Careful Where You Cut: Strategies for Successful Nerve-preserving Mastectomy.

Breast neurotization represents an evolving technique that is not widely practiced in most centers specializing in breast cancer treatment. Recognizing the limited educational resources available for breast and plastic surgeons concerning mastectomy techniques that emphasize nerve preservation, our study sought to bridge this gap. Specifically, we aimed to provide a comprehensive exploration of the surgical applied anatomy of breast sensory innervation and a detailed, step-by-step guide for incorporating nerve-sparing mastectomy and breast neurotization into clinical practice. The significance of this work lies in its potential to enhance the understanding and implementation of nerve-preserving techniques in mastectomy procedures, contributing to improved patient outcomes and quality of life post surgery. We hope that by familiarizing breast and reconstructive surgeons with this procedure, we can gain momentum in our research efforts and ultimately enhance the care provided to mastectomy patients.

Oncologic Safety of Nipple-Sparing Mastectomy for Breast Cancer in BRCA Gene Mutation Carriers: Outcomes at 70 Months Median Follow-Up.

BACKGROUND: Retention of the nipple-areola complex with nipple-sparing mastectomy (NSM) techniques provides a more natural cosmetic result than procedures that sacrifice the nipple. While the oncologic safety of NSM is established by several studies, there is little long-term data on outcomes in BRCA mutation carriers with breast cancer. PATIENTS AND METHODS: BRCA1/2 mutation carriers who underwent NSM and immediate reconstruction from 2008 to 2019 were reviewed and patients with breast cancer on biopsy or final pathology were included. Patient demographics and tumor characteristics, as well as treatment, recurrence, and survival data were collected. RESULTS: A total of 114 therapeutic NSM were performed in 105 BRCA mutation carriers (56 BRCA1, 47 BRCA2, and two women with both mutations). Median age was 45 years. Cancers were 18% stage 0, 52% stage I, 27% stage II, and 3% stage III. Mean invasive tumor size was 1.6 cm and 33 (35%) invasive tumors were triple negative. There were five (4.4%) positive nipple margins on final pathology; all underwent nipple excision. Most patients (80, 76%) received systemic therapy: 65 (62%) received chemotherapy and 48 (46%) received endocrine therapy. At 70 months median follow-up (range 15-150 months), no patient had developed a recurrence in the retained nipple-areola complex or at the site of a nipple excised for a positive margin. The rate of locoregional recurrence outside the nipple was 2.6%, and the rate of distant recurrence was 3.8%. Overall survival was 96%. CONCLUSIONS: NSM is a safe option for BRCA1 and BRCA2 mutation carriers who undergo mastectomy for breast cancer.

Supraclavicular and Contralateral Axillary Lymph Node Involvement in Breast Cancer Patients.

Ipsilateral supraclavicular disease was reclassified from Stage IV, distant metastatic disease, to Stage IIIC, locally advanced breast cancer 20 years ago. Treatment with curative intent with multimodality therapy has led to improved outcomes over time. In contrast, metastatic disease to contralateral axillary lymph nodes remains as Stage IV distant disease. Despite this, in the absence of other distant metastases, many patients with contralateral axillary disease are treated more aggressively than other Stage IV patients. Outcomes of patients with contralateral axillary disease treated with curative intent are more like patients with ipsilateral supraclavicular disease and other locally advanced breast cancers than patients with de novo distant metastases elsewhere. Therefore, some favor reclassification of contralateral axillary metastases without distant metastasis from Stage IV to Stage III breast cancer similar to ipsilateral supraclavicular metastases.

Comparison of Wireless Localization Alternatives with Wire Localization for Nonpalpable Breast Lesions.

BACKGROUND: Radiofrequency identification tag localization (TL) and magnetic seed localization (MSL) are alternatives to wire localization (WL) for excision of nonpalpable breast lesions. We sought to compare localization methods with respect to operative time, specimen volume, and re-excision rate. STUDY DESIGN: A retrospective cohort analysis was performed on TL, MSL, and WL lumpectomies and excisional biopsies at a single institution. Association between localization method and operative time, specimen volume, and re-excision rate was assessed by multiple logistic regression using odds ratios (ORs) and 95% CIs. RESULTS: A total of 506 procedures were included: 147 TL (29.0%), 140 MSL (27.7%), and 219 WL (43.3%). On logistic regression analysis, MSL was associated with longer operative times than WL for excisional biopsies only (OR 4.24, 95% CI 1.92 to 9.34, p < 0.001). Mean excisional biopsy time was 39.1 minutes for MSL and 33.0 minutes for WL. Specimen volume did not vary significantly across surgery types between localization methods. In an analysis of all lumpectomies with an indication of carcinoma, marker choice was not associated with rate of re-excision (TL vs WL OR 0.64, 95% CI 0.26 to 1.60, p = 0.342; MSL vs WL OR 1.22, 95% CI 0.60 to 2.49, p = 0.587; TL vs MSL OR 0.65, 95% CI 0.26 to 1.64, p = 0.359). CONCLUSION: TL, MSL, and WL are comparable in performance for excision of nonpalpable breast lesions. Although increased operative time associated with MSL vs WL excisional biopsies is statistically significant, clinical significance warrants additional study. With similar outcomes, physicians may choose the marker most appropriate for the patient and setting.

Does An ERAS Protocol Reduce Postoperative Opiate Prescribing in Plastic Surgery?

BACKGROUND: Enhanced recovery after surgery (ERAS) protocols are effective at reducing inpatient opiate use. There is a paucity of studies on the effects of an ERAS protocol on outpatient opiate prescriptions. The aim of this study was to determine whether an ERAS protocol for plastic and reconstructive surgery would reduce opiate use in the outpatient postoperative setting. METHODS: A statewide (Massachusetts, USA) controlled substance prescription monitoring database was retrospectively reviewed to assess the prescribing patterns of a single academic plastic surgeon performing common plastic surgical outpatient operations. The time period prior to implementation of the ERAS protocol was then compared with the time period following protocol implementation. An additional three months of post-implementation data were then compared with those of each of the previous time periods to investigate whether the results were sustained. RESULTS: A comparison of opiate prescriptions in pre-ERAS, immediate post-ERAS procedures, and follow-up ERAS implementation procedures revealed a statistically significant decrease in opiate prescriptions after ERAS protocol implementation. This decrease in the quantity of opiates prescribed was sustained over time . CONCLUSIONS: ERAS protocols are effective at reducing outpatient opiate prescriptions after a variety of plastic surgery operations. Appropriate patient and physician education is paramount for success.

The safety of performing breast reconstruction during the COVID-19 pandemic.

PURPOSE: Elective operations including surgeries for breast cancer were significantly reduced during the height of the surge of COVID-19 cases in Massachusetts. The safety of performing breast reconstruction during the pandemic was unknown. This study aims to review the safety of performing mastectomy with immediate breast reconstruction during the first COVID-19 surge in Massachusetts. METHODS: A retrospective chart review of patients who underwent mastectomy with immediate breast reconstruction by Massachusetts General Hospital breast and plastic surgeons immediately preceding and during the COVID-19 pandemic was performed. RESULTS: Thirty patients (34 breasts) underwent mastectomies with immediate breast reconstruction during the COVID-19 restriction period in Massachusetts. Most reconstructions were unilateral. All reconstructions were performed with implants or expanders, and no autologous reconstructions were performed. Two patients (2 breasts) had operative complications. The complication rate during the pandemic was similar to the complication rate pre-pandemic. No patients or surgeons experienced symptoms or positive COVID-19 tests. Over 90% of patients were discharged the same day. CONCLUSION: Prosthetic breast reconstruction was able to be performed safely during the height of the COVID-19 pandemic surge in Massachusetts. Strict screening protocols, proper use of personal protective equipment, and same-day discharge when possible are essential for patient and surgeon safety during the pandemic.

Nipple-Sparing Mastectomy versus Skin-Sparing Mastectomy: Does Saving the Nipple Impact Short- and Long-Term Patient Satisfaction?

BACKGROUND: Nipple-sparing mastectomy (NSM) is an oncologically safe alternative to skin-sparing mastectomy (SSM). This study evaluated whether NSM patients were more satisfied than SSM patients in short- and long-term follow-up. METHODS: Women who underwent NSM or SSM between 2009 and 2019 completed a postoperative BREAST-Q survey at least 1 year after surgery and patient characteristics were compared. Patient satisfaction at 1-5 years and 6-10 years after NSM and SSM were analyzed. RESULTS: Overall, 431 patients were included; 247 had NSM and 184 had SSM 1-10 years prior to BREAST-Q survey completion. SSM patients were older, had higher body mass index (BMI), larger breast weight, and more hypertension than NSM patients, but oncologic treatments were similar between groups. BREAST-Q Psychosocial Well-Being and Sexual Well-Being scores were significantly higher in NSM patients compared with SSM patients in the 1-5 years cohort; however, scores attenuated in the 6-10 years cohort. Satisfaction with breasts was nearly significantly higher in NSM patients compared with SSM patients in the 1-5 years cohort (p = 0.056), but no different in the 6-10 years cohort. Receipt of adjuvant chemotherapy, receipt of postmastectomy radiation therapy, and BMI ≥30 were independent risk factors for dissatisfaction with breasts. CONCLUSIONS: Women who are not candidates for NSM should be reassured that long-term qualify of life is not significantly different between SSM and NSM. Dissatisfaction with reconstructed breasts is linked with other factors (besides the nipple), which patients should be made aware of at the time of surgical decision making.

How Protective are Nipple-Sparing Prophylactic Mastectomies in BRCA1 and BRCA2 Mutation Carriers?

BACKGROUND: Nipple-sparing mastectomy (NSM) is now routinely offered to BRCA mutation carriers for risk reduction. We assessed the rates of ipsilateral cancer events after prophylactic and therapeutic NSM in BRCA1 and BRCA2 mutation carriers. METHODS: BRCA1 and BRCA2 mutation carriers undergoing NSM from October 2007 to June 2019 were identified in a single-institution prospective database, with variants of unknown significance being excluded. Patient, tumor, and outcomes data were collected. Follow-up analysis was by cumulative breast-years (total years of follow-up of each breast) and woman-years (total years of follow-up of each woman). RESULTS: Overall, 307 BRCA1 and BRCA2 mutation carriers (160 BRCA1, mean age 41.4 years [range 21-65]; and 147 BRCA2, mean age 43.8 years [range 23-65]) underwent 607 NSMs, with a median follow-up of 42 months (range 1-143). 388 bilateral prophylactic NSMs had 744 cumulative woman-years of follow-up, with no new cancers seen (< 0.0013 new cancers per woman-years); 251 BRCA1 prophylactic NSMs had 1034 cumulative breast-years of follow-up, with no new ipsilateral cancers seen (< 0.0010 per breast-year); 66 BRCA1 therapeutic NSMs had 328 cumulative breast-years of follow-up, with one ipsilateral cancer recurrence not directly involving the nipple or areola (0.0030 per breast-year); 237 BRCA2 prophylactic NSMs had 926 cumulative breast-years of follow-up, with no new ipsilateral cancers seen (< 0.0011 per breast-year); and 53 BRCA2 therapeutic NSMs had 239 cumulative breast-years of follow-up, with two ipsilateral recurrent cancers, neither of which directly involved the nipple or areola (0.0084 per breast-year). CONCLUSIONS: The risk of new ipsilateral breast cancers is extremely low after NSM in BRCA1 and BRCA2 mutation carriers. NSM is an effective risk-reducing strategy for BRCA gene mutations.

Management and outcomes of men diagnosed with primary breast cancer.

BACKGROUND: Fewer than 1% of all breast cancers occur in men. As a result, a distinct lack of data exists regarding the management and outcomes in this cohort. METHODS: Any male patient with pathologically confirmed breast cancer diagnosed between August 2000 and October 2017 at either Massachusetts General Hospital or Brigham and Women's Hospital/Dana-Farber Cancer Institute and their affiliate satellite locations were included. Primary chart review was used to assess clinical and pathologic characteristics. Patient and treatment variables were reported via descriptive statistics. Local-regional failure (LRF), overall survival (OS), breast cancer-specific survival (BCSS), and disease-free survival (DFS) were estimated using the Kaplan-Meier method. RESULTS: 100 patients were included in this study. Median follow-up was 112 months (range 1-220 months). Approximately 1/3 of patients experienced at least a 3-month delay to presentation. 83 patients ultimately underwent mastectomy as definitive surgical treatment. 46 patients received adjuvant radiation therapy, and 37 patients received chemotherapy. Of 82 hormone receptor-positive patients with invasive cancer, 94% (n = 77) received endocrine therapy. Of the fifty-eight patients who underwent genetic testing, 15 (26%) tested positive. The 5-year OS, BCSS, DFS, and LRF rates were 91.5%, 96.2%, 86%, and 4.8%, respectively. Delay to presentation was not associated with worse survival. CONCLUSIONS: Male breast cancer remains a rare diagnosis. Despite this, the majority of patients in this study received standard of care therapy and experienced excellent oncologic outcomes. Penetration for genetic testing improved over time.

Similar rates of residual disease in patients with DCIS within 2 mm of lumpectomy margin regardless of the presence of invasive carcinoma.

PURPOSE: The 2014 Society of Surgical Oncology/American Society for Radiation Oncology (SSO/ASTRO) breast-conserving surgery (BCS) margin guidelines for invasive cancer recommended "no ink on tumor" as an adequate margin width. However, 2016 SSO/ASTRO margin guidelines for pure DCIS recommended a 2 mm margin. Thus, management of a margin with DCIS > 0 mm but < 2 mm differs based on presence or absence of invasive carcinoma. We compared rates of residual disease in patients with pure DCIS to patients with invasive cancer with DCIS. METHODS: BCS with complete shaved cavity margins (SCM) for invasive carcinoma or pure DCIS from 2004 to 2006 at our institution was reviewed. Margin width was measured on the main specimen and the presence of carcinoma in the SCM was used as a surrogate for residual disease in the cavity. Rates of residual disease were determined for varying margin widths of invasive carcinoma and DCIS. RESULTS: Of 329 BCS patients, 123 (37%) patients had pure DCIS and 206 (63%) had invasive cancer with DCIS. In the pure DCIS cohort, 61 patients had DCIS between 0 and 2 mm from the inked margin; 32 (52%) of which had residual disease in the SCM. In the invasive cancer plus DCIS cohort, 92 had DCIS between 0 and 2 mm from the inked margin; 39 (42%) of which had residual disease in the SCM (p = 0.221). CONCLUSION: Rates of residual disease are similar in patients treated with lumpectomy for pure DCIS and those with invasive carcinoma with DCIS when DCIS is found between 0 and 2 mm from the inked margin.

Axillary Ultrasound Evaluation in Breast Cancer Patients: A Multidisciplinary Viewpoint and Middle Ground.

Over the past decade, there has been a trend toward de-escalation of axillary surgery. Certain patients may now forego axillary lymph node dissection even in the setting of a positive sentinel lymph node biopsy (SLNB), and some patients may not even undergo a SLNB. However, there is wide variability in the imaging approach to assessing axillary lymph nodes in patients with breast cancer. Approaches range from performing axillary US in all patients with newly diagnosed breast cancer to omitting axillary imaging evaluation in all patients. This article provides a multidisciplinary middle ground approach for axillary nodal evaluation. The clinical impact and rationale for appropriate axillary nodal imaging are discussed and an imaging algorithm is proposed.

Imaging Evaluation of the Axilla-A National Survey of Clinical Practice Among Radiologists.

OBJECTIVE: To assess awareness and implementation of the American College of Surgeons Oncology Group Z0011 trial findings, approaches to axillary nodal imaging, and to identify differences in practice based on respondent characteristics. METHODS: An online survey was distributed to members of the Society of Breast Imaging. Questions regarded demographics, evaluation approaches, and impact of the Z0011 trial. Poisson regression with robust standard errors to regression was used to generate multivariable-adjusted relative risks and 95% confidence intervals (CIs) for associations. RESULTS: The response rate was 21.7% (430/2007). The majority (295/430, 68.6%) reported always performing axillary US in patients with a BI-RADS 4B, 4C, or 5 breast mass. Most respondents (299/430, 69.5%) were familiar with the findings of the Z0011 trial. Radiologists in academic practice were 0.67 (95% CI: 0.54-0.83) times less likely than private practice radiologists to perform axillary US in all masses and 1.31 (95% CI: 1.13-1.52) times more likely to be very familiar with the trial. Frequency of axillary US showed no association with time spent in breast imaging, years in practice, or presence of dedicated breast surgeons. Increased time in breast imaging and presence of dedicated breast surgeons was strongly associated with familiarity with the trial. No association was observed with years in practice. Most respondents (291/430, 67.7%) made little or no change to their practice based on trial findings. CONCLUSION: There is wide variability in approaches to axillary nodal evaluation, demonstrating a need for improved education and guidelines for axillary imaging in breast cancer patients.

Baseline Screening MRI Uptake and Findings in Women with ≥ 20% Lifetime Risk of Breast Cancer.

BACKGROUND: The American Cancer Society recommends screening magnetic resonance imaging (MRI) for patients with a ≥ 20% lifetime breast cancer risk. This study assesses the outcomes of baseline MRI screens in women from a high-risk breast clinic (HRBC). METHODS: We retrospectively reviewed patients from our institution's HRBC, excluding those with prior breast cancer and predisposing genetic mutations. Screening MRI was recommended for a lifetime risk of ≥ 20% using the Tyrer-Cuzick model. We determined baseline MRI results, biopsy rates, and frequency of MRI-detected high-risk lesions (HRLs) and breast cancers. RESULTS: Overall, 319 women attended our HRBC; median age was 48 years and 4.7% had prior atypia/lobular carcinoma in situ. Screening MRI was recommended for 282 patients, of whom 196 (69.5%) completed a baseline screen. A Breast Imaging-Reporting and Data System (BIRADS) 3 or 4 finding occurred in 19.6% of patients; 23 (12.3%) required 6-month follow-up MRI, 16 (8.6%) underwent core biopsy, and 4 (2.1%) underwent excisional biopsy after initial core. An additional 7 (3.7%) patients had a non-breast incidental finding. An HRL was identified in 2 (1.1%) patients (atypical ductal and lobular hyperplasia, respectively), and 2 (1.1%) were diagnosed with T1N0 breast cancers. CONCLUSIONS: In the setting of an HRBC, 70% of women with a ≥ 20% lifetime risk of breast cancer pursued screening MRI when recommended. On baseline screen, the rate of MRI-detected breast cancer was low (1%); however, malignancies were mammographically occult and identified at an early stage. Despite a low cancer rate, nearly one in four women required additional diagnostic investigation. Prescreening counselling should include a discussion of this possibility, and longer-term follow-up of screening MRI is needed in this high-risk population.

Performance of Breast Cancer Risk-Assessment Models in a Large Mammography Cohort.

BACKGROUND: Several breast cancer risk-assessment models exist. Few studies have evaluated predictive accuracy of multiple models in large screening populations. METHODS: We evaluated the performance of the BRCAPRO, Gail, Claus, Breast Cancer Surveillance Consortium (BCSC), and Tyrer-Cuzick models in predicting risk of breast cancer over 6 years among 35 921 women aged 40-84 years who underwent mammography screening at Newton-Wellesley Hospital from 2007 to 2009. We assessed model discrimination using the area under the receiver operating characteristic curve (AUC) and assessed calibration by comparing the ratio of observed-to-expected (O/E) cases. We calculated the square root of the Brier score and positive and negative predictive values of each model. RESULTS: Our results confirmed the good calibration and comparable moderate discrimination of the BRCAPRO, Gail, Tyrer-Cuzick, and BCSC models. The Gail model had slightly better O/E ratio and AUC (O/E = 0.98, 95% confidence interval [CI] = 0.91 to 1.06, AUC = 0.64, 95% CI = 0.61 to 0.65) compared with BRCAPRO (O/E = 0.94, 95% CI = 0.88 to 1.02, AUC = 0.61, 95% CI = 0.59 to 0.63) and Tyrer-Cuzick (version 8, O/E = 0.84, 95% CI = 0.79 to 0.91, AUC = 0.62, 95% 0.60 to 0.64) in the full study population, and the BCSC model had the highest AUC among women with available breast density information (O/E = 0.97, 95% CI = 0.89 to 1.05, AUC = 0.64, 95% CI = 0.62 to 0.66). All models had poorer predictive accuracy for human epidermal growth factor receptor 2 positive and triple-negative breast cancers than hormone receptor positive human epidermal growth factor receptor 2 negative breast cancers. CONCLUSIONS: In a large cohort of patients undergoing mammography screening, existing risk prediction models had similar, moderate predictive accuracy and good calibration overall. Models that incorporate additional genetic and nongenetic risk factors and estimate risk of tumor subtypes may further improve breast cancer risk prediction.

Long-Term Outcomes of Multiple-Wire Localizations for More Extensive Breast Cancer: Multiple-Wire Excision Does Not Increase Recurrence, Unplanned Imaging, or Biopsies.

BACKGROUND: We previously reported that breast conservation was feasible for women with large or irregularly shaped breast cancers when tumor resection was guided by multiple localizing wires. We now report long-term outcomes of multiple-wire versus single-wire localized lumpectomies for breast cancer. PATIENTS AND METHODS: We retrospectively reviewed wire-localized lumpectomies at our institution from May 2000 to November 2006. Rates of ipsilateral in-breast tumor recurrence, metastasis, and subsequent unplanned diagnostic imaging and biopsy were compared between multiple-wire and single-wire cohorts. RESULTS: We identified 112 multiple-wire and 160 single-wire breast cancer lumpectomies that achieved clear margins. Median age was 64 years in the multiple-wire cohort and 57 years in the single-wire cohort. Mean lumpectomy volume was 75 mL in multiple-wire patients and 49 mL in single-wire patients (P = .003). Invasive tumor size, axillary node status, and use of radiation and systemic therapy were similar, but the multiple-wire group had more patients with ductal carcinoma-in-situ only (38% vs. 28%). At 108 months' median follow-up, there was no significant difference in local or distant recurrence rates between multiple-wire and single-wire cohorts. Six (5%) multiple-wire patients and 6 (4%) single-wire patients had local recurrences and 3 (3%) multiple-wire and 5 (3%) single-wire patients developed metastatic disease. Unplanned diagnostic imaging was required for 53 (47%) multiple-wire and 65 (41%) single-wire patients. Subsequent ipsilateral biopsy occurred in 15 (13%) multiple-wire and 19 (12%) single-wire patients. CONCLUSION: Breast-conserving surgery with multiple localizing wires is a safe alternative to mastectomy for breast cancer patients with large mammographic lesions.