Research on the influence of yogalates comprehensive rehabilitation training on postoperative recovery of breast cancer patients

BACKGROUND

In the present study, we analyzed the effects of comprehensive yogalates rehabilitation training on side effects caused by postoperative adjuvant treatment and postoperative physical and mental health in breast cancer patients who had undergone radical mastectomy.The purpose of this investigation was to test the hypothesis that 12 weeks of yogalates training would reduce the peripheral diameter of the upper arm, improve flexibility and posture, and improve sleep quality compared with a non-treated control group.

METHODS

36 women with breast cancer who had undergone radical mastectomy in Shanghai were selected and randomly divided into the experimental group (n=20) and the control group (n=16). The patients in the experimental group underwent yogalates comprehensive rehabilitation training, while the control group did not participate in yogalates course. Anthropometric measurements and the "Pittsburgh Sleep Quality Index (PSQI)" questionnaire were administered to both the experimental and control groups before and after the training sessions.

RESULTS

The experimental group corrected the hunchback posture through yogalates training. Spine extension increased their height and decreased their BMI. The range of motion of upper arm joints in extension, bending and abduction increased. The peripheral diameter of the upper arm decreased, the grip strength increased, and the sleep quality gradually improved.

CONCLUSION

(1)Prolonging the period of yogalates training stabilized and improve the physical and mental health of patients. (2)In yogalates course, providing proper guidance to patients for diaphragmatic breathing and incorporating yoga relaxation techniques can effectively enhance the sleep quality of patients.(3)Exercise regimens must be designed taking into account individual differences.

Impact of breast surgical procedure on survival in BRCA mutated patients with invasive breast cancer: Mastectomy versus conservative treatment

INTRODUCTION

Patients with BRCA1/2 mutations have a higher risk of developing breast cancer compared to the wild-type population. For patients with a BRCA mutation, there are no specific recommendations for surgical management. The aim of this study was therefore to retrospectively investigate overall survival (OS) and recurrence-free survival (RFS) of BRCA mutated patients with localized invasive breast cancer, by comparing conservative surgery versus mastectomy.

METHODS

This study was based on data from the Côte d'Or breast and gynecological cancer registry. Data from patients with a constitutional BRCA1/2 mutation who presented with invasive breast cancer were collected retrospectively from 1998 to 2018. The Kaplan-Meier method was used to describe RFS and OS.

RESULTS

A total of 104 patients were included in the analysis, of whom 69 had conservative surgery and 35 underwent mastectomy. Regarding survival, there was no significant difference in OS (HR =1.49; 95 % confidence interval (CI) [0.76-2.93], p = 0.25). Similarly, there was no significant difference in RFS (HR =1.40; 95 % CI [0.81-2.40], p = 0.22), survival without homolateral recurrence (HR =0.88; 95 % CI [0.30-2.61], p = 0.89), without contralateral recurrence (HR =1.50; 95 % CI [0.55-4.09], p = 0.42), or without distant metastatic recurrence (HR =1.42, 95 % CI [0.69-2.90], p = 0.33).

CONCLUSION

In invasive breast cancer in a patient with a germline BRCA1/2 mutation, conservative surgery, when possible, appears to be a feasible option over total mastectomy, with no difference in overall survival. However, the patient should be informed of the aggressive nature of recurrence in this population requiring chemotherapy in most cases.

Management of the axilla in breast cancer patients: critical review, regional modified Delphi consensus and implementation in the Tuscan breast network

PURPOSE

Data from recently trials have provided practice-changing recommendations in management of the axilla in early breast cancer (eBC). However, further controversies have been raised, resulting in heterogeneous diffusion of these recommendations. Our purpose was to obtain a better homogeneity.

MATERIAL AND METHODS

In 2021, the Tuscan Breast Network (TBN) established a consensus with the aim to update recommendations in this area. We performed a literature review on axillary management in eBC patients which led to an expert Delphi consensus aiming to explore the gray areas, build consensus and propose evidence-based suggestions for an appropriate management. Thereafter, we investigate their implementation in clinical practice.

RESULTS

(1) DCIS patients should have SLN biopsy only in case of mastectomy or in conservative surgery if tumor is in a location that would preclude future nodal sampling or in case of a mass; (2) ALND may be omitted for 1-2 positive SLN patients undergoing BCS in T1-2 tumors with 1-2 SLN positive, eligible for whole-breast irradiation and adjuvant systemic therapies; (3) consider the option of RNI in patients with 1-3 positive lymph nodes and one or more high-risk characteristics; (4) the population identified in 2) should NOT undergo lymph node irradiation as an alternative to axillary surgery and (5) patients with clinically (pre-operatively) positive axilla, or undergoing primary systemic therapy, or outside the criteria reported in 2) must receive additional ALND and/or RT as per local policy.

CONCLUSION

This consensus provided a practical tool to stimulate local and national breast surgical and radiotherapy protocols.

Immigration Status and Breast Cancer Surgery Quality of Care Metrics: A Population-Level Analysis

INTRODUCTION

As immigrant women face challenges accessing health care, we hypothesized that immigration status would be associated with fewer women with breast cancer receiving surgery for curable disease, fewer undergoing breast conserving surgery (BCS), and longer wait time to surgery.

METHODS

A population-level retrospective cohort study, including women aged 18-70 years with Stage I-III breast cancer diagnosed between 2010 and 2016 in Ontario was conducted. Multivariable analysis was performed to assess odds of undergoing surgery, receiving BCS and wait time to surgery.

RESULTS

A total of 31,755 patients were included [26,253 (82.7%) Canadian-born and 5502 (17.3%) immigrant women]. Immigrant women were younger (mean age 51.6 vs. 56.1 years) and less often presented with Stage I/II disease (87.4% vs. 89.8%) (both p < .001). On multivariable analysis, there was no difference between immigrant women and Canadian-born women in odds of undergoing surgery [Stage I OR 0.93 (95% CI 0.79-1.11), Stage II 1.04 (0.89-1.22), Stage III 1.22 (0.94-1.57)], receiving BCS [Stage I 0.93 (0.82-1.05), Stage II 0.96 (0.86-1.07), Stage III 1.00 (0.83-1.22)], or wait time [Stage I 0.45 (-0.61-1.50), Stage II 0.33 (-0.86-1.52), Stage III 3.03 (-0.05-6.12)]. In exploratory analysis, new immigrants did not have surgery more than established immigrants (12.9% vs. 10.1%), and refugee women had longer wait time compared with economic-class immigrants (39.5 vs. 35.3 days).

CONCLUSIONS

We observed differences in measures of socioeconomic disadvantage and disease characteristics between immigrant and Canadian-born women with breast cancer. Upon adjusting for these factors, no differences emerged in rate of surgery, rate of BCS, and time to surgery. The lack of disparity suggests barriers to accessing basic components of breast cancer care may be mitigated by the universal healthcare system in Canada.

Implications of Highly Penetrant Genetic Variants on Breast Surgery

It seems the most probable beneficiaries from the molecular era are those harboring hereditary genetic variants, which are responsible for 5% to 10% of all breast cancer diagnoses. There are several key implications of such variants on clinical practice, from expedited anticipation of primary cancer diagnoses, which can have their risk mitigated by risk reduction surgery, to pragmatism surrounding the management of male breast cancer patients. This communication discusses the implications of highly penetrant (or pathogenic) hereditary variants in contemporary breast surgery practice.

Do HER2-Low Tumors Have a Distinct Clinicopathologic Phenotype?

BACKGROUND

Breast cancer subtypes, distinguished by hormone receptor (HR) and HER2 status, have different clinicopathologic features. With recognition of the clinical relevance of HER2-low, there is debate as to whether this is a distinct subtype. Our study aimed to determine whether HER2-low breast cancers have specific clinicopathologic features that differ from those of HER2-negative and HER2-positive cancers.

PATIENTS AND METHODS

A total of 11,072 patients undergoing upfront surgery from 1998 to 2010 were identified from a single-institution prospectively maintained database. HER2 status was classified by immunohistochemistry (IHC)/fluorescence in situ hybridization (FISH) as HER2 negative (41.2%), HER2 low (45%; IHC 1+ or 2+ with negative FISH), and HER2 positive (13.7%), and stratified by HR status. Univariate (UVA) and multivariable multinomial logistic regression analysis (MVA) were performed to determine associations among variables and subtypes.

RESULTS

Compared with HER2-negative tumors, HER2 low was associated with lymphovascular invasion [odds ratio (OR) 1.2, 95% confidence interval (CI) 1.06-1.36; p = 0.003], multifocality (OR 1.26, 95% CI 1.12-1.42; p < 0.001), nodal micrometastasis (OR 1.15, 95% CI 1.02-1.31; p = 0.024), and lower rates of ≥ 3 positive nodes (OR 0.77, 95% CI 0.66-0.90, p = 0.001). When stratified by HR expression, in both HR-positive and HR-negative tumors, age and multifocality were associated with HER2 low on UVA. On MVA, no variables were independently associated with both HR-negative and HR-positive/HER2-low tumors compared with HER2-negative tumors. In contrast, HER2-positive tumors, regardless of HR status, were associated with multifocality and an extensive intraductal component.

CONCLUSION

Clinicopathologic features of HER2-low tumors appear to be primarily related to HR status. Our findings do not support the characterization of HER2 low as a separate subtype.

A New Level II Oncoplastic Technique for Inferior Pole Defects: The Three-Petal Glandular Reconstruction (3-PR)

INTRODUCTION

Oncoplastic surgery (OPS) allows wide excisions and accurate tumor resection and reduces breast deformities by immediate reconstruction of large defects. Superior pedicled mammaplasties allow excellent results in large breasts. Conversely, loco-regional flaps are the standard of care in small-to-medium breasts. However, both techniques show limitations in case of large resections of the lower pole, resulting in skin retraction and downward deviation of nipple and areola. We present a new technique for inferior pole reconstruction to overcome these limitations. It is called "the three-petal reconstruction" (3-PR).

METHODS

Between September 2016 and May 2019, ten patients with invasive breast cancer of the lower pole underwent breast conservation and 3-PR.

RESULTS

The 3-PR was uneventful in all patients. No major or minor complications were recorded. Patient and surgeon evaluations scored as good to excellent in all cases. Surveillance examinations in the follow-up did not reveal calcifications nor any findings of suspicion within the reconstructed area.

CONCLUSIONS

In case of very large defect of lower pole, the 3-PR reveals to be an easy, fast, reproducible method for inferior pole reconstruction. It can represent a niche between therapeutic mammaplasty and perforator flaps, and it could be added to existing available options for tailored reconstruction.

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 .

Contemporary Analysis of Reexcision and Conversion to Mastectomy Rates and Associated Healthcare Costs for Women Undergoing Breast-Conserving Surgery

PURPOSE

This study was designed to provide a comprehensive and up-to-date understanding of population-level reoperation rates and incremental healthcare costs associated with reoperation for patients who underwent breast-conserving surgery (BCS).

METHODS

This is a retrospective cohort study using Merative™ MarketScan® commercial insurance data and Medicare 5% fee-for-service claims data. The study included females aged 18-64 years in the commercial cohort and females aged 18 years and older in the Medicare cohort, who underwent initial BCS for breast cancer in 2017-2019. Reoperation rates within a year of the initial BCS and overall 1-year healthcare costs stratified by reoperation status were measured.

RESULTS

The commercial cohort included 17,129 women with a median age of 55 (interquartile range [IQR] 49-59) years, and the Medicare cohort included 6977 women with a median age of 73 (IQR 69-78) years. Overall reoperation rates were 21.1% (95% confidence interval [CI] 20.5-21.8%) for the commercial cohort and 14.9% (95% CI 14.1-15.7%) for the Medicare cohort. In both cohorts, reoperation rates decreased as age increased, and conversion to mastectomy was more prevalent among younger women in the commercial cohort. The mean healthcare costs during 1 year of follow-up from the initial BCS were $95,165 for the commercial cohort and $36,313 for the Medicare cohort. Reoperations were associated with 24% higher costs in both the commercial and Medicare cohorts, which translated into $21,607 and $8559 incremental costs, respectively.

CONCLUSIONS

The rates of reoperation after BCS have remained high and have contributed to increased healthcare costs. Continuing efforts to reduce reoperation need more attention.

Chronic pain after breast surgery: incidence, risk factors and impact on quality of life

INTRODUCTION AND OBJECTIVES

Breast cancer is the most frequently diagnosed malignancy, and chronic pain after breast surgery (CPBS) is an increasingly recognized therapy-related problem. We evaluated CPBS incidence, characteristics, associated factors, and impact on patient quality of life (QoL).

MATERIALS AND METHODS

Six-month observational prospective study conducted in patients undergoing breast surgery in a tertiary university hospital. Data were collected using several questionnaires: Pain Catastrophizing Scale, Brief Pain Inventory-Short Form, Douleur Neuropathique 4 Questionnaire, and European Organization for Research and Treatment of Cancer Quality of Life Questionnaire and its Breast Cancer Module.

RESULTS

A total of 112 patients completed the study. Approximately, one third (34.8%) developed CPBS, and almost all with potentially neuropathic pain. CPBS interfered with patients' daily life and reduced their QoL. Diabetes (p = 0.028), catastrophizing (p = 0.042), and acute postoperative pain severity (p < 0.001) were associated with CPBS.

CONCLUSIONS

This study broadens our understanding of CPBS and shows the impact of this syndrome. Healthcare workers need to be aware of CPBS and take steps to prevent and treat it, and provide patients with adequate information.

Modified oncoplastic lift, lymphatic excision, and reconstruction: Introduction of a novel technique in oncoplastic breast surgery with simple surgical principles

INTRODUCTION

Oncoplastic surgery is an important component of the management of breast cancer. As prognosis has improved, the need for proficient techniques to achieve disease eradication while maintaining cosmesis for naturally appearing breasts has gained importance. This study describes an easy-to-learn modified oncoplastic technique for patients undergoing breast-conserving treatment.

DESCRIPTION OF THE TECHNIQUE

Tumor resection is performed through different peri-areolar, inframammary, or radial incisions. To reduce the size of the surgical defect created after tissue resection, an internal purse-string is performed parallel to the chest wall or base of the wound with subsequent staggering in three or more layers as needed, while maintaining the parallel orientation of the needle. This is followed by the creation and overlapping of internal breast tissue flaps that are rearranged to decrease the dead space with the aim of improving cosmesis. The redundant skin is removed for the skin envelope to maintain shape. The wound is closed in layers. We also describe steps in performing sentinel lymph node and tumor extraction through the same periareolar, inframammary, or radial incisions for tumors located in outer quadrants. Following closure, contour and projection of the breast were maintained without indentation or loss of projection, with a symmetrical appearance to the contralateral side.

CONCLUSION

This simplified oncoplastic (MOLLER) technique can be easily learned and used by surgeons who treat cancer patients and have limited oncoplastic training. It uses basic known surgical principles to decrease the size of the defect created while minimizing the need for larger incisions/pedicles.

Recent Advances in the Upfront Surgical Management of the Axilla in Patients with Breast Cancer

Nodal status is an important prognostic indicator. Upfront axillary surgery for patients with breast cancer has historically been both diagnostic and therapeutic-serving to determine nodal status and inform adjuvant therapies, and to remove clinically significant disease. However, trials of de-escalation or omission of axillary surgery altogether consistently demonstrate noninferior oncologic outcomes in a wide variety of patient subsets. These strategies also reduce the morbidity associated with either sentinel lymphadenectomy or axillary lymph node dissection. Here we will briefly review landmark trials that have shaped upfront axillary surgery as well as recent advances, and discuss areas of ongoing investigation and future needs.

A systematic review of robotic breast surgery versus open surgery

Robotic-assisted breast surgery (RABS) is controversial. We systematically reviewed the evidence about RABS, comparing it to open conventional breast surgery (CBS). Following prospective registration (osf.io/97ewt), a search was performed in January 2023, without time or language restrictions, through bibliographic databases (PubMed, Web of Science, EMBASE, Scopus, Trip database and CDSR) and grey literature. Quality was assessed in duplicate using Qualsyst criteria (score range 0.0-1.0); reviewer agreement was 98%. The 16 selected studies (total patients: 334,804) had overall high quality (mean score 0.82; range 0.68-0.91). Nine of 16 (56.3%) were cohort studies, 2/16 (12.5%) RCTs, and 5/16 (31.3%) case-control studies. Taking p < 0.05 as the significance threshold, RABS versus CBS was better in aesthetic results and patient satisfaction (10/11 studies; 90%), was surgically costly (4/4 studies; 100%), time-consuming (9/13 studies; 69%), and less painful in the first 6-24 h (2/2 studies; 100%) and without statistically significant differences in complication rates (10/12 studies; 83%) or short-term oncological outcomes (10/10 studies; 100%). Surgical time could be dramatically reduced by training surgical teams, reaching no significant differences between approaches (p = 0.120). RABS was shown to be feasible and safe. The advantages of RABS and long-term outcomes need further research.

Serum lidocaine (lignocaine) concentrations during prolonged perioperative infusion in patients undergoing breast cancer surgery: A secondary analysis of a randomised controlled trial

Perioperative lidocaine (lignocaine) infusions are being employed with increasing frequency. The determinants of systemic lidocaine concentrations during prolonged administration are unclear. In the Long-term Outcomes after Lidocaine Infusions for PostOperative Pain (LOLIPOP) pilot trial, the impact of infusion duration and body size metrics on serum lidocaine concentrations was examined with regression models in 48 women undergoing breast cancer surgery. Lidocaine was delivered as an intravenous bolus (1.5 mg/kg) and infusion (2 mg/kg per h) intraoperatively, followed by a 12-h subcutaneous infusion (1.33 mg/kg per h) postoperatively. Dosing was based on total body weight. Wound infiltration with other long-acting local anaesthetics was permitted. Protein binding and pharmacogenomic data were also collected. Lidocaine concentrations (median (interquartile range) (range)) during prolonged administration were in the safe and potentially therapeutic range: post-anaesthesia care unit 2.16 (1.73-2.82) (1.12-6.06) µg/ml; ward 1.41 (1.22-1.75) (0.64-2.81) µg/ml. Concentrations increased non-linearly during the early intravenous phase of administration (mean rise 1.21 µg/ml per hour of infusion, P = 0.007) but reached a pseudo steady-state during the later subcutaneous phase. Higher dose rates received per kilogram of lean (P = 0.004), adjusted (P = 0.006) and ideal body weight (P = 0.009) were associated with higher steady-state concentrations. The lidocaine free fraction was unaffected by the presence of ropivacaine, and phenotypes linked to slow metabolism were infrequent. Serum lidocaine concentrations reached a pseudo steady-state during a 12-h postoperative infusion. Greater precision in steady-state concentrations can be achieved by dosing on lean body weight versus adjusted or ideal body weight (equivalent lean body weight doses: intravenous bolus 2.5 mg/kg; intravenous infusion 3.33 mg/kg per h; subcutaneous infusion 2.22 mg/kg per h.

Accuracy of Intraoperative Frozen Section Analysis of Lymph Nodes in Women Undergoing Axillary Sampling for Treatment of Breast Cancer: Single Institution Audit

BACKGROUND

Axillary lymph node (LN) positivity is an important prognostic factor in breast cancer. Almost 30% clinically node negative (cN0) early breast cancers have positive nodes on pathology, wherein an axillary dissection is done as a second stage surgery. Intra operative frozen section (FS) potentially avoids redo surgery.

MATERIALS AND METHODS

We performed a retrospective audit for the false negative rate of intraoperative FS, from 2014 to 2018. All cN0 women undergoing upfront surgery, who underwent low axillary sampling (LAS) with FS were included.

RESULTS

Of 22,854 breast cancer cases, 2230 underwent LAS, of which 877 were node positive. Intraoperative FS was negative in 1423/2230 (63.81%) cases, of which 71/1423 (4.98%) were false negative, and came positive on final histopathology report (HPR). These 71 women had a median of 5 nodes (mean 4.85) dissected on FS (range 1-12) with a median 1 (mean 1.3) node positive (range 1-6) on HPR. The sensitivity of FS was 91.89% (95% CI, 89.89-93.62), with a negative predictive value of 95.01% (95% CI, 93.84-95.97), accuracy of 96.73% (95% CI, 95.90-97.43) and false negative rate 4.98%. On logistic regression analysis, micrometastasis (Odds ratio (OR) 7.76, 95% CI, 3.49-17.25, P < .001) lobular histology (OR 2.50, 95% CI, 1.007-6.223, P = .04) and nodes dissected (OR 1.18, 95% CI, 1.07-1.30, P = .001) were associated with higher false negative FS, and extra nodal extension (OR 0.32, 95% CI, 0.18-0.57, P ≤ .001) with lower false negative FS.

CONCLUSION

The high concordance between intraoperative FS and definitive histology, suggests it's routine use for Sentinel lymph node/LAS LN can help avoid a second surgery.

The American Society of Breast Surgeons classification system for oncoplastic breast conserving surgery independently predicts the risk of delayed wound healing

INTRODUCTION

Oncoplastic breast conserving surgery (OBCS) aims to provide safe and satisfying surgery for breast cancer patients. The American Society of Breast Surgeons (ASBrS) classification system is based on volumetric displacement cut-offs (level I for <20% of breast volume; level II for 20-50%). It aims to facilitate communication among treating physicians and patients. Here, we investigate whether the extent of OBCS as classified by ASBrS independently predicts postoperative complications.

MATERIALS AND METHODS

This retrospective analysis of a prospectively maintained database included patients with stage I-III breast cancer who underwent OBCS between 03/2011 and 12/2020 at a Swiss university hospital. Outcomes included short-term (≤30 days) complications and chronic (>30 days) pain after surgery. Multivariate logistic regression models were used to identify independent predictors.

RESULTS

In total, 439 patients were included, 314 (71.5%) received ASBrS level I surgery, and 125 (28.5%) underwent ASBrS level II surgery. ASBrS level II was found to be an independent predictor of delayed wound healing (odds ratio [OR] 9.75, 95% confidence intervals (CI) 2.96-32.10). However, ASBrS level did not predict chronic postoperative pain (incidence rate ratio [IRR] 1.20, 95%CI 0.85-1.70), as opposed to age (IRR 1.19, 95%CI 1.11-1.27 per 5 years decrease), and weight disorders (underweight [BMI <18.5] vs. normal weight [BMI 18.5 < 25]: IRR 4.02, 95%CI 1.70-9.54; obese [BMI ≥30] vs. normal weight: IRR 2.07, 95%CI 1.37-3.13).

CONCLUSION

ASBrS level II surgery predicted delayed wound healing, warranting close clinical follow-up and prompt treatment to avoid delays in adjuvant therapy.

Evaluating Receptor-Specific Fresh Specimen Staining for Tumor Margin Detection in Clinical Breast Specimens

PURPOSE

Reliable and rapid identification of tumor in the margins of breast specimens during breast-conserving surgery to reduce repeat surgery rates is an active area of investigation. Dual-stain difference imaging (DDSI) is one of many approaches under evaluation for this application. This technique aims to topically apply fluorescent stain pairs (one targeted to a receptor-of-interest and the other a spectrally distinct isotype), image both stains, and compute a normalized difference image between the two channels. Prior evaluation and optimization in a variety of preclinical models produced encouraging diagnostic performance. Herein, we report on a pilot clinical study which evaluated HER2-targeted DDSI on 11 human breast specimens.

PROCEDURES

Gross sections from 11 freshly excised mastectomy specimens were processed using a HER2-receptor-targeted DDSI protocol shortly after resection. After staining with the dual-probe protocol, specimens were imaged on a fluorescence scanner, followed by tissue fixation for hematoxylin and eosin and anti-HER2 immunohistochemical staining. Receiver operator characteristic curves and area under the curve (AUC) analysis were used to assess diagnostic performance of the resulting images. Performance values were also compared to expression level determined from IHC staining.

RESULTS

Eight of the 11 specimens presented with distinguishable invasive ductal carcinoma and/or were not affected by an imaging artifact. In these specimens, the DDSI technique provided an AUC = 0.90 ± 0.07 for tumor-to-adipose tissue and 0.81 ± 0.15 for tumor-to-glandular tissue, which was significantly higher than AUC values recovered from images of the targeted probe alone. DDSI values and diagnostic performance did not correlate with HER2 expression level, and tumors with low HER2 expression often produced high AUC, suggesting that even the low expression levels were enough to help distinguish tumor.

CONCLUSIONS

The results from this preliminary study of rapid receptor-specific staining in human specimens were consistent with prior preclinical results and demonstrated promising diagnostic potential.

Trends in use of neoadjuvant systemic therapy in patients with clinically node-positive breast cancer in Europe: prospective TAXIS study (OPBC-03, SAKK 23/16, IBCSG 57-18, ABCSG-53, GBG 101)

PURPOSE

The aim of this study was to evaluate clinical practice heterogeneity in use of neoadjuvant systemic therapy (NST) for patients with clinically node-positive breast cancer in Europe.

METHODS

The study was preplanned in the international multicenter phase-III OPBC-03/TAXIS trial (ClinicalTrials.gov Identifier: NCT03513614) to include the first 500 randomized patients with confirmed nodal disease at the time of surgery. The TAXIS study's pragmatic design allowed both the neoadjuvant and adjuvant setting according to the preferences of the local investigators who were encouraged to register eligible patients consecutively.

RESULTS

A total of 500 patients were included at 44 breast centers in six European countries from August 2018 to June 2022, 165 (33%) of whom underwent NST. Median age was 57 years (interquartile range [IQR], 48-69). Most patients were postmenopausal (68.4%) with grade 2 and 3 hormonal receptor-positive and human epidermal growth factor receptor 2-negative breast cancer with a median tumor size of 28 mm (IQR 20-40). The use of NST varied significantly across the countries (p < 0.001). Austria (55.2%) and Switzerland (35.8%) had the highest percentage of patients undergoing NST and Hungary (18.2%) the lowest. The administration of NST increased significantly over the years (OR 1.42; p < 0.001) and more than doubled from 20 to 46.7% between 2018 and 2022.

CONCLUSION

Substantial heterogeneity in the use of NST with HR+/HER2-breast cancer exists in Europe. While stringent guidelines are available for its use in triple-negative and HER2+ breast cancer, there is a need for the development of and adherence to well-defined recommendations for HR+/HER2-breast cancer.

Value of Ambulatory Modified Radical Mastectomy

BACKGROUND

Modified radical mastectomy (MRM) still is largely performed in inpatient settings. This study sought to determine the value (expenditures and complications) of ambulatory MRM.

METHODS

Health Care Utilization Project (HCUP) state databases from 2016 were queried for patients who underwent MRM. The study examined rates of 30-day readmission for surgical-site infection (SSI) or hematoma, charges by index care setting, and predictors of 30-day readmission.

RESULTS

Overall, 8090 patients underwent MRM: 5113 (63 %) inpatient and 2977 (37 %) ambulatory patients. Compared with the patients who underwent inpatient MRM, those who underwent ambulatory MRM were older (61 vs. 59 years), more often white (66 % vs. 57 %), in the lowest income quartile (28 % vs. 21 %), insured by Medicare (43 % vs. 33 %) and residents in a small metro area (6 % vs. 4 %) (all p < 0.01). Of the 5113 patients treated as inpatients, 126 (2.5 %) were readmitted, whereas 50 (1.7 %) of the ambulatory patients were readmitted (p = 0.02). The adjusted charge for inpatient MRM without readmission was $113,878 (range, $107,355-120,402) compared with $94,463 (range, $86,021-102,907) for ambulatory MRM, and the charge for inpatient MRM requiring readmission was $159,355 (range, $147,142-171,568) compared with $139,940 (range, $125,808-154,073) for ambulatory MRM (all p < 0.01). This difference remained significant after adjustment for hospital length of stay. Adjusted logistic regression showed that the ambulatory setting was protective for readmission (odds ratio, 0.49; 95 % confidence interval, 0.35-0.70; p < 0.01).

CONCLUSIONS

The analyses suggest that ambulatory MRM is both safe and less expensive. The findings advocate that MRM, a last holdout of inpatient care within breast surgical oncology, can be transitioned to the ambulatory setting for appropriate patients.

The QUILT study: quilting sutures in patients undergoing breast cancer surgery: a stepped wedge cluster randomized trial study

BACKGROUND

Seroma is the most common complication following breast cancer surgery, with reported incidence up to 90%. Seroma causes patient discomfort, is associated with surgical site infections (SSI), often requires treatment and increases healthcare consumption. The quilting suture technique, in which the skin flaps are sutured to the pectoralis muscle, leads to a significant reduction of seroma with a decrease in the number of aspirations and surgical site infections. However, implementation is lagging due to unknown side effects, increase in operation time and cost effectiveness. Main objective of this study is to assess the impact of large scale implementation of the quilting suture technique in patients undergoing mastectomy and/or axillary lymph node dissection (ALND).

METHODS

The QUILT study is a stepped wedge design study performed among nine teaching hospitals in the Netherlands. The study consists of nine steps, with each step one hospital will implement the quilting suture technique. Allocation of the order of implementation will be randomization-based. Primary outcome is 'textbook outcome', i.e.no wound complications, no re-admission, re-operation or unscheduled visit to the outpatient clinic and no increased use of postoperative analgesics. A total of 113 patients is required based on a sample size calculation. Secondary outcomes are shoulder function, cosmetic outcome, satisfaction with thoracic wall and health care consumption. Follow-up lasts for 6 months.

DISCUSSION

This will be one of the first multicentre prospective studies in which quilting without postoperative wound drain is compared with conventional wound closure. We hypothesize that quilting is a simple technique to increase textbook outcome, enhance patient comfort and reduce health care consumption.

Use of sentinel lymph node biopsy in elderly patients with breast cancer - 10-year experience from a Swiss university hospital

BACKGROUND

The Choosing Wisely initiative recommended the omission of routine sentinel lymph node biopsy (SLNB) in patients ≥ 70 years of age, with clinically node-negative, early stage, hormone receptor (HR) positive and human epidermal growth factor receptor 2 (Her2) negative breast cancer in August 2016. Here, we assess the adherence to this recommendation in a Swiss university hospital.

METHODS

We conducted a retrospective single center cohort study from a prospectively maintained database. Patients ≥ 18 years of age with node-negative breast cancer were treated between 05/2011 and 03/2022. The primary outcome was the percentage of patients in the Choosing Wisely target group who underwent SLNB before and after the initiative went live. Statistical significance was tested using chi-squared test for categorical and Wilcoxon rank-sum tests for continuous variables.

RESULTS

In total, 586 patients met the inclusion criteria with a median follow-up of 2.7 years. Of these, 163 were ≥ 70 years of age and 79 were eligible for treatment according to the Choosing Wisely recommendations. There was a trend toward a higher rate of SLNB (92.7% vs. 75.0%, p = 0.07) after the Choosing Wisely recommendations were published. In patients ≥ 70 years with invasive disease, fewer received adjuvant radiotherapy after omission of SLNB (6.2% vs. 64.0%, p < 0.001), without differences concerning adjuvant systemic therapy. Both short-term and long-term complication rates after SLNB were low, without differences between elderly patients and those < 70 years.

CONCLUSIONS

Choosing Wisely recommendations did not result in a decreased use of SLNB in the elderly at a Swiss university hospital.

Mobile care app development process: using the ADDIE model to manage symptoms after breast cancer surgery (step 1)

The use of mobile applications is widespread in patient monitoring or education today. This study aims to describe the design and development process of a mobile app that supports patient self-care after breast cancer surgery. We used the ADDIE model to develop and test the mobile app. ADDIE (Analysis, Design, Development, Implementation, Evaluation) is a systematic approach based on a standard instructional design model for creating training materials. The model consists of five phases, each with its own set of steps. Once the steps within each phase are completed, the model progresses to the next phase, ultimately resulting in a "usable" product. Different team collaborations were established within each phase, and support was obtained from multiple experts during the design process. Thanks to this model, the information that patients need was transformed into a technological product. This article, which explains the stages of the product design process for mobile applications, provides information that may be helpful to researchers working on similar products.

Preferences Regarding Breast Surgery Omission Among Patients With Breast Cancer Who Receive Neoadjuvant Chemotherapy

BACKGROUND/AIM

Currently, several ongoing prospective studies are investigating the safety of breast surgery omission in patients with breast cancer who are exceptional responders to neoadjuvant chemotherapy. However, there is little information about the preferences of these patients regarding omission of breast surgery.

PATIENTS AND METHODS

We conducted a questionnaire survey to assess preferences regarding omission of breast surgery among patients with breast cancer who had human epidermal growth factor receptor 2-positive or estrogen receptor-negative tumors and good clinical response after neoadjuvant chemotherapy. Patients' estimation of the risk of ipsilateral breast tumor recurrence (IBTR) after definitive surgery or breast surgery omission was also assessed.

RESULTS

Of 93 patients, only 22 (23.7%) said they would omit breast surgery. Under the scenario of omitting breast surgery, the 5-year IBTR rate estimated by patients who said they would omit breast surgery was significantly lower (median, 10%) than the rate estimated by patients who preferred undergoing definitive surgery (median, 30%) (p=0.017).

CONCLUSION

The proportion of our surveyed patients who were willing to omit breast surgery was low. Patients who said they preferred to omit breast surgery overestimated the 5-year IBTR risk.

Povidone Iodine Sclerotherapy for the Treatment of Persistent Seromas after Breast Cancer Surgery

Persistent seroma following breast cancer surgery causes morbidity and delays adjuvant treatment. Sclerotherapy helps in managing recalcitrant seromas. We evaluated efficacy of 10% povidone iodine sclerotherapy treatment for persistent seromas after breast cancer surgery. Persistent drainage of > 100 mL/day 15 days following surgery, and seromas that required aspiration > 100 mL/week 2 weeks after drain removal, was considered for 10% povidone sclerotherapy in a non-randomized observational study. Resolution (drain output < 20 mL/day), treatment days, recurrence, and complications were assessed as measures of efficacy. Descriptive measures of central tendency and dispersion were reported. The relationship of the seroma quantity with risk factors (age, body mass index, levels and number of axillary lymph nodes dissected, neoadjuvant chemotherapy) and efficacy was analysed. We examined the correlation using Pearson and Spearman' signed rank, Student's t, and Mann-Whitney U-tests, to compare the means. Of 14/312 (4.5%) patients with persistent seroma, 13 (92.8%) had complete resolution after sclerotherapy within 6.71 days (range: 6-8). AC (p = 0.04), neoadjuvant chemotherapy (NACT) (p = 0.005), and number of nodes harvested without NACT (p = 0.025) were significantly associated with the quantity of discharge, while age (p = 0.072), body mass index (p = 0.432), type of surgery (breast conservation surgery vs. modified radical mastectomy) (p = 0.28), and total number of axillary lymph nodes (p = 0.679) were not. When used in this unique innovative manner, 10% povidone iodine sclerotherapy was found to be very effective (93%), minimally invasive, and safe in our study, and therefore appears to be an ideal sclerosing agent.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13193-022-01629-0.

Impact of COVID-19 on the Diagnosis and Surgical Care of Patients with Breast Cancer-a Retrospective Observational Cohort Study from Kerala, South India

The COVID-19 pandemic has strained the healthcare system worldwide. Our study aimed to evaluate the impact of the COVID-19 pandemic on the diagnosis and surgical care of patients with breast cancer in Amrita Institute of Medical Sciences, Kochi. This is a single-centre retrospective observational cohort study conducted in a tertiary care institution intended to analyse the management of patients with breast cancer before and after the pandemic outbreak. The number of mammograms dropped from 3689 in the pre-pandemic phase to 1901 in the post-pandemic phase, whilst the number of core biopsies remained almost the same (391 before the pandemic and 367 after the pandemic). The number of new patients decreased by 57.7% (from 614 to 354). However, the number of breast cancer surgeries has remained almost the same (318 before the pandemic and 287 after the pandemic). The number of breast conservation surgeries dropped from 127 in 2019 to 93 in 2020 (p-value = 0.01). Conversely, 24 patients underwent neoadjuvant chemotherapy in 2019, and this number increased to 37 in 2020, representing a statistically significant increase (p = 0.04). Even during a pandemic, cancer care is possible with proper resource allocation and by adopting a multidisciplinary approach.

The no-vertical scar technique for oncoplastic breast reconstruction

INTRODUCTION

Oncoplastic reconstruction can optimize breast conserving therapy. Nipple loss is a concern in patients with significant ptosis and breast hypertrophy particularly with pedicle undermining during tumor resection. The modified Robertson technique (No-Vertical Scar reduction) has been previously described for breast reduction in large, ptotic patients using a wide, bell-shaped inferior pedicle with only inframammary fold and peri‑areolar incisions. The purpose of this study was to evaluate the No-Vertical Scar (NVS) technique applied to oncoplastic reconstruction.

METHODS

Women undergoing oncoplastic breast reduction using a NVS, Wise, or Vertical method were assessed. Predictive variables included patient demographics, comorbidities, and sternal notch to nipple (SNN) distance. Outcome variables were delayed wound healing, surgical site infection, seroma, fat necrosis, nipple necrosis, use of a free nipple graft, and time between surgery and adjuvant radiation.

RESULTS

Fifty patients met inclusion criteria using NVS (N = 15), Wise (N = 16), and Vertical (N = 19) methods. The NVS group had a significantly higher BMI (p=.009), greater sternal notch to nipple distance (p=<0.001) and increased resection volume (p=<0.001) as compared to Wise and Vertical groups. There was no significant difference in complications (p=.25). No nipple necrosis occurred, and no free nipple grafts were required.

CONCLUSION

The NVS approach is a useful technique for oncoplastic reconstruction in select patients with macromastia and severe Grade II or Grade III ptosis. The wide, bell-shaped pedicle is versatile for obliterating a lumpectomy cavity and optimizing nipple perfusion if pedicle undermining occurs during resection.

Identifying research priorities in breast cancer surgery: a UK priority setting partnership with the James Lind Alliance

PURPOSE

A James Lind Alliance priority setting partnership was developed to identify research priorities in breast cancer surgery from individuals with lived experience, at high genetic risk of breast cancer, and healthcare professionals (HCPs).

METHODS

'Uncertainties' were collected using an online survey. Following an evidence check and development of summary questions, an interim survey asked participants to rank their top 10 research priorities from the question list. Top-ranked questions from patient/carer, high-risk and professional groups were carried forward for discussion to a final online prioritisation workshop.

RESULTS

260 participants (101 patients/carers, 156 HCPs) submitted 940 uncertainties via the initial survey. These were analysed thematically into 128 summary questions in six topic areas. Following evidence checking, 59 questions were included in the interim survey which was completed by 572 respondents. Marked differences were seen in questions prioritised by patients/carers, HCPs and women at high-risk. The top eight priorities in patient/carer and professional groups and top two priorities for high-risk women were carried forward to the online workshop at which 22 participants discussed and agreed the final top 10. Key themes included de-escalation of breast and axillary surgery, factors impacting the development/detection of locoregional recurrence and optimal provision of support for informed treatment decision-making.

CONCLUSION

The top 10 research priorities in breast cancer surgery have been agreed. However, the observed differences in research priorities identified by patients and professional groups were not anticipated. Top priorities from both groups should inform future UK breast cancer surgical research, to ensure that it addresses questions that are important to breast cancer community as a whole.

Axillary Reverse Mapping in the Prevention of Lymphoedema: A Systematic Review and Pooled Analysis

BACKGROUND

This is a systematic review of randomized controlled trials (RCT) comparing the use of axillary reverse mapping (ARM) with conventional technique for axillary dissection (AD) in breast cancer surgery.

METHODS

This review was written in line with the PRISMA protocol. Articles were retrieved from PubMed, EMBASE, CINAHL and Cochrane databases, using keywords ..úaxillary reverse mapping..Ñ and "axillary lymph node dissection". Non-RCT were excluded. Abstracts were screened independently by 2 reviewers. Data from eligible studies were retrieved for qualitative synthesis and pooled analysis. 73 publications were identified for initial screening.

RESULTS

68 articles were excluded from analysis according to the pre-defined systematic review protocol. 5 RCTS with 1696 subjects were included for analysis. 802 patients received ARM, 894 patients received AD. Pooled ARM node detection rate was 84.9% (Range 79.2 - 94.9%). There was a lower rate of post-operative lymphedema in ARM group patients across all 5 RCTs. The pooled lymphedema incidence in the ARM group was 4.8% (37/766) when compared to 18.8% (164/873) in the AD group (P < .0001). Axillary recurrence rate with median followof 37 months was 1.03% (8/778) in the ARM group, which was identical to 1.03% (9/870) in the AD group (P = 1).

CONCLUSION

ARM resulted in decreased incidence of lymphedema. There was no significant increase in axillary recurrence at 37 months post-operation.

The impact of neoadjuvant systemic treatment on postoperative complications in breast cancer surgery

PURPOSE

The aim of the study was to analyze the impact of neoadjuvant systemic treatment (NST) on postoperative complications and the beginning of adjuvant treatment.

METHODS

This study includes data from a prospectively maintained database including patients with breast cancer (BC) stage I-IV with or without NST undergoing breast cancer surgery between January 2010 and September 2021.

RESULTS

Out of 517 enrolled patients, 77 received NST, 440 had primary breast surgery. After NST patients underwent surgery after a meantime of 34 days (26.5-40 days). No statistical significance could be found comparing the complication grading according to the Clavien Dindo classification. The complications were most frequently rated as grade 3b. There were no complications with grade 4 or higher. When differentiating into short and long-term, the overall rate of short-term complications was 20.3% with no significant difference between the two groups (20.8% vs. 20.2%). Regarding long-term complications, there was more impairment of shoulder mobility (26.0% vs. 9.5%, p ≤ 0.001) and chronic pain (42.9% vs. 28.6%, p ≤ 0.016) for patients with NST. The beginning of the administration of the adjuvant treatment was comparable in both groups (46.3 days vs. 50.5 days).

CONCLUSION

In our cohort, complications between both groups were comparable according to Clavien Dindo. This study shows that NST has no negative impact on postoperative short-term complications and most importantly did not lead to a delay of the beginning of adjuvant treatment. Therefore, NST can be safely admitted, even when followed by extensive breast reconstruction surgery.

A comparative and prospective study of different anesthetic techniques

INTRODUCTION

The main reason for high mortality in breast cancer is local recurrence and metastasis, despite surgery as the first therapeutic option. The anesthesia used in the operation room can determine the immune response.

METHODS

A prospective, comparative and non- randomised study in patients undergoing breast cancer surgery was conducted in our hospital after obtaining approval from the Hospital's Institutional Review Board. Patients were divided in two groups: Group A received general anesthesia with propofol and opioids. Group B, in addition to general anesthesia, three interfascial blocks (Pec I, Pec II and BRILMA) were performed in all patients. Three blood samples were taken 1) previous anesthetic induction; 2) two hours after the end of the surgery and 3) 24-48 h after surgery. Leukocytes, CD3, CD4, CD8 and Natural Killer cells were determined at each time.

RESULTS

103 patients were included. 59 (group A) received general anesthesia and 54 (group B) general anesthesia and interfascial blocks. Regarding baseline characteristics, age was significantly higher in the group that received general anesthesia and mastectomy was more frequent in the group that received interfascial blocks. We observed after surgery an increase in leukocytes level that returns close to baseline levels. On the other hand, a reduction in the immune response was observed that also returns to the previous level 48 h after surgery. Group A and B get similar results and also subgroups of hormonal receptors (HER+, PR and/or ER+).

CONCLUSIONS

Interfascial blocks in chest wall added to general anesthesia in breast cancer surgery has not shown a significant difference in the inflammatory response or immunological depression compared to general anesthesia as the only anesthetic technique. It seems to trend less immunological depression in the interfascial block group.

Comparison of patient-reported outcomes among different types of oncoplastic breast surgery procedures

BACKGROUND

This study aims to compare patient-reported outcomes (PROs) after different types of oncoplastic surgery (OPS) procedures and correlate the results with previously published normative data from women with no prior history of breast cancer (BC) and breast surgery.

METHODS

Cross-sectional study of patients with stage I-II BC undergoing a specific selection of OPS procedures from 04/2012 to 12/2018 by three breast surgeons at a single tertiary referral hospital in Switzerland. PROs were evaluated using the postoperative BREAST-Q questionnaire.

RESULTS

One hundred twenty-seven patients met the inclusion criteria and were surveyed. All OPS techniques achieved comparably elevated scores in satisfaction with breasts, psychosocial, and sexual well-being. Compared to normative data of healthy women, all OPS groups postoperatively achieved significantly better satisfaction with breasts, psychosocial, and sexual well-being.

CONCLUSION

This study shows high PROs across all types of OPS, which were superior to normative data from healthy women. Our findings confirm that OPS is associated with high quality of life and patient satisfaction.

The Margins' Challenge: Risk Factors of Residual Disease After Breast Conserving Surgery in Early-stage Breast Cancer

BACKGROUND/AIM

Clinicopathological features of patients undergoing margin enlargement after lumpectomy for early breast cancer with positive/close excision margins were analyzed in order to define whether a re-operative procedure could have been avoided. Furthermore, a standardized protocol of specimen orientation was adopted in order to optimize both the widening procedure as well as the oncologic outcome.

PATIENTS AND METHODS

A retrospective analysis was performed including pre-, peri-, and post-operative parameters, and a predictive score by means of a multivariate model was developed using all clinically and statistically significant variables associated with residual disease (RD).

RESULTS

RD was significantly related to positive tumor margins, hormone receptor negative, HER2-positive, and tumors with high Ki67 proliferation index (p<0.001); the corresponding contribution to the prognostic score was as follows: close margins, 3 points; hormone receptor positive disease, 2 points; low Ki67, 2 points; HER2 negativity, 1 point. In 102 patients with a score >3, only 2 patients (2.0%) had RD, while in 81 patients with a score ≤3, 55 patients (67.9%) had RD (p<0.001).

CONCLUSION

This predictive model might aid in clinical-decision making of patients with positive margins who actually require a widening procedure after intraoperative and/or definitive histology.

Biopsychosocial risk factors for pain and pain-related disability 1 year after surgery for breast cancer

PURPOSE

Knowledge regarding risk factors for pain in the long term after surgery for breast cancer may be of great value in preventing this prevalent and debilitating side effect. Despite the biopsychosocial nature of pain, the predictive value of both pre- and postoperative biopsychosocial functioning for long-term pain intensity and pain-related disability has not yet been studied.

METHODS

One hundred sixty-six women planned for unilateral breast cancer surgery were included in this prospective cohort study. Pre- and postoperative outcomes related to pain, psychosocial, and somatosensory functioning (questionnaires and quantitative sensory testing) were evaluated as risk factors for pain intensity (visual analog scale) and pain-related disability (pain disability index) 1 year after surgery for breast cancer. Both bivariable and stepwise linear regression analyses were performed.

RESULTS

The most consistent biopsychosocial risk factors were symptoms related to altered central somatosensory functioning (central sensitization inventory), psychological symptoms, and social support (psychological symptoms and support subscale of McGill Quality of Life Questionnaire). Results also showed that a pre- and postoperative disturbed functioning of the somatosensory nervous system in the surgical area could provide additional information regarding pain intensity or pain-related disability in the long term after surgery for breast cancer.

CONCLUSION

This study revealed several biopsychosocial characteristics that might be used to identify women more vulnerable to have pain and pain-related disability in the long term after surgery for breast cancer, allowing for more effective pain management and prevention.

Effect of perioperative cognitive behavioural therapy on chronic post-surgical pain among breast cancer patients with high pain catastrophising characteristics: protocol for a double-blinded randomised controlled trial

BACKGROUND

Surgery is regarded as the primary treatment for breast cancer. Chronic post-surgical pain (CPSP) is a recognised complication after breast cancer surgery, and it is estimated to affect 20-30% of women. Pain catastrophizing has emerged as one of the most influential psychological variables associated with CPSP.

METHODS

This trial will be a single-centre, prospective, double-blinded, superiority, randomised controlled trial (RCT). Patients scheduled for elective breast cancer surgery (wide local excision or mastectomy with or without axillary lymph node dissection) will be screened preoperatively for high pain catastrophising. Patients with high pain catastrophising, defined as a score of ≥ 24 on the Pain Catastrophising Scale will be deemed eligible for inclusion in the study. Participants will be randomly assigned to receive either a cognitive behavioural therapy or an educational mindfulness based programme during their perioperative period. The primary outcome is the Brief Pain Inventory short form average pain severity score at 3 months postoperatively. Secondary outcomes include patient-reported quality of recovery at days 1-2 after surgery, levels of pain catastrophising, reported depressed mood and anxiety.

DISCUSSION

To the best of our knowledge, this protocol describes the first RCT which directly examines the effect of perioperative cognitive behavioural therapy on CPSP among breast cancer patients with high pain catastrophising characteristics. The outcomes of this trial may have significant implications for these patients because perioperative cognitive behavioural therapy has the potential to become an important perioperative intervention to complement patient management.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04924010 . Registered on 11 June 2021. All item from the World Health Organisation Trial Registration Data set have been included.

Pre-surgery supportive and goal-oriented strategies are associated with lower post-surgery perceived distress in women diagnosed with breast cancer

BACKGROUND

Psycho-oncology literature pointed out that individual health outcomes may depend on patients' propensity to adopt approach or, conversely, avoidant coping strategies. Nevertheless, coping factors associated with postoperative distress remain unclear, unfolding the lack of tailored procedures to help breast cancer patients manage the psychological burden of scheduled surgery. In view of this, the present study aimed at investigating: 1. pre-/post-surgery distress variations occurring among women diagnosed with breast cancer; 2. the predictivity of approach and avoidant coping strategies and factors in affecting post-surgery perceived distress.

METHODS

N = 150 patients (mean age = 59.37; SD =  ± 13.23) scheduled for breast cancer surgery were administered a screening protocol consisting of the Distress Thermometer (DT) and the Brief-COPE. The DT was used to monitor patients' distress levels before and after surgery (± 7 days), whereas the Brief-COPE was adopted only preoperatively to evaluate patients' coping responses to the forthcoming surgical intervention. Non-parametric tests allowed for the detection of pre-/post-surgery variations in patients' perceived distress. Factor analysis involved the extraction and rotation of principal components derived from the Brief-COPE strategies. The predictivity of such coping factors was investigated through multiple regression (Backward Elimination).

RESULTS

The Wilcoxon Signed-Rank Test yielded a significant variation in DT mean scores (TW = -5,68 < -zα/2 = -1,96; p < .001) indicative of lower perceived distress following surgery. The four coping factors extracted and Varimax-rotated were, respectively: 1. cognitive processing (i.e., planning + acceptance + active coping + positive reframing); 2. support provision (i.e., instrumental + emotional support); 3. emotion-oriented detachment (i.e., self-blame + behavioral disengagement + humor + denial); 4. goal-oriented detachment (i.e., self-distraction). Among these factors, support provision (B = .458; β = - .174; t = - 2.03; p = .045), encompassing two approach coping strategies, and goal-oriented detachment (B = .446; β = - .176; t = - 2.06; p = .042), consisting of one avoidant strategy, were strongly related to post-surgery distress reduction.

CONCLUSION

The present investigation revealed that the pre-surgery adoption of supportive and goal-oriented strategies led to postoperative distress reduction among breast cancer patients. These findings highlight the importance of timely psychosocial screening and proactive interventions in order to improve patients' recovery and prognosis.

Health-related quality of life in patients with breast cancer surgery and undergoing chemotherapy in Ahmednagar district

Background

Breast cancer in India it varies from as low as 5 per 100,000 female populations per year in rural areas to 30 per 100,000 female populations per year in urban areas. Medical treatments of surgery, chemotherapy etc. for cancer usually precipitates with serious adverse effects affecting overall quality of life in physical, psychological and social aspects.

Objective of the Study

To evaluate health related quality of life in patients who had been followed up after the breast cancer surgery for chemotherapy at our hospital.

Methods

Quality of life was documented using European Organization of Research and Treatment for Cancer Quality of life Questionnaire-Cancer 30 (EORTC QOL-C30) and European Organization of Research and Treatment for Cancer Quality of life Questionnaire-Breast 23 (EORTC QOL-BR23).

Results

After analysis of EORTC QOL-C30 questionnaire, participants had maximum affection of cognitive, social and physical functions and reported high levels of pain, fatigue and insomnia. Domains of EORTC QOL-BR23, the such as worry about self body image, sexual dysfunction, upset by hair loss, systemic therapy side effects, breast and arm symptom were reported by maximum participants. Various domains of quality of life were maximally affected in patients of breast cancer surgery undergoing chemotherapy. Health care professionals in the field of Oncology should address the above mentioned domains of quality of life in Indian patients with breast cancer surgery undergoing chemotherapy.

Conclusion

Comprehensive cancer management plan should include psychological counseling, emotional support, physiotherapy care for pain and other musculoskeletal problems etc. along with medical treatment of patients with breast cancer.

The Effect of Preoperative Ultrasound-Guided Erector Spinae Plane Block on Chronic Postsurgical Pain After Breast Cancer Surgery: A Propensity Score-Matched Cohort Study

Introduction

The high incidence of chronic postsurgical pain (CPSP) has been a major issue after breast cancer surgery (BCS). The impact of regional anesthesia (RA) techniques on CPSP remains conflicting. In this propensity score-matched cohort study, we aimed to investigate the effect of preoperative single-shot erector spinae plane block (ESPB) adding to general anesthesia (GA) on the incidence of CPSP at 1 year following BCS.

Methods

Data of adult female patients who underwent unilateral BCS between October 2019 and June 2020 were retrospectively collected. Patients were grouped to ESPB combined with GA (ESPB + GA) and GA alone, respectively. All patients were prospectively followed up at 1 year after surgery. CPSP and neuropathic pain (NP) were measured using the brief pain inventory–short form (BPI-SF) and ID Pain scale. Eleven confounding factors were managed by propensity score matching (PSM) to achieve between-group balance. The primary outcome was the incidence of CPSP at 1 year after BCS. The secondary outcomes include proportion of NP, severity, and interference of CPSP at 1 year after surgery, acute postoperative pain, postoperative nausea and vomiting (PONV), hospital length of stay (LOS), and adverse events.

Results

After PSM, data for 194 patients were available for analysis (97 in each group). No significant difference in the incidence of CPSP (P = 1.000) nor percentage of patients with NP (P = 0.442) was found between the two groups. Both matched groups had similar intensity of CPSP (P = 0.547) measured by BPI-SF as well as the rates of moderate to severe CPSP (P = 1.000). A significant decrease in acute pain scores (P = 0.043) and rates of rescue analgesics demand (P = 0.042) were observed in the ESPB + GA group compared to the GA group. Multivariate logistic regression on the total study cohort showed that axillary lymph node dissection (ALND) (OR 3.541, 95% CI: 1.273–9.851, P = 0.015), radiotherapy (OR 1.918, 95% CI: 1.067–3.448, P = 0.029) and acute postoperative pain within 24 h (OR 2.109, 95% CI: 1.097–4.056, P = 0.036) were independent risk factors for the development of CPSP.

Conclusions

We found that preoperative single-shot ESPB was not associated with reduced incidence of CPSP at 1 year after BCS. ALND, radiotherapy, and acute postoperative pain within 24 h were independent risk factors for the development of CPSP after BCS.

Trial Registration

The study was registered in the Chinese Clinical Trial Registry (ID: ChiCTR2000038464, date of registration: September 23, 2020).

Safety of autologous fat grafting in breast cancer: a multicenter Italian study among 17 senonetwork breast units autologous fat grafting safety: a multicenter Italian retrospective study

BACKGROUND

Autologous fat grafting (AFG), defined as the re-implant to the breast of fat tissue from different body areas, has been firstly applied to esthetic plastic surgery and then has moved to reconstructive surgery, mainly used for scar correction and opposite breast altering. Nevertheless, due to the potentially unsafe stem-like properties of adipocytes at the tumoral bed level, no clear evidence of the procedure's oncological safety has been clearly documented at present.

PATIENTS AND METHODS

We retrospectively collected data of early breast cancer (BC) patients from 17 Italian Breast Units and assessed differences in terms of locoregional recurrence rate (LRR) and locoregional recurrence-free survival (LRFS) between patients who underwent AFG and patients who did not. Differences were analyzed in the entire cohort of invasive tumors and in different subgroups, according to prognostic biological subtypes.

RESULTS

With a median follow-up time of 60 months, LRR was 5.3% (n = 71) in the matched population, 3.9% (n = 18) in the AFG group, and 6.1% (n = 53) in the non-AFG group, suggesting non-inferiority of AFG (p = 0.084). Building Kaplan-Meier curves confirmed non-inferiority of the AFG procedure for LRFS (aHR 0.73, 95% CI 0.41-1.30, p = 0.291). The same effect, in terms of LRFS, was also documented among different biological subtypes (luminal-like group, aHR 0.76, 95% CI 0.34-1.68, p = 0.493; HER2 enriched-like, aHR 0.89, 95% CI 0.19-4.22, p = 0.882; and TNBC, aHR 0.61, 95% CI 0.12-2.98, p = 0.543).

CONCLUSIONS

Our study confirms in a very large, multicenter cohort of early BC patients that, aside the well-known benefits on the esthetic result, AFG do not interfere negatively with cancer prognosis.

Are we choosing wisely? Drivers of preoperative MRI use in breast cancer patients

INTRODUCTION

Factors contributing to the use of preoperative MRI remain poorly understood.

METHODS

Data from a randomized controlled trial of stage 0-3 breast cancer patients undergoing breast conserving surgery between 2016 and 2018 were analyzed.

RESULTS

Of the 396 patients in this trial, 32.6% had a preoperative MRI. Patient age, race, ethnicity, tumor histology, and use of neoadjuvant therapy were significant predictors of MRI use. On multivariate analysis, younger patients with invasive lobular tumors were more likely to have a preoperative MRI. Rates also varied significantly by individual surgeon (p < 0.001); in particular, female surgeons (39.9% vs. 24.0% for male surgeons, p = 0.001) and those in community practice (58.9% vs. 14.2% for academic, p < 0.001) were more likely to order preoperative MRI. Rates declined over the two years of the study, particularly among female surgeons.

CONCLUSIONS

Preoperative MRI varies with patient age and tumor histology; however, there remains variability by individual surgeon.

Breast Surgery: Management of Postoperative Complications Following Operations for Breast Cancer

Breast cancer surgery is associated with low rates of surgical morbidity. Postoperative complications related to breast surgery include seroma, infection, hematoma, mastectomy flap necrosis, wound dehiscence, persistent postsurgical pain, Mondor disease, fat necrosis, reduced tactile sensation after mastectomy, and venous thromboembolism. Postoperative complications related to axillary surgery include seroma, infection, lymphedema, nerve injury, and reduced shoulder/arm mobility. The overall rate of complication related to axilla surgery may be confounded by the type of breast surgery performed. The management of postoperative complications related to oncologic breast and axillary surgery independent of reconstruction is reviewed here.

Magnetic Seed (Magseed) Localisation in Breast Cancer Surgery: A Multicentre Clinical Trial

INTRODUCTION

The aim of this study was to evaluate the accuracy and reliability of the Magseed magnetic marker in breast cancer surgery.

METHODS

Thirty-nine patients with 41 implanted Magseeds undergoing surgical treatment in 3 surgical oncology departments were included in the retrospective trial to study pilot use of the Magseed magnetic marker in the Czech Republic for localisation of breast tumours or pathological axillary nodes in breast cancer patients.

RESULTS

Thirty-four breast cancer and 7 pathological lymph node localisations were performed by Magseed implantation. No placement failures, or perioperative detection failures of Magseeds were observed (0/41, 0.0%), but one case of Magseed migration was present (1/41, 2.4%). All magnetic seeds were successfully retrieved (41/41, 100.0%). Negative margins were achieved in 29 of 34 (85.3%) breast tumour localisations by Magseed.

CONCLUSION

Magseed is a reliable marker for breast tumour and pathological axillary node localisation in breast cancer patients. Magseed is comparable to conventional localisation methods in terms of oncosurgical radicality and safety.

Serratus anterior plane block reduces the prevalence of chronic postsurgical pain after modified radical mastectomy: A randomized controlled trial

STUDY OBJECTIVE

To determine whether ultrasound-guided serratus anterior plane block (SAPB) is associated with decreased prevalence of chronic postsurgical pain (CPSP) after modified radical mastectomy.

DESIGN

Randomized, double-blind, placebo-controlled study.

SETTING

University hospital.

PATIENTS

We enrolled 198 patients aged 18-65 years with American Society of Anesthesiologists physical status I to II, undergoing unilateral modified radical mastectomy.

INTERVENTIONS

Patients were randomly allocated to receive SAPB with 30 ml of 0.5% ropivacaine (SAPB group) or 0.9% normal saline (Control group).

MEASUREMENTS

The primary outcome was the prevalence of CPSP three months after surgery. Secondary outcomes were area under the curve of the numeric rating scale pain scores over 24 h, postoperative 24-h morphine consumption, quality of recovery, length of post-anesthesia care unit stay, postoperative nausea and vomiting, dizziness, SAPB-related adverse events, the prevalence of CPSP at six months, and pain-related function at three and six months.

MAIN RESULTS

Preoperative SAPB with 0.5% ropivacaine reduced the prevalence of CPSP at three postoperative months from 46/89 (51.7%) to 22/90 (25.6%), relative risk (95% confidence interval): 0.47 (0.31-0.72), P < 0.001. The prevalence of CPSP was reduced at six months from 37/89 (41.6%) to 17/90 (18.9%), relative risk (95% confidence interval): 0.72 (0.58-0.88), P = 0.001. Moreover, SAPB decreased the area under the curve of the numeric rating scale pain scores over 24 h, shortened the length of post-anesthesia care unit stay, reduced postoperative 24-h morphine consumption and the occurrence of postoperative nausea and vomiting, and improved quality of recovery and patient satisfaction, with P < 0.05 for all. No SAPB-related complications occurred.

CONCLUSIONS

Preoperative SAPB with ropivacaine improved acute postoperative analgesia and quality of recovery and decreased the prevalence of CPSP at three and six months after modified radical mastectomy.

An Optimal Timing for Removing a Drain After Breast Surgery: A Systematic Review and Meta-Analysis

BACKGROUND

In clinical practice, drains had been routinely used for reducing seroma formation after breast surgery. However, an optimal timing to remove drains does not identify yet.

METHODS

This study aimed to compare the clinical outcome, such as seroma formation, surgical site infection (SSI), and a length of hospital stay between early removal and late removal. A systematic review was performed using PubMed, MEDLINE, and the Cochrane Library. Breast cancer patients who received surgery using drains were eligible. Those parameters were compared between early vs late removal.

RESULTS

Eleven studies included in this meta-analysis. Seroma formation in the early removal group was significantly higher than the one in the late removal group (RR = 1.58: 95%CI [1.25-2.01], P = 0.0001), meanwhile no significant difference was found among the groups for SSI (RR = 0.82: 95%CI [0.51-1.31], P= 0.40). A length of hospital stay in the early removal group was also significantly shorter than late removal (RR -3.31: 95%CI [-5.13-1.49], P = 0.0004).

CONCLUSIONS

Seroma formation was significantly higher in patients who had early drain removal. Conversely, SSI incidence was low, and early removal did not increase SSI incidence. In conclusion, early drain removal has no proved clinical benefit in these settings besides reduction of hospital stays.

Factors Involved in Delaying Initiation of Adjuvant Chemotherapy After Breast Cancer Surgery

BACKGROUND

Delays in initiating adjuvant chemotherapy after breast cancer surgery seems to have an impact on patients' risk of relapse and their survival rate. The aim of this retrospective study was to identify factors delaying initiation of adjuvant chemotherapy after breast surgery.

MATERIAL AND METHODS

All patients undergoing surgical treatment for mammary cancer between June 2014 and June 2015 and receiving adjuvant chemotherapy were selected retrospectively.

RESULTS

In multivariate analysis, 3 factors significantly delay initiation of adjuvant chemotherapy: a secondary procedure (odds ratio [OR], 6.67; P = .00012), inclusion in a therapeutic trial (OR, 8.46; P = .0013), and a positive HER2 status (OR, 3.02; P = .063 [statistically significant]).

DISCUSSION

This study provides a brief overview of the population most likely to experience a delay in the initiation of their adjuvant chemotherapy after cancer surgery. Our findings should assist interventions during initial management.

Efficacy of ultrasound-guided erector spinae plane block following breast surgery - A double-blinded randomised, controlled study

Background and Aims:

Regional anaesthesia has been used to reduce acute post-operative pain as well as opioid-related side effects in breast cancer surgery. Erector spinae plane (ESP) block is a relatively new fascial plane block being tried in various surgical procedures. Our study is a double-blind randomised trial, designed to prove the efficacy of this block in breast surgeries.

Methods:

Seventy female patients scheduled for unilateral breast surgery were enroled in this prospective, randomised, double-blind study. Patients were randomised to group A and group B. All patients received general anaesthesia while group B received additional ultrasound-guided erector spinae block given at thoracic level—T5 with 20ml of 0.25% bupivacaine. Time to first rescue analgesia was the primary outcome. Secondary outcomes were total intraoperative opioid consumption, pain scores over 24 h, post-operative nausea and vomiting and patient satisfaction score at discharge. The Shapiro–Wilk test was used to check the normality of each variable. A comparison was done using Mann–Whitney test and the level of significance was set at 0.05.

Results:

The median time to first rescue analgesia in group A versus group B was 1 h (1–12h) versus 8 h (1–26h), respectively, with a P value of 0.044. Group B patients had lower pain scores post-operatively and better satisfaction scores at discharge. There was no statistically significant difference in intraoperative fentanyl consumption.

Conclusion:

Ultrasound-guided ESP block with general anaesthesia offers superior post-operative analgesia compared to general anaesthesia alone in patients undergoing unilateral nonreconstructive breast cancer surgeries.

Physical therapy enhances functions and quality of life in older patients with breast cancer-related lymphedema: A prospective experimental study

Background

Lymphedema of the arm is one of the most common complications following breast cancer surgery.

Aims

The primary aim of this study was to evaluate the effects of complex decongestive physical therapy (CDPt) on upper extremity functions, activities of daily living (ADL), and quality of life (QoL), and secondly the effects of the degree of lymphedema on post-treatment differences in older patients with breast cancer-related lymphedema (BCRL).

Subjects and Methods

Sixty-eight patients who had BCRL were included between 2015 and 2017. Arm function was evaluated with the Constant-Murley scale, while ADL was measured with the Lawton Instrumental Activities of Daily Living Scale, and QoL was measured with the Lymphedema Functioning, Disability and Health Questionnaire as pre- and post-treatment tests. The patients underwent a CDPt program for 6 weeks.

Results

There were statistically significant improvements for all outcome measurements in older patients with Grade 1 and 2 lymphedemas after the treatment (P < 0.001). The Grade 1 patients had a greater difference at mobility, participation in the life and social activities, and their total scores of quality of life had a significance level of P < 0.001.

Conclusion

Older patients with Grade 1 BCRL had better mobility, participation in the life, and social activities. CDPt provides enhancement of arm functions, ADL, and QoL in older patients with breast cancer-related lymphedema.

The impact of age on patient-reported outcomes after oncoplastic versus conventional breast cancer surgery

Purpose

Some studies have indicated age-specific differences in quality of life (QoL) among breast cancer (BC) patients. The aim of this study was to compare patient-reported outcomes after conventional and oncoplastic breast surgery in two distinct age groups.

Methods

Patients who underwent oncoplastic and conventional breast surgery for stage I-III BC, between 6/2011–3/2019, were identified from a prospectively maintained database. QoL was prospectively evaluated using the Breast-Q questionnaire. Comparisons were made between women < 60 and ≥ 60 years.

Results

One hundred thirty-three patients were included. Seventy-three of them were ≥ 60 years old. 15 (20.5%) of them received a round-block technique (RB) / oncoplastic breast-conserving surgeries (OBCS), 10 (13.7%) underwent nipple-sparing mastectomies (NSM) with deep inferior epigastric perforator flap (DIEP) reconstruction, 23 (31.5%) underwent conventional breast-conserving surgeries (CBCS), and 25 (34.2%) received total mastectomy (TM). Sixty patients were younger than 60 years, 15 (25%) thereof received RB/OBCS, 22 (36.7%) NSM/DIEP, 17 (28.3%) CBCS, and 6 (10%) TM. Physical well-being chest and psychosocial well-being scores were significantly higher in older women compared to younger patients (88.05 vs 75.10; p < 0.001 and 90.46 vs 80.71; p = 0.002, respectively). In multivariate linear regression, longer time intervals had a significantly positive effect on the scales Physical Well-being Chest (p = 0.014) and Satisfaction with Breasts (p = 0.004). No significant results were found concerning different types of surgery.

Conclusion

Our findings indicate that age does have a relevant impact on postoperative QoL. Patient counseling should include age-related considerations, however, age itself cannot be regarded as a contraindication for oncoplastic surgery.

Surgery and health-related quality of life - A prospective follow up study on breast cancer patients in Finland

INTRODUCTION

The influence of different surgical approaches on breast cancer patients' Health-related Quality of life (HRQoL) is an important determinant when making decisions on the choice of treatment. Knowledge on how patients actually perceive different surgical treatments regarding long-term HRQoL is still scarce.

MATERIALS & METHODS

1065 patients with primary breast cancer operated on from 2008 to 2015 at Helsinki University Hospital, Finland were prospectively followed-up for two years. They filled in two HRQoL questionnaires, the EORTC QLQ C30 - BR 23 and the 15D, at baseline and at 3, 6, 12 and 24 months after surgery. Clinical data on treatments given and the course of recovery were collected from patient records. Patients were divided into four mutually exclusive groups according to surgical method: breast resection (n = 415), oncoplastic resection (n = 248), mastectomy (n = 351) and immediate reconstruction (n = 51). Clinical data were combined with HRQoL scores and analysed as multivariate modelling.

RESULTS

All groups experienced initially worsening overall HRQoL after baseline. Oncoplastic resection patients had the best body image and their HRQoL reached the highest level after treatments at 12 months whereas the reconstruction patients reached the highest HRQoL level first at 24 months. Mastectomy patients had the lowest scores throughout the 24-month follow-up.

CONCLUSION

Extensive surgery, in terms of immediate reconstruction, led to slower HRQoL recovery than oncoplastic techniques. Mastectomy patients are at risk of having the lowest HRQoL scores throughout their recovery after surgery.

A Novel Local Transposition Flap for Lateral Breast Reconstruction After Breast Conserving Surgery

BACKGROUND

Breast conserving surgery (BCS) followed by radiotherapy is used for the management of early-stage breast cancers. There are different techniques to reconstruct the breast after BCS, each has its own advantages and disadvantages. In this study, we aim to present a novel local transposition flap and report the follow-up results of patients who underwent breast reconstruction using this method in the short and long term.

MATERIAL AND METHODS

We enrolled 100 patients who underwent BCS in the form of upper or lower outer quadrant lumpectomy with or without axillary lymph node dissection. After lumpectomy, the patients underwent breast reconstruction using the local transposition flap technique. We followed the patients for 1 year, and the satisfaction results are assessed and reported postoperation, after radiochemotherapy, and after 1 year.

RESULTS

The patients' mean age is 47.6 (±11.7) years, and the mean BMI is 32.4 (±2.5). The duration of hospitalization was 1 day in 96 patients and 2 days in 2 patients. There were 2 patients hospitalized for 3 days. Three patients developed seroma and there were no cases of any other complication. The surgeon and patients satisfaction surveys conducted postop, after the radiochemotherapy course, and 1 year after BCS shows that the excellent and good satisfaction rate is 85%, 85%, and 92% respectively.

CONCLUSION

We believe that the local transposition flap can be an excellent substitution for the existing methods in the reconstruction of the lateral side breast defects.

Surgical treatment for breast cancer in a patient with erythropoietic protoporphyria and photosensitivity: a case report

Background

Erythropoietic protoporphyria (EPP) is a rare disorder of heme synthesis. Patients with EPP mainly show symptoms of photosensitivity, but approximately 20% of EPPs are associated with the liver-related complications. We report a case of breast cancer in a 48-year-old female patient with EPP in whom meticulous perioperative management was required in order to avoid complications resulting from this disease.

Case presentation

The patient was diagnosed with EPP at the age of 33 and had a rich family history of the disease. For right breast cancer initially considered as TisN0M0 (Stage 0), the right mastectomy and sentinel lymph node biopsy were performed, while the final stage was pT1bN0M0, pStage I. In the perioperative period, we limited the drug use and monitored light wavelength measurements. Besides, we covered surgical lights, headlights, and laryngoscope’s light with a special polyimide film that filtered the wavelength of light causing dermal photosensitivity. After the surgery, any emerging complications were closely monitored.

Conclusions

The surgery, internal medicine, anesthesiology, and operation departments undertook all possible measures through close cooperation to ensure a safe surgery for the patient with a rare condition.