Breast Reconstruction Following Cancer Treatment

Immediate breast reconstruction in breast cancer patients with the use of Serasynth and SeragynBR synthetic meshes. Single-oncological center experience, analysis of complications

<br><b>Introduction:</b> The use of meshes in mastectomies with immediate breast reconstruction (IBR) has become the gold standard.</br> <br><b>Aim:</b> The use of meshes in mastectomies with immediate breast reconstruction (IBR) has become a gold standard. The purpose of the study was to analyze the complications and own experience with the use of Serasynth fully absorbable and SeragynBR partially absorbable synthetic meshes.</br> <br><b>Material and methods:</b> In the period from December 2017 to July 2020, 118 IBR were performed in the Author's Department with the use of SeragynBR and Serasynth meshes in 93 patients operated for breast cancer. 78 Serasynth meshes (Group 1) and 40 SeragynBR meshes (Group 2) were implanted.</br> <br><b>Results:</b> The most common complication was persistent seroma collection, which was reported in 17.9% of cases in Group 1 and 25% in Group 2. Skin inflammation was reported in 7.6% and 17.5%, while infections in 2.5% and 5% of the operated breasts in Group 1 and Group 2. Reoperation was required in 5.1% and 5% of the patients in Group 1 and Group 2. The percentage of complications was lower when Serasynth rather than Seragyn BR meshes were implanted. The frequent incidence of the seroma collection did not contribute in any significant way to serious complications such as removal of mesh/implant or infection. The complications, which developed following the implantation of both mesh types, were similar to those presented in other publications concerning mastectomy with IBR with the use of synthetic meshes. The percentage of implant losses/explanations in the discussed groups was lower than that reported in the literature.</br> <br><b>Conclusion:</b> Despite the complications, both types of meshes can be considered as safe additions to reconstructive breast surgeries.</br> <br><b>Level of Evidence:</b> Level III.</br>.

[Update and Trends in Breast Reconstruction After Mastectomy]

Due to refinements in operating techniques, autologous breast reconstruction has become part of standard care. It has become more difficult to advise patients due to the expansion of oncologic options for mastectomy, radiation therapy and the variety of reconstructive techniques. The goal of reconstruction is to achieve oncologically clear margins and a long-term aesthetically satisfactory result with a high quality of life. Immediate reconstruction preserves the skin of the breast and its natural form and prevents the psychological trauma associated with mastectomy. However, secondary reconstructions often have a higher satisfaction, since here no restitutio ad integrum is assumed. Alloplastic, i. e., implant-based, breast reconstruction and autologous breast reconstruction are complementary techniques. This article provides an overview of current options for breast reconstruction including patients' satisfaction and quality of life following breast reconstruction. Although immediate reconstruction is still the preferred choice of most patients and surgeons, delayed reconstruction does not appear to compromise clinical or patient-reported outcomes. Recent refinements in surgical techniques and autologous breast reconstruction include stacked-flaps, as well as microsurgical nerve coaptation to restore sensitivity, which lead to improved outcomes and quality of life. Nowadays Skin-sparing and nipple-sparing mastectomy, accompanied by improved implant quality, allows immediate prosthetic breast reconstruction as well as reemergence of the prepectoral implantation. The choice of breast reconstruction depends on the type of mastectomy, necessary radiation, individual risk factors, as well as the patient's habitus and wishes. Overall, recent developments in breast reconstruction led to an increase in patient satisfaction, quality of life and aesthetic outcome with oncological safety.

The therapeutic effect of adipose-derived stem cells on soft tissue injury after radiotherapy and their value for breast reconstruction

Background

Postmastectomy radiotherapy is considered to be a necessary treatment in the therapy of breast cancer, while it will cause soft tissue damage and complications, which are closely related to the success rate and effectiveness of breast reconstruction. After radiotherapy, cutaneous tissue becomes thin and brittle, and its compliance decreases. Component fat grafting and adipose-derived stem cell therapy are considered to have great potential in treating radiation damage and improving skin compliance after radiotherapy.

Main body

In this paper, the basic types and pathological mechanisms of skin and soft tissue damage to breast skin caused by radiation therapy are described. The 2015–2021 studies related to stem cell therapy in PubMed were also reviewed. Studies suggest that adipose-derived stem cells exert their biological effects mainly through cargoes carried in extracellular vesicles and soluble secreted factors. Compared to traditional fat graft breast reconstruction, ADSC therapy amplifies the effects of stem cells in it. In order to obtain a more purposeful therapeutic effect, proper stem cell pretreatment may achieve more ideal and safe results.

Conclusion

Recent research works about ADSCs and other MSCs mainly focus on curative effects in the acute phase of radiation injury, and there is little research about treatment of chronic phase complications. The efficacy of stem cell therapy on alleviating skin fibrosis and its underlying mechanism require further research.

Sub-Muscular Direct-to-Implant Immediate Breast Reconstruction in Previously Irradiated Patients Avoiding the Use of ADM: A Preliminary Study

BACKGROUND

The aim of this paper is to present a preliminary experience of sub-muscular primary direct-to-implant (DTI) breast reconstruction without acellular dermal matrix (ADM), after salvage mastectomy for local recurrence following prior irradiation.

METHODS

A retrospective investigation was performed on a prospectively maintained database of breast reconstruction cases at our institution between January 2015 and December 2020. We considered only immediate DTI breast reconstructions without ADM following radiotherapy and salvage mastectomy for local recurrence, with at least a 12-month follow-up.

RESULTS

The study considered 18 female patients with an average of 68 years. According to the BREAST-Q questionnaire, all patients reported high levels of "satisfaction with outcome" with good "psychosocial wellness" and "physical impact" related to the reconstruction. The aesthetic evaluation showed a significant difference between the VAS score gave by the patient (mean 6.9) and the surgeon (mean 5.4). No implant exposure occurred in this series. In terms of complications, four patients (22%) suffered from wound dehiscence and were managed conservatively. Three patients (17%) required primary closure in day surgery following superficial mastectomy flap necrosis. Late capsular contracture was seen in seven patients (four Baker stage II and three Baker stage III, totally 39%); however, no patient was willing to undergo implant exchange.

CONCLUSIONS

DTI breast reconstruction following prior irradiation can be considered as an option in patients who are not good candidates for autologous breast reconstruction. Our general outcomes compared favorably with literature data regarding the use of staged procedures, with acceptable complication rates and levels of patient satisfaction.

Cost-utility analysis of risk-reducing strategies to prevent breast and ovarian cancer in BRCA-mutation carriers in Switzerland

OBJECTIVE

We aimed to identify the most cost-effective of all prophylactic measures available in Switzerland for women not yet affected by breast and ovarian cancer who tested positive for a BRCA1/2 mutation.

METHODS

Prophylactic bilateral mastectomy (PBM), salpingo-oophorectomy (PBSO), combined PBM&PBSO and chemoprevention (CP) initiated at age 40 years were compared with intensified surveillance (IS). A Markov model with a life-long time horizon was developed from the perspective of the Swiss healthcare system using mainly literature-derived data to evaluate costs, quality-adjusted life years (QALYs) and survival. Costs and QALYs were discounted by 3% per year. Robustness of the results was tested with deterministic and probabilistic sensitivity analyses.

RESULTS

All prophylactic measures were found to be cost-saving with an increase in QALYs and life years (LYs) compared to IS. PBM&PBSO were found to be most cost-effective and dominated all other strategies in women with a BRCA1 or BRCA2 mutation. Lifetime costs averaged to 141,293 EUR and 14.5 QALYs per woman with a BRCA1 mutation under IS, versus 76,639 EUR and 19.2 QALYs for PBM&PBSO. Corresponding results for IS per woman with a BRCA2 mutation were 102,245 EUR and 15.5 QALYs, versus 60,770 EUR and 19.9 QALYs for PBM&PBSO. The results were found to be robust in sensitivity analysis; no change in the dominant strategy for either BRCA-mutation was observed.

CONCLUSION

All more invasive strategies were found to increase life expectancy and quality of life of women with a BRCA1 or BRCA2 mutation and were cost-saving for the Swiss healthcare system compared to IS.

[Hybrid Breast Reconstruction Following Mastectomy]

The challenge following mastectomy is to safely reconstruct breasts of adequate size, shape, symmetry, softness, and sensation ("6 S"). Historically, patients have been offered two reconstructive modalities, namely either implant-based or autologous reconstruction. While this binary approach is appropriate for most patients, there remain a subset of patients for whom this simplistic approach is not suitable. For these, hybrid reconstruction, i. e., the combination of an implant with microsurgical tissue transfer, offers the possibility of individualised reconstruction, which avoids some of the limitations of traditional approaches. Hybrid breast reconstruction, thus expands the indications for microsurgical reconstruction and offers the advantages of this reconstructive modality to a larger patient population. In this article, the surgical technique of hybrid breast reconstruction is described, along with a discussion of important parameters related to this reconstructive modality, including plane and timing of implant placement, and the issue of radiotherapy.

Human Acellular Dermal Matrix (Epiflex®) in Immediate Implant-Based Breast Reconstruction after Skin- and Nipple-Sparing Mastectomy and Treatment of Capsular Fibrosis: Results of a Multicenter, Prospective, Observational NOGGO-AWOGyn Study

Background

Over the last decades, the number of acellular dermal matrix (ADM)-assisted implant-based breast reconstructions (IBBR) has substantially increased. However, there is still a lack of prospective data on complication rates.

Methods

We performed a non-interventional, multicenter, prospective cohort study to evaluate complication rates of a human ADM in patients undergoing an IBBR after skin- and nipple-sparing mastectomies. Patients with primary reconstruction (cohort A) and patients undergoing a secondary reconstruction after capsular fibrosis (cohort B) using the human ADM Epiflex® (DIZG gGmbH, Berlin, Germany) were enrolled in this study. Patients were followed-up for 12 months after surgery.

Results

Eighty-four eligible patients were included in this study of whom 28 women underwent a bilateral breast reconstruction, leading to 112 human ADM-assisted reconstructions in total (cohort A: 73, cohort B: 39). In 33.0% of the reconstructed breasts at least one of the complications of primary interest occurred, including implant loss 7.1%, seroma 15.2%; infection 5.4%, rash 8.0%, and Baker grade III/IV capsular fibrosis 2.7%, with no statistically significant differences between the cohorts. Previous radiation therapy was significantly associated with occurrence of any postoperative complication (OR 20.41; p value 0.027).

Conclusion

The rates of most complications were comparable to the rates reported for other ADMs with relatively low rates of capsular fibrosis and infections. The rate of seroma was increased in our study. Prior radiation therapy increased the risk of any postoperative complications. Therefore, the use of ADM in these patients should be considered carefully.

A Novel Method of Outcome Assessment in Breast Reconstruction Surgery: Comparison of Autologous and Alloplastic Techniques Using Three-Dimensional Surface Imaging

BACKGROUND

Breast reconstruction is an important coping tool for patients undergoing a mastectomy. There are numerous surgical techniques in breast reconstruction surgery (BRS). Regardless of the technique used, creating a symmetric outcome is crucial for patients and plastic surgeons. Three-dimensional surface imaging enables surgeons and patients to assess the outcome's symmetry in BRS. To discriminate between autologous and alloplastic techniques, we analyzed both techniques using objective optical computerized symmetry analysis. Software was developed that enables clinicians to assess optical breast symmetry using three-dimensional surface imaging.

METHODS

Twenty-seven patients who had undergone autologous (n = 12) or alloplastic (n = 15) BRS received three-dimensional surface imaging. Anthropomorphic data were collected digitally using semiautomatic measurements and automatic measurements. Automatic measurements were taken using the newly developed software. To quantify symmetry, a Symmetry Index is proposed.

RESULTS

Statistical analysis revealed that there is no difference in the outcome symmetry between the two groups (t test for independent samples; p = 0.48, two-tailed).

CONCLUSION

This study's findings provide a foundation for qualitative symmetry assessment in BRS using automatized digital anthropometry. In the present trial, no difference in the outcomes' optical symmetry was detected between autologous and alloplastic approaches. Level of evidence Level IV.

LEVEL OF EVIDENCE IV

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 .

Nationwide population-based study of the impact of immediate breast reconstruction after mastectomy on the timing of adjuvant chemotherapy

BACKGROUND

Initiation of adjuvant chemotherapy within 6-12 weeks after mastectomy is recommended by guidelines. The aim of this population-based study was to investigate whether immediate breast reconstruction (IBR) after mastectomy reduces the likelihood of timely initiation of adjuvant chemotherapy.

METHODS

All patients with breast cancer who had undergone mastectomy and adjuvant chemotherapy between 2012 and 2016 in the Netherlands were identified. Time from surgery to adjuvant chemotherapy was categorized as within 6 weeks or after more than 6 weeks, within 9 weeks or after more than 9 weeks, and within 12 weeks or after more than 12 weeks. The impact of IBR on the initiation of adjuvant chemotherapy for these three scenarios was estimated using propensity score matching to adjust for treatment by indication bias.

RESULTS

A total of 6300 patients had undergone primary mastectomy and adjuvant chemotherapy, of whom 1700 (27·0 per cent) had received IBR. Multivariable analysis revealed that IBR reduced the likelihood of receiving adjuvant chemotherapy within 6 weeks (odds ratio (OR) 0·76, 95 per cent c.i. 0·66 to 0·87) and 9 weeks (0·69, 0·54 to 0·87), but not within 12 weeks (OR 0·75, 0·48 to 1·17). Following propensity score matching, IBR only reduced the likelihood of receiving adjuvant chemotherapy within 6 weeks (OR 0·95, 0·90 to 0·99), but not within 9 weeks (OR 0·97, 0·95 to 1·00) or 12 weeks (OR 1·00, 0·99 to 1·01).

CONCLUSION

Postmastectomy IBR marginally reduced the likelihood of receiving adjuvant chemotherapy within 6 weeks, but not within 9 or 12 weeks. Thus, IBR is not contraindicated in patients who need adjuvant chemotherapy after mastectomy.

Clinical Approaches to Breast Reconstruction: What Is the Appropriate Reconstructive Procedure for My Patient?

Breast reconstruction after breast cancer is an emotional subject for women. Consequently, the correct timing and surgical procedure for each individual woman are important. In general, heterologous or autologous reconstructive procedures are available, both having advantages and disadvantages. Breast size, patient habitus, and previous surgeries or radiation therapy need to be considered, independent of the chosen procedure. New surgical techniques, refinement of surgical procedures, and the development of supportive materials have increased the general patient collective eligible for breast reconstruction. This review highlights the different approaches to immediate breast reconstruction using autologous or heterologous techniques.

Prophylactic Surgery: For Whom, When and How?

Risk-reducing surgery has proved to be a reasonable procedure in healthy women with a definitely elevated risk of developing cancer. Here we consider the elevated risk of breast and ovarian cancer. There is a clear indication for such surgery in healthy women with a pathogenic BRCA1/2 mutation. For these patients, a risk-reducing bilateral mastectomy leads to a verifiable reduction in mortality from breast cancer, particularly for young patients. In most cases, surgery is combined with breast reconstruction. The pros and cons of surgical treatment and the different surgical techniques have to be explained to and carefully considered with the patient. As yet, no unequivocal data for the benefits of intensifying early detection have been ascertained with respect to mortality from breast carcinoma. In index patients with a BRCA mutation, the surgical treatment should depend on the prognosis of the primary disease. A lower age at onset and a better prognosis of the primary disease make a contralateral mastectomy (CPM) more reasonable. In the case of BRCA mutation-related cancer, a reduction of mortality through CPM has been proven. A risk-reducing adnexectomy is basically recommended for BRCA mutation carriers. Healthy premenopausal women need a subsequent hormone replacement therapy. The prognosis of the patients is dominated by the ovarian carcinoma. This can be prevented by risk-reducing salpingo-oophorectomy in 95% of the cases.

Neoadjuvant radiotherapy followed by mastectomy and immediate breast reconstruction : An alternative treatment option for locally advanced breast cancer

BACKGROUND

The optimal sequence of mastectomy with immediate breast reconstruction (IBR) and radiotherapy (RT) for the treatment of locally advanced breast cancer (LABC) is still under debate. Increased rates of postoperative complications are described following postmastectomy RT. Neoadjuvant RT aims to improve the aesthetic results and simplify the reconstructive pathway.

PATIENTS

A total of 22 patients diagnosed with LABC and treated with neoadjuvant RT followed by mastectomy and IBR between 04/2012 and 03/2015 were retrospectively analyzed. RT consisted of external beam RT to the breast and the regional lymphatics, if indicated. Both implant-based and autologous tissue-transfer reconstruction techniques were used.

RESULTS

At the time of RT, 10 patients had no prior surgery and 12 patients had previously undergone breast-conserving surgery (BCS) with positive resection margins without the possibility to perform a second BCS. Additional neoadjuvant chemotherapy was administered in 18 patients prior to RT. A complete pathological response was achieved in 55.0% of patients. The 2‑year overall survival rate was 89.3%, the 2‑year disease-free-survival 79.8% and the local-recurrence-free survival was 95.2%. The cosmetic result was excellent or good in 66% of the patients treated with upfront mastectomy and 37% of the patients who had previously undergone BCS. Among patients who received implant-based IBR, 4 patients developed serious wound-healing problems with implant loss. The most satisfactory results were achieved with autologous tissue reconstruction.

CONCLUSION

A sequential neoadjuvant chemo-/radiotherapy to allow IBR following mastectomy in selected cases of LABC seems feasible and can be safely attempted. Careful patient selection, close monitoring, and continuous patient support is mandatory to ensure compliance in this treatment strategy.

A novel method to limit breast cancer stem cells in states of quiescence, proliferation or differentiation: Use of gel stress in combination with stem cell growth factors

The majority of cancer stem cells exist in the G0, or quiescent phase of the cell cycle. However, the cells can escape quiescence following routine radiotherapy and chemotherapy, resulting in tumor recurrence. Presently, achieving the accurate regulation of cancer stem cell growth in order to study a specific state, including the quiescent (mostly G0 or G1 phase), proliferative (mostly S phase) or differential (mostly G2/M phase) states, can be challenging. This makes the determination of cell cycle state-specific characteristics and analysis of potential intervention treatments difficult, particularly for quiescent cells. Breast cancer stem cells were cultured on a soft or hard agar matrix surface in the presence or absence of stem cell growth factors. Cells could be successfully limited in either the quiescent, proliferative or differentiated states. These findings provide a foundation for further study of the cell cycle in breast cancer stem cells.