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

BACKGROUND: The optimal sequence of mastectomy with immediate breast reconstruction (IBR) and radiotherapy (RT) for the treatment of locally advanced breast cancer (LABC) is still under debate. Increased rates of postoperative complications are described following postmastectomy RT. Neoadjuvant RT aims to improve the aesthetic results and simplify the reconstructive pathway. PATIENTS: A total of 22 patients diagnosed with LABC and treated with neoadjuvant RT followed by mastectomy and IBR between 04/2012 and 03/2015 were retrospectively analyzed. RT consisted of external beam RT to the breast and the regional lymphatics, if indicated. Both implant-based and autologous tissue-transfer reconstruction techniques were used. RESULTS: At the time of RT, 10 patients had no prior surgery and 12 patients had previously undergone breast-conserving surgery (BCS) with positive resection margins without the possibility to perform a second BCS. Additional neoadjuvant chemotherapy was administered in 18 patients prior to RT. A complete pathological response was achieved in 55.0% of patients. The 2­year overall survival rate was 89.3%, the 2­year disease-free-survival 79.8% and the local-recurrence-free survival was 95.2%. The cosmetic result was excellent or good in 66% of the patients treated with upfront mastectomy and 37% of the patients who had previously undergone BCS. Among patients who received implant-based IBR, 4 patients developed serious wound-healing problems with implant loss. The most satisfactory results were achieved with autologous tissue reconstruction. CONCLUSION: A sequential neoadjuvant chemo-/radiotherapy to allow IBR following mastectomy in selected cases of LABC seems feasible and can be safely attempted. Careful patient selection, close monitoring, and continuous patient support is mandatory to ensure compliance in this treatment strategy.

Prophylactic mastectomy with immediate reconstruction combined with simultaneous laparoscopic salpingo-oophorectomy via a transmammary route: a novel surgical approach to female BRCA-mutation carriers.

INTRODUCTION: Breast reconstruction with salpingo-oophorectomy can easily be performed in patients with genetic mutations increasing the risk for mammary and ovarian carcinoma. However, many patients are skeptical about having several surgeries, as they may result in additional anesthesiological risks as well as multiple visible scars. Therefore, the purpose of this study was to evaluate the feasibility of prophylactic mastectomy and breast reconstruction combined with simultaneous transmammary salpingo-oophorectomy for BRCA carriers. MATERIALS AND METHODS: Of the six patients (1 %) who chose prophylactic mastectomy with salpingo-oophorectomy at our hospital four patients had BRCA-1 mutations, one patient had a BRCA-2 mutation and one patient had a family inheritance pattern with no mutations. All patients chose to reduce their risk for mammary and ovarian cancer by undergoing bilateral mastectomy and bilateral salpingo-oophorectomy. Prophylactic mastectomy with immediate reconstruction was performed, followed by bilateral salpingo-oophorectomy with a procedure that relies on transmammary access and reduces the number of necessary surgeries without compromising cosmetic results, surgical risks and operating time. RESULT: The mean age of the patients was 46.7 ± 1.8 years (SD). The mean operative time was 190.2 ± 13.7 min. No complications were observed during the operations. The mean intra-operative loss of blood was 363.3 ± 77.9 ml. The operative method was successful in all six cases and was performed with no complications. All of the patients were satisfied with the cosmetic results. CONCLUSION: In conclusion, prophylactic mastectomy and breast reconstruction combined with simultaneous laparoscopic salpingo-oophorectomy via transmammary access is feasible, easy to perform and provides an intriguing and novel approach to female BRCA carriers who desire operative prophylactic measures in one surgical session with no visible abdominal scars and no additional risks and complications.

Sexuality in German urogynecological patients and healthy controls: is there a difference with respect to the diagnosis?

OBJECTIVE: To evaluate sexual function among German urogynecological patients compared to a control group without urogynecological symptoms, using the validated German version of the Australian pelvic floor questionnaire. STUDY DESIGN: Retrospective study including 313 women divided into five subgroups: women with stress urinary incontinence (SUI), overactive bladder (OAB), mixed incontinence (MI), pelvic organ prolapse (POP) and healthy controls. The self-administered questionnaire is divided into three domains: bladder, pelvic organ prolapse, and sexual function. It also includes severity, bothersomeness and condition-specific quality of life. Only completely filled out questionnaires were included. The Mann-Whitney U-test was used as a non-parametric test to calculate significances for ordinal data. A p-value <.05 was taken as significant. RESULTS: 16/59 (27.1%) women in the control group were not sexually active compared to 19/60 (31.7%) in the SUI group, 51/98 (52.0%) in the mixed-incontinence group, 19/43 (44.2%) in the OAB group, and 24/53 (45.3%) in the prolapse group. Coital incontinence was present significantly more often in women with SUI (15/41, 36.6%) or mixed incontinence (20/44, 45.5%) than among the controls (1/49, 2.1%). Hence, concerning sexuality, women with urogynecological symptoms were all significantly more affected than the healthy controls. CONCLUSION: The German version of the Australian pelvic floor questionnaire is a feasible tool to evaluate not only symptoms of urinary incontinence and pelvic organ prolapse but also sexual dysfunction. A substantial proportion of our urogynecological patients suffer immensely from problems with their sexuality, and it is therefore our responsibility as physicians to provide assistance and improve our education in this field.

Clinical relevance of occult stress urinary incontinence (OSUI) following vaginal prolapse surgery: long-term follow-up.

INTRODUCTION AND HYPOTHESIS: Patients with genital prolapse and occult stress urinary incontinence (OSUI) are typically treated with prolapse surgery and anti-incontinence surgery based on either a one-step approach or a two-step approach. The aim of our study was to determine whether anti-incontinence surgery is necessary based on the occurrence of OSUI in a study cohort with a long follow-up period. METHODS: Prolapse surgery was performed using a vaginal approach. Preoperatively, a stress test, a pad test and an assessment of the urodynamics were performed with and without prolapse reduction. Over a follow-up period of 2-8 years, the patients with preoperative evidence of OSUI underwent urogynaecological examinations, stress tests and pad tests. RESULTS: Of 113 patients with preoperative evidence of OSUI, 57 (50.4 %) were followed up for an average of 5.7 years (range 2-8) after prolapse surgery. Of 57 patients, 16 (28.1 %) had objective and/or subjective stress urinary incontinence (SUI) during the follow-up period, but only 3 patients (5.3 %) required subsequent tension-free vaginal tape (TVT) surgery. In 17 of 57 patients (29.8 %), prolapse recurred. CONCLUSIONS: Despite the preoperative evidence of OSUI, the manifestation of SUI rarely occurs, with 28.1 % of patients experiencing SUI over long-term follow-up after vaginal prolapse surgery. Anti-incontinence surgery was necessary in only three cases (5.3 %). These results indicate that with the one-step approach, 54 of 57 patients (94.7 %) would have received prophylactic anti-incontinence surgery unnecessarily. In conclusion, we recommend the two-step approach in the management of vaginal prolapse surgery in patients with OSUI.

Worldwide first experiences with vacuum-assisted closure as alternative treatment method to repair defects of an extended thoracic wall recurrence of breast cancer.

INTRODUCTION: Loco-regional recurrences of the breast cancer are associated with a bad prognosis. Often costly autologous-tissue treatment as a surgery aiming at repairing the defects is necessary. PATIENTS AND METHODS: Four female patients were treated with the vacuum-assisted closure (VAC)-system in context with the recurrence resection. In all cases a primary local masking was not possible. RESULTS: In the described cases the wounds healed well during the post-operative phase. There occurred no problems either during the radiation treatment or during chemotherapy in the case of lying VAC-Systems. CONCLUSION: Using vacuum-assisted wound closure one can avoid autologous-tissue treatment in the case of extensive loco-regional recurrences.