1
|
Geers J, Wildiers H, Van Calster K, Laenen A, Floris G, Vandevoort M, Fabre G, Nevelsteen I, Smeets A. Oncological safety of autologous breast reconstruction after mastectomy for invasive breast cancer. BMC Cancer 2018; 18:994. [PMID: 30340548 PMCID: PMC6194715 DOI: 10.1186/s12885-018-4912-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Accepted: 10/08/2018] [Indexed: 11/11/2022] Open
Abstract
Background The number of patients requesting autologous breast reconstruction (ABR) after mastectomy for breast cancer has increased over the past decades. However, concern has been expressed about the oncological safety of ABR. The aim of our study was to assess the effect of ABR on distant relapse. Methods In this retrospective cohort study, data was analysed from patients who underwent mastectomy for invasive breast cancer in University Hospitals Leuven between 2000 and 2011. In total, 2326 consecutive patients were included, 485 who underwent mastectomy with ABR and 1841 who underwent mastectomy alone. The risk of relapse in both groups was calculated using a Cox proportional hazards analysis, adjusted for established prognostic factors. ABR was considered as a time-dependent variable. Additionally, the evolution of the risk over follow-up time was calculated. Results With a median follow-up of 68 months, 8% of patients in the reconstruction group developed distant metastases compared to 15% in the mastectomy alone group (univariate HR 0.70, 95% CI 0.50–0.97, p = 0.0323). However, after adjustment for potential confounding factors in a Cox multivariable analysis, the risk of distant relapse was no longer significantly different between groups (multivariate HR 0.82, 95% CI 0.55–1.22, p = 0.3301). Moreover, the risk of metastasis after reconstruction was not time-dependent. Conclusions These findings suggest that there is no effect of ABR on distant relapse rate and thus that ABR is an oncological safe procedure. The rate of local recurrence was too low to make any significant conclusions.
Collapse
Affiliation(s)
- Joachim Geers
- Multidisciplinary Breast Centre, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Hans Wildiers
- Multidisciplinary Breast Centre, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium.,Department of General Medical Oncology, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Katrien Van Calster
- Multidisciplinary Breast Centre, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Annouschka Laenen
- Department of Public Health and Primary Care, Interuniversity Institute of Biostatistics and Statistical Bioinformatics, University Hospitals Sint-Raphaël, Kapucijnenvoer 35, blok D, bus 7001, 3000, Leuven, Belgium
| | - Giuseppe Floris
- Multidisciplinary Breast Centre, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium.,Department of Imaging and Pathology, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Marc Vandevoort
- Multidisciplinary Breast Centre, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium.,Department of Plastic, Reconstructive and Aesthetic Surgery, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Gerd Fabre
- Multidisciplinary Breast Centre, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium.,Department of Plastic, Reconstructive and Aesthetic Surgery, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Ines Nevelsteen
- Multidisciplinary Breast Centre, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium.,Department of Oncology, Surgical Oncology University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Ann Smeets
- Multidisciplinary Breast Centre, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium. .,Department of Oncology, Surgical Oncology University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium.
| |
Collapse
|
2
|
Grandhi RK, Lee S, Abd-Elsayed A. The Relationship Between Regional Anesthesia and Cancer: A Metaanalysis. Ochsner J 2017; 17:345-361. [PMID: 29230120 PMCID: PMC5718448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023] Open
Abstract
BACKGROUND Some studies have suggested using epidural analgesia after cancer surgery to reduce metastasis. This article examines the relationship between regional anesthesia (RA) and cancer metastasis in an array of cancers. METHODS We conducted a review of the literature using PubMed and included 67,577 patients across 28 studies in a metaanalysis, evaluating the hazard ratios (HRs) of overall survival, recurrence-free survival, and biochemical recurrence-free survival. RESULTS We found no benefit to RA as it relates to cancer. The HR was 0.92 for overall survival, 1.06 for recurrence-free survival, and 1.05 for biochemical recurrence-free survival. Despite the overall analysis showing no benefit, we found some benefit when we evaluated only the randomized trials. However, we found no significant benefit of RA when we evaluated the cancers (gastrointestinal, prostate, breast, and ovarian) individually. CONCLUSION This metaanalysis shows that RA has no overall survival, recurrence-free survival, or biochemical recurrence-free survival benefit. However, some individual studies have shown significant benefit in terms of cancer recurrence. Further, RA reduces the use of opioids, which has led to some secondary benefits. Further studies are needed to establish the benefits of RA as it relates to cancer.
Collapse
Affiliation(s)
- Ravi K. Grandhi
- Department of Anesthesiology, Maimonides Medical Center, Brooklyn, NY
| | - Samuel Lee
- Department of Anesthesiology, University of Cincinnati, Cincinnati, OH
| | - Alaa Abd-Elsayed
- Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, Madison, WI
| |
Collapse
|
3
|
Cerebral protection: inflammation, endothelial dysfunction, and postoperative cognitive dysfunction. Curr Opin Anaesthesiol 2014; 27:89-97. [PMID: 24300462 DOI: 10.1097/aco.0000000000000032] [Citation(s) in RCA: 91] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE OF REVIEW Postoperative cognitive dysfunction (POCD) is a well recognized perioperative syndrome, with approximately 15% of patients over the age of 60 years displaying objectively measured decrease in cognitive function as a consequence of anesthesia and surgery. The exact cause, however, remains unknown. This review aims to update anesthesiologists on the recent advancements in the understanding of the pathophysiology of POCD. RECENT FINDINGS Recent evidence suggests that the observed predilection to POCD is likely mediated by a neuro-inflammatory response - with surgery being a major contributing factor. The blood-brain barrier, a highly specialized endothelial layer, is exquisitely sensitive to an inflammatory insult and implicated in the cause of other neurocognitive syndromes also characterized by neuro-inflammation such as cerebral malaria. Inflammatory changes may disrupt the blood-brain barrier and facilitate migration of macrophages into the brain, damaging synapses and neurones and ultimately lead to POCD. This review explores the important question of causality - the potential relationship between inflammation, endothelial dysfunction, and postoperative cognitive decline. SUMMARY Recent research points to a central role of a neuro-inflammatory cascade in POCD, with endothelial dysfunction potentially aggravating the insult. Investigating the genomic and molecular mechanisms that underlie the intervariation in the inflammatory response to surgery, improving the identification of appropriate endothelial and inflammatory biomarkers, and developing endothelial modulatory and anti-inflammatory (prevention and resolution) strategies are key areas of future translational research. This is important as the elderly, who show increased susceptibility to this and other perioperative illness syndromes, represent an ever-increasing proportion of patients presenting for surgery.
Collapse
|
4
|
Ash SA, Buggy DJ. Does regional anaesthesia and analgesia or opioid analgesia influence recurrence after primary cancer surgery? An update of available evidence. Best Pract Res Clin Anaesthesiol 2013; 27:441-56. [PMID: 24267550 DOI: 10.1016/j.bpa.2013.10.005] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2013] [Accepted: 10/07/2013] [Indexed: 12/12/2022]
Abstract
Cancer continues to be a key cause of morbidity and mortality worldwide and its overall incidence continues to increase. Anaesthetists are increasingly faced with the challenge of managing cancer patients, for surgical resection to debulk or excise the primary tumour, or for surgical emergencies in patients on chemotherapy or for the analgesic management of disease- or treatment-related chronic pain. Metastatic recurrence is a concern. Surgery and a number of perioperative factors are suspected to accelerate tumour growth and potentially increase the risk of metastatic recurrence. Retrospective analyses have suggested an association between anaesthetic technique and cancer outcomes, and anaesthetists have sought to ameliorate the consequences of surgical trauma and minimise the impact of anaesthetic interventions. Just how anaesthesia and analgesia impact cancer recurrence and consequent survival is very topical, as understanding the potential mechanisms and interactions has an impact on the anaesthetist's ability to contribute to the successful outcome of oncological interventions. The outcome of ongoing, prospective, randomized trials are awaited with interest.
Collapse
Affiliation(s)
- Simon A Ash
- Mater Misericordiae University Hospital, Eccles Street, Dublin 7, Ireland.
| | | |
Collapse
|
5
|
Katharina P. Tumor cell seeding during surgery-possible contribution to metastasis formations. Cancers (Basel) 2011; 3:2540-53. [PMID: 24212822 PMCID: PMC3757431 DOI: 10.3390/cancers3022540] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2011] [Revised: 05/23/2011] [Accepted: 05/26/2011] [Indexed: 01/11/2023] Open
Abstract
In spite of optimal local control in breast cancer, distant metastases can develop as a systemic part of this disease. Surgery is suspected to contribute to metastasis formation activating dormant tumor cells. Here we add data that seeding of cells during surgery may add to the risk of metastasis formation. The change in circulating epithelial tumor cells (CETC) was monitored in 66 breast cancer patients operated on with breast conserving surgery or mastectomy and during the further course of the disease, analyzing CETC from unseparated white blood cells stained with FITC-anti-EpCAM. An increase in cell numbers lasting until the start of chemotherapy was observed in about one third of patients. It was more preeminent in patients with low numbers of CETC before surgery and, surprisingly, in patients without involved lymph nodes. Patients with the previously reported behavior—Reincrease in cell numbers during adjuvant chemotherapy and subsequent further increase during maintenance therapy—were at increased risk of relapse. In addition to tumor cells already released during growth of the tumor, cell seeding during surgery may contribute to the early peak of relapses observed after removal of the primary tumor and chemotherapy may only marginally postpone relapse in patients with aggressively growing tumors.
Collapse
Affiliation(s)
- Pachmann Katharina
- Department of Experimental Hematology and Oncology, Clinic for Internal Medicine II, Friedrich Schiller University, Jena D-07747, Germany.
| |
Collapse
|
6
|
Retsky MW. Guest Editor's Concluding Remarks-Advances in Usage of ANN, Discussion of an Unsolved Problem, and Some Differences between Papers Written by Engineers and by Physicians. SENSORS (BASEL, SWITZERLAND) 2009; 9:8126-8129. [PMID: 22408497 PMCID: PMC3292099 DOI: 10.3390/s91008126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/05/2009] [Revised: 08/18/2009] [Accepted: 08/28/2009] [Indexed: 05/31/2023]
Affiliation(s)
- Michael W Retsky
- Harvard Medical School, Children's Hospital, Karp Family Research Labs 12, 300 Longwood Ave., Boston, MA 02115, USA; E-Mail:
| |
Collapse
|