Prophylactic Mastectomy: Postoperative Skin Flap Thickness Evaluated by MRT, Ultrasound and Clinical Examination

Prediction of Mastectomy Skin Flap Necrosis With Indocyanine Green Angiography and Thermography: A Retrospective Comparative Study

OBJECTIVE

This study investigates the predictive role of indocyanine green angiography and thermography in assessing mastectomy skin flap necrosis in the intraoperative and postoperative setting.

METHODS

A retrospective review of 45 patients who underwent nipple-sparing mastectomy and immediate prepectoral reconstruction was performed. Mastectomy flap viability was evaluated intraoperatively with indocyanine green angiography and thermography after placement of an implant sizer and again postoperatively at 24 hours. Fluorescence pattern was analyzed with a near-infrared camera (IC-FlowTM Imaging System, Diagnostic Green GmbH, Germania) and thermographic images with FLIR ONE device. FLIR ONE and ICG images were then transposed on macroscopic breast images with a scale 1:1. The mastectomy skin flap was evaluated using the SKIN score (Mayo Clinic Classification).

RESULTS

Overlap between angiography and thermography images was 87.95% intraoperatively and 95.95% 24 hours postoperatively. Overlay with mastectomy flap necrosis was higher in the intraoperative angiography group with statistical significance. Contrarily, such a difference was not apparent in the postoperative period.

CONCLUSIONS

ICG appears to be a superior tool when used intraoperatively with fundamental implications on reconstructive decision-making, while thermography could be a valuable assessment method in the postoperative setting. Further studies are necessary to confirm such results and determine their clinical applicability.

What did we catch? Predictors of infection after tissue expander-based breast reconstruction in a safety-net system

BACKGROUND

Infection is a common complication following tissue expander (TE)-based breast reconstruction. Few studies have examined risk factors specifically in the unique populations encountered at safety-net hospitals. The purpose of this study was to identify predictors of TE infection at Harris Health safety-net hospitals, which serve the third most populous county in the United States.

METHODS

A retrospective review was performed to evaluate women over the age of 18 years who underwent TE placement at two safety-net hospitals from October 2015 to November 2022. Demographic information, medical history, operative details, and postoperative course were recorded for each individual TE. The primary outcome was TE infection, for which univariate and multivariate analysis was conducted. The secondary outcome was the time to onset of TE infection, for which a Kaplan-Meier analysis was undertaken.

RESULTS

There were 279 patients, totaling 372 breasts, meeting the inclusion criteria. The TE infection rate was 23%. Increased body mass index (BMI), diabetes, use of acellular dermal matrix (ADM), and prolonged surgical drain use were all significantly associated with TE infection in univariate and multivariate analysis. Similarly, BMI ≥30 kg/m2, diabetes, and ADM use were also associated with earlier onset of TE infection.

CONCLUSIONS

This study demonstrated similar TE infection rates at our safety-net hospitals compared with previously reported literature. To optimize the quality of care for patients in safety-net institutions, these risk factors must be addressed in the context of the unique challenges encountered in these settings.

A BRILLIANT-BRCA study: residual breast tissue after mastectomy and reconstruction

INTRODUCTION

Different types of mastectomies leave different amounts of residual breast tissue. The significance of the residual breast volume (RBV) is not clear. Therefore, we developed an MRI tool that allows to easily assess the RBV. In this study we evaluated factors associated with RBV after skin or nipple sparing mastectomy (SSM/NSM) in breast cancer BRCA pathogenic variant (PV) carriers who underwent both therapeutic and risk reducing SSM/NSM and its relation to breast cancer outcomes using an innovative MRI-based tool.

METHODS

Data of breast cancer BRCA PV who were treated between 2006 and 2020 were retrieved from of the oncogenetics unit databases. Only patients who underwent SSM/NSM and had a postoperative breast MRI available for analysis were included. Data collected included demographics, clinicopathological features, and outcomes. The MRI tool was developed by a breast cancer imaging laboratory. A logistic regression test and 95% confidence interval (CI) were used to assess the associated risk of increased RBV. A forward stepwise linear regression was used to correlate tumour-patient specific factors and RBV, and a Kaplan-Meier curve to show the probability of locoregional relapse.

RESULTS

A total of 84 patients undergoing 89 mastectomies were included. At a median follow-up of 98 months, 5 local, 2 regional, and 4 distant recurrences were observed. RBV was not significantly related with breast cancer outcomes (p value = NS). A higher body mass index (BMI) was associated with a higher RBV (p < 0.0001). A larger number of involved axillary nodes was associated with a smaller RBV (p = 0.025). The RBV on the risk-reducing mastectomy side was significantly higher compared to the breast cancer side (p value = 0.007). Local recurrences occurred in the vicinity of the primary tumour.

Updated findings of skin flap thickness and residual breast tissue after mastectomy for breast cancer: a systematic review of the literature

BACKGROUND

There is limited evidence on the ideal retention thickness of skin flap in mastectomy. Residual breast tissue (RBT) after mastectomy still represents an unknown risk for local recurrence or new breast cancer lesions. We made this systematic review to identify the optimal flap after mastectomy with minimal complications and better oncological safety.

METHODS

A systematic review was performed using MEDLINE search in PubMed, Embase, and Cochrane Library with the search terms relevant to skin flap thickness and residual breast tissue in breast cancer patients undergoing mastectomy.

RESULTS

Twenty-one studies were included of which fifteen studies enrolled 3814 patients who received mastectomy, and additional six studies were based on cadavers or breast specimens. Four studies confirmed the presence of the superficial fascial layer (Camper's fascia) which can theoretically be used as an anatomical marker for flap retention during mastectomy. Two other studies confirmed Camper's fascia deficiency to a greater or lesser extent. The flap thickness ranged from 3.8 mm to 23 mm in 2692 patients of 7 studies, which was related to BMI, breast size, and examination modalities. Two retrospective and one prospective studies confirmed flaps exceeding 5 mm could significantly increase postoperative complications. Nine studies including 1122 patients explored the association among flap thickness, RBT, and complications, 3 studies of which confirmed excessive flap thickness could cause a significant increase in RBT, which proved to be a potential risk factor for local recurrence in 3 studies. Flaps beyond 5 mm were also found to significantly increase the chance of local recurrence in 4 studies.

CONCLUSION

Camper's fascia can serve as an ideal demarcation between fat and breast tissue based on most current studies. 5 mm thickness of the flap retention in mastectomy is recommended if Camper's fascia is absent or obscure, through which better cosmetic outcomes and less RBT can be achieved.

Delay in the initiation of adjuvant chemotherapy in patients with breast cancer with mastectomy with or without immediate breast reconstruction

BACKGROUND

Patients with breast cancer undergoing mastectomy should be offered the option of immediate breast reconstruction (IBR). The aim of this retrospective study was to assess whether there is a delay in the initiation of adjuvant chemotherapy in patients undergoing mastectomy with or without IBR.

METHOD

The study included patients aged 70 years or younger with clinically node-negative breast cancer who underwent unilateral mastectomy with IBR (IBR group) or mastectomy alone (no-IBR group) followed by adjuvant chemotherapy at the Helsinki University Hospital between January 2012 to July 2018.

RESULTS

A total of 645 patients were included; 186 in the IBR group and 459 in the no-IBR group. Sixty-six (35.5 per cent) patients in the IBR group and 102 (22.2 per cent) patients in the no-IBR group received their first chemotherapy cycle later than 6 weeks after surgery (P < 0.001). The respective numbers for later than 8 weeks were 17 (9.1 per cent) and 14 (3.1 per cent) (P = 0.001). Among all 645 patients, postoperative complications were a significant risk factor for a delay in the initiation of chemotherapy. Sixty-seven (39.9 per cent) patients with and 101 (21.2 per cent) patients without complications had a delay in chemotherapy (P < 0.001). The delay in chemotherapy was due to complications in 39 (59.1 per cent) in the IBR group and in 28 (27.5 per cent) in the no-IBR group (P < 0.001).

CONCLUSION

Patients undergoing mastectomy alone were more likely to receive adjuvant chemotherapy within 6 weeks after surgery compared with the IBR patients. IBR significantly increased the risk of postoperative complications in comparison with mastectomy alone. The complications, in turn, were a significant risk factor for delay in adjuvant chemotherapy.

Pattern of local recurrence after mastectomy and reconstruction in breast cancer patients: a systematic review

Background

This study aimed to describe the locations of local recurrences based on the mastectomy and reconstruction type in breast cancer patients.

Methods

In November 2020, a systematic literature review was performed through MEDLINE/PubMed and the Cochrane Centre Register of Controlled Trials. Publications that included skin-sparing or nipple-sparing mastectomy followed by breast reconstruction and described the location of local recurrences were analyzed. Exclusion criteria included salvage or prophylactic mastectomy, unclear distinction between local and regional recurrences, rare tumor types.

Results

From 19 publications, 272 local recurrences lesions were reported in a total of 4,787 patients. After autologous reconstruction (n=2,465), local recurrences were located in the skin in 45 (1.8%) patients, in the chest wall in 18 (0.7%), and in the nipple-areolar complex in 9 (0.4%). After implant reconstruction (n=1,917), local recurrences sites included the skin in 91 (4.7%) patients, chest wall in 8 (0.4%), and nipple-areolar complex in 8 (0.4%). Of the 70 lesions with reported in-breast location, 57 (81.4%) relapsed in the original tumor location.

Discussion

Although meta-analysis was not conducted, present analysis demonstrated that most local recurrences after skin-sparing or nipple-sparing mastectomy occurred within the skin or subcutaneous tissues. It was found that the original tumor location was the most frequent site of relapse. Therefore, special attention should be paid to the original tumor overlying the skin while planning postmastectomy radiation therapy.