruction in China: A nationwide cross-sectional survey of 110 hospitals

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.

Delayed post mastectomy breast reconstructions with allogeneic acellular dermal matrix prepared by a new decellularizationmethod

Acellular dermal matrix (ADM) is a tissue graft of allogeneic origin from post-mortem tissue donors prepared by an innovative decellularization process. The newly developed non-toxic and low cost decellularization process of cadaver origin dermis included ADM in breast reconstruction procedures proved to help coverage of the lower-pole of breast expanders or implants. As the results have shown, it did help to eliminate autologous dermis donor site morbidity along with shortening the operation time by avoiding elevation of additional muscle or fascia during the operation. Main aims of this article include histology evaluation of allogeneic acellular dermal matrix prepared by a new decellularization method and presentation of clinical results of its use. A total of 22 patients underwent 26 ADM based breast reconstructions. The mean patient's follow up was 12.6 months. Average total size of ADM used for one breast was 273 cm². Post-operative complications occurred in 3 patients including one expander infection, one expander extrusion and one expander pocket disfiguration. Microscopic analysis of tissue samples has confirmed incorporation of the acellular dermal matrices into the surrounding connective tissue without any noticeable immune reaction. In a majority of the ADM samples we found pseudocapsullar formation on implant side of samples without acute or chronic inflammatory cells. The use of ADM prepared by new preparation method in expansive post mastectomy breast reconstruction was associated by a relatively low complication rate resulting in good outcomes.

Variation in the provision and practice of implant-based breast reconstruction in the UK: Results from the iBRA national practice questionnaire

Introduction

The introduction of biological and synthetic meshes has revolutionised the practice of implant-based breast reconstruction (IBBR) but evidence for effectiveness is lacking. The iBRA (implant Breast Reconstruction evAluation) study is a national trainee-led project that aims to explore the practice and outcomes of IBBR to inform the design of a future trial. We report the results of the iBRA National Practice Questionnaire (NPQ) which aimed to comprehensively describe the provision and practice of IBBR across the UK.

Methods

A questionnaire investigating local practice and service provision of IBBR developed by the iBRA Steering Group was completed by trainee and consultant leads at breast and plastic surgical units across the UK. Summary data for each survey item were calculated and variation between centres and overall provision of care examined.

Results

81 units within 79 NHS-hospitals completed the questionnaire. Units offered a range of reconstructive techniques, with IBBR accounting for 70% (IQR:50–80%) of participating units' immediate procedures. Units on average were staffed by 2.5 breast surgeons (IQR:2.0–3.0) and 2.0 plastic surgeons (IQR:1.0–3.0) performing 35 IBBR cases per year (IQR:20-50). Variation was demonstrated in the provision of novel different techniques for IBBR especially the use of biological (n = 62) and synthetic (n = 25) meshes and in patient selection for these procedures.

Conclusions

The iBRA-NPQ has demonstrated marked variation in the provision and practice of IBBR in the UK. The prospective audit phase of the iBRA study will determine the safety and effectiveness of different approaches to IBBR and allow evidence-based best practice to be explored.

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Implant breast reconstruction (IBBR) and the range of techniques is poorly evidence based.

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We aimed to explore the current practice of IBBR in the UK to inform the design of a future definitive study.

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Significant variation was demonstrated in the availability of techniques and patient selection for IBBR.

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There is a need for well-designed studies to establish best practice and improve outcomes for patients considering IBBR.

Bioresorbable scaffold as a dermal substitute

INTRODUCTION

Bioresorbable polymers are often used in medical procedures. Since they are biocompatible, this class of materials is a viable alternative for cases in which tissue regeneration is strongly compromised. Bioresorbable synthetic polymers may be used as membranes to support and guide cell growth through the process of tissue repair.

OBJECTIVE

To assess the efficiency of a porous bioresorbable membrane Poly (L-co-DL lactic acid)-co-trimethylene carbonate, PL-co-DLA-co-TMC, as a dermal substitute associated with partial skin graft in rats.

METHODS

A 1.5×1.5 cm defect was created on the backs of 40 Wistar rats. The rats were divided into a control group, in which the defects were filled with partial skin graft, and a treated group, in which a membrane associated with the graft was implemented. The animals were sacrificed 7 days or 60 days after the procedure and the results were evaluated by macroscopic and microscopic analysis.

RESULTS

The polymer was biocompatible and allowed better regeneration of the dermis with less shrinkage, unlike what occurs in second intention healing. Compared to the control group, the treated group showed a thicker and wider dermis with the presence of skin appendages, suggesting partial graft integration and better healing. The skin graft acted as a biological protection of the wound.

CONCLUSION

The study material was shown to act as a biocompatible dermal substitute and promoted less scarring of the dermis. Further studies should be conducted to improve the methodology of the surgical procedure.

The BREASTrial Stage II: ADM Breast Reconstruction Outcomes from Definitive Reconstruction to 3 Months Postoperative

Background:

The Breast Reconstruction Evaluation of Acellular Dermal Matrix as a Sling Trial is a prospective randomized trial comparing outcomes of tissue expander breast reconstruction using either AlloDerm or DermaMatrix. The trial was divided into 3 outcome stages; this study reports stage II outcomes, which are those from the time of definitive reconstruction to 3 months postoperative.

Methods:

A randomized trial was conducted to compare complication rates between AlloDerm and DermaMatrix groups. The impact of matrix type, age, obesity, radiation therapy, chemotherapy, and reconstruction type on complications was analyzed with regression models.

Results:

Of the 128 patients (199 breasts) who were randomly assigned into the trial, 111 patients (173 breasts) were available for analysis in stage II. There was no difference in overall rates of complications (15.4% vs 18.3%, P = 0.8) or implant loss (2.2% vs 3.7%, P = 0.5) between the AlloDerm and DermaMatrix groups, respectively. Obesity was the only significant predictor of complications on regression analysis (odds ratio, 4.31, P = 0.007). Matrix type, age, radiation therapy, chemotherapy, or reconstruction type had no impact on the incidence/severity of complications.

Conclusions:

Acellular dermal matrix (ADM) will likely continue to have a role in breast reconstructive surgery; however, caution should be taken when using ADM because of relatively high complication rates, especially in obese patients. The particular ADM product should be selected based on individual surgeon preference, experience, and success rates. These data and forthcoming long-term outcomes from the Breast Reconstruction Evaluation of Acellular Dermal Matrix as a Sling Trial will enable surgeons to carefully weigh the risks and benefits of ADM use in breast reconstruction.

Highlights from the Tenth European Breast Cancer Conference (EBCC10), Amsterdam, 9-11 March 2016

The Tenth European Breast Cancer Conference, EBCC 10, was held in Amsterdam in March 2016 with a total of 3061 participants from 95 different countries spread over five continents. The EBCC council is a joint venture of ESO, EORTC Breast Cancer Group, EUSOMA, and Europa Donna. The Scientific Programme for EBCC-10 tried to bring to the stage all the active participants in the diagnostic and treatment of breast cancer along with patients themselves. The need to achieve 'patient's access to high quality treatment' through breast units that have been accredited through a European certification process was the basis of the EBCC 10 manifesto. The congress scientific programme allowed participants to review the most up-to-date knowledge in the breast cancer field presented by experts having in mind its application to every day practice. The purpose of this summary is to describe to the readers the results of the late-breaking and best abstracts presented at EBCC10.

Alloplastic adjuncts in breast reconstruction

BACKGROUND

There has been an increasing role of acellular dermal matrices (ADMs) and synthetic meshes in both single- and two-stage implant/expander breast reconstruction. Numerous alloplastic adjuncts exist, and these vary in material type, processing, storage, surgical preparation, level of sterility, available sizes and cost. However, there is little published data on most, posing a significant challenge to the reconstructive surgeon trying to compare and select the most suitable product. The aims of this systematic review were to identify, summarize and evaluate the outcomes of studies describing the use of alloplastic adjuncts for post-mastectomy breast reconstruction. The secondary aims were to determine their cost-effectiveness and analyze outcomes in patients who also underwent radiotherapy.

METHODS

Using the PRSIMA 2009 statement, a systematic review was conducted to find articles reporting on the outcomes on the use of alloplastic adjuncts in post-mastectomy breast reconstruction. Multiple databases were searched independently by three authors (Cabalag MS, Miller GS and Chae MP), including: Ovid MEDLINE (1950 to present), Embase (1980 to 2015), PubMed and Cochrane Database of Systematic Reviews.

RESULTS

Current published literature on available alloplastic adjuncts are predominantly centered on ADMs, both allogeneic and xenogeneic, with few outcome studies available for synthetic meshes. Outcomes on the 89 articles, which met the inclusion criteria, were summarized and analyzed. The reported outcomes on alloplastic adjunct-assisted breast reconstruction were varied, with most data available on the use of ADMs, particularly AlloDerm(®) (LifeCell, Branchburg, New Jersey, USA). The use of ADMs in single-stage direct-to-implant breast reconstruction resulted in lower complication rates (infection, seroma, implant loss and late revision), and was more cost effective when compared to non-ADM, two-stage reconstruction. The majority of studies demonstrated inferior outcomes in ADM assisted, two-stage expander-to-implant reconstruction compared to non-ADM use. Multiple studies suggest that the use of ADMs results in a reduction of capsular contracture rates. Additionally, the reported beneficial effects of ADM use in irradiated tissue were varied.

CONCLUSIONS

ADM assisted two-stage breast reconstruction was associated with inferior outcomes when compared to non-ADM use. However, alloplastic adjuncts may have a role in single stage, direct-to-implant breast reconstruction. Published evidence comparing the long-term outcomes between the different types of adjuncts is lacking, and further level one studies are required to identify the ideal product.

The BREAST-Q in surgical research: A review of the literature 2009-2015

BACKGROUND

Health outcomes research has gained considerable traction over the past decade as the medical community attempts to move beyond traditional outcome measures such as morbidity and mortality. Since its inception in 2009, the BREAST-Q has provided meaningful and reliable information regarding health-related quality of life (HRQOL) and patient satisfaction for use in both clinical practice and research. In this study, we review how researchers have used the BREAST-Q and how it has enhanced our understanding and practice of plastic and reconstructive breast surgery.

METHODS

An electronic literature review was performed to identify publications that used the BREAST-Q to assess patient outcomes. Studies developing and/or validating the BREAST-Q or an alternate patient-reported outcome measure (PROM), review papers, conference abstracts, discussions, comments and/or responses to previously published papers, studies that modified a version of BREAST-Q, and studies not published in English were excluded.

RESULTS

Our literature review yielded 214 unique articles, 49 of which met our inclusion criteria. Important trends and highlights were further examined.

DISCUSSION

The BREAST-Q has provided important insights into breast surgery highlighted by literature concerning autologous reconstruction, implant type, fat grafting, and patient education. The BREAST-Q has increased the use of PROMs in breast surgery and provided numerous important insights in its brief existence. The increased interest in PROMs as well as the underutilized potential of the BREAST-Q should permit its continued use and ability to foster innovations and improve quality of care.

Conservative mastectomies and immediate reconstruction with the use of ADMs

BACKGROUND

In recent years, a novel approach to immediate breast reconstruction has been introduced with the advent of acellular dermal matrix (ADM). In the setting of conservative mastectomies where the native skin envelope is preserved, placement of ADM at the lower pole in continuity with the pectoralis major muscle (PMM) provides additional support, allowing direct-to-implant breast reconstruction. The following manuscript presents the senior author's experience with ADM-assisted reconstruction and provides a detailed description of surgical technique along with a comprehensive discussion of patient selection and potential complications.

METHODS

A retrospective chart review of patients undergoing direct-to-implant breast reconstruction following skin sparing or nipple sparing mastectomy with the use of ADM (AlloDerm; LifeCell Corp., Branchburg, USA) was conducted at Women's College Hospital in Toronto over a 5-year period [2008-2013]. Demographic data, previous radiation therapy and post-operative complications were recorded.

RESULTS

A total of 72 patients representing 119 breasts were identified. Average follow-up was 16 months (range, 3-51 months). Twenty-seven complications were recorded for a complication rate of 22.7% (27/119). Complications included six cases of capsular contracture (Baker III/IV), five cases of red skin syndrome, four cases of rippling, three cases of dehiscence and two cases of seroma. Overall, direct-to-implant reconstruction was successfully completed in 97.5% of breasts (116/119). One case of infection was treated with explantation and conversion to autogenous reconstruction. Two breasts with tissue necrosis or dehiscence had the implants removed and replaced with tissue expanders. Overall reoperation rate was 9.7% (7/72 patients).

CONCLUSIONS

ADM assisted direct-to-implant breast reconstruction has been shown to be a safe option for women who are candidates for skin sparing or nipple sparing mastectomies. Judicious patient selection, effective collaboration between the oncologic and reconstructive surgeon, careful evaluation of post-mastectomy skin flaps and precise surgical technique are paramount to the success of this technique.

Current opinions on indications and algorithms for acellular dermal matrix use in primary prosthetic breast reconstruction

Acellular dermal matrix (ADM) is widely used in primary prosthetic breast reconstruction. Many indications and contraindications to use ADM have been reported in the literature, and their use varies by institution and surgeon. Developing rational, tested algorithms to determine when ADM is appropriate can significantly improve surgical outcomes and reduce costs associated with ADM use. We review the important indications and contraindications, and discuss the algorithms that have been put forth so far. Further research into algorithmic decision-making for ADM use will allow optimized balancing of cost with risk and benefit.

Quality of life and patient satisfaction after microsurgical abdominal flap versus staged expander/implant breast reconstruction: a critical study of unilateral immediate breast reconstruction using patient-reported outcomes instrument BREAST-Q

Staged expander-implant breast reconstruction (EIBR) and microsurgical abdominal flap breast reconstruction (MAFBR) are the most common modes of breast reconstruction (BR) in the United States. Whether the mode of breast reconstruction has an impact on patient quality of life (QoL) and satisfaction remains a question. A retrospective study was conducted identifying a population of 119 patients who underwent unilateral immediate BR. Only patients who were eligible for either EIBR or MAFBR based on preoperative characteristics were included in the study. The following parameters were retrieved: demographics, mode of reconstruction, cancer, recovery, QoL, and patient satisfaction. The latter two parameters were determined using the BREAST-Q BR module questionnaire. Two-way analysis of variance with mode of reconstruction and occurrence of complication as independent variables was used to determine the effect on patient satisfaction and QoL. The association between mode of reconstruction and patient response with each item of the QoL and satisfaction survey domains was analyzed. The overall response rate was 62.2 %. Non-respondents and respondents did not significantly differ in demographics, surgery type, cancer staging, adjuvant therapy, and complication rate. Age and BMI were significantly higher in MAFBR, while level of education was higher in EIBR. MAFBR had higher scores in psychosocial and sexual wellbeing, satisfaction with outcome, breast, information, and plastic surgeon when compared with patients who underwent EIBR. For patients eligible for both MAFBR and EIBR, MAFBR is associated with higher levels of satisfaction and QoL. Comprehensive pre-operative information of pros and cons of both modes of BR is crucial for patients to make a well-informed decision, thus, resulting in higher levels of satisfaction.