National long-term patient-reported outcomes following mastectomy with or without breast reconstruction: The Swedish Breast Reconstruction Outcome Study Part 2 (SweBRO 2).

BACKGROUND: The Swedish Breast Reconstruction Outcome Study (SweBRO) initiative is a nationwide study with the primary aim of assessing long-term outcomes after mastectomy with and without breast reconstruction (BR). The current part (SweBRO 2) is designed to evaluate health-related quality of life (HRQoL), with the hypothesis that BR has a positive impact on patient-reported HRQoL in the long-term. METHODS: Women who underwent mastectomy in Sweden in 2000, 2005, or 2010 and were alive at the time of the survey were identified through the National Breast Cancer Registry. Eligible participants received formal invitation letters to take part in a survey evaluating their HRQoL at 5 , 10, or 15 years post-mastectomy. The EORTC QLQ-C30, EORTC QLQ-BR23, and EQ-5D-3L questionnaires were employed. RESULTS: Of 2904 respondents (50% of 5853 invited), 895 (31%) had received BR. Among them, 516 (58%) were reconstructed with implants and 281 (31%) with autologous tissue. Women with BR scored significantly better in the EORCT QLQ-C30 physical functioning domain (mean 90 versus 81 points), fatigue (mean 21 versus 25), and dyspnoea (mean 16 versus 22) compared to non-reconstructed women. The EORTC QLQ-BR23 revealed that women with BR experienced favourable sexual functioning compared with non-reconstructed women (mean 26 versus 14). The EQ-5D-3L visual analogue scale score was similar between groups. CONCLUSION: The current study underscores the benefits of BR for long-term well-being, for example, in terms of physical and sexual functioning. These underline the importance of informing women undergoing mastectomy about BR alternatives and its potential benefits in enhancing long-term well-being.

Warzone pediatric trauma care: Lessons from civilian medical staff in Kyiv.

INTRODUCTION: The article discusses the challenges faced by civilian healthcare providers in Kyiv, Ukraine, during the conflict in treating pediatric trauma resulting from war-related incidents. METHODS: The authors share their experiences and insights from managing a series of 12 pediatric patients admitted to the Ohmatdyt children's hospital between February 25 and April 1, 2022. During this period, the hospital was under constant threat due to the military conflict. RESULTS: The patients, ranging in age from 3 months to 17 years, suffered injuries from various causes, including vehicle shootings, explosions, and other traumatic events. The interventions and timely management are discussed, and two detailed clinical cases are presented to illustrate the complexities of treating pediatric trauma in a warzone. CONCLUSION: In summary, the article sheds light on the unique challenges faced by healthcare providers in a warzone when treating pediatric trauma. It underscores the importance of timely intervention, effective triage, and the utilization of advanced medical techniques to improve patient outcomes in such challenging circumstances.

Breast reconstruction patterns from a Swedish nation-wide survey.

OBJECTIVES: The overall aim of the Swedish Breast Reconstruction Outcome Study was to investigate national long-term outcomes after mastectomy with or without breast reconstruction. The current report evaluates breast reconstruction (BR) patterns in Sweden over time. MATERIALS AND METHODS: This is a cross-sectional, registry-based study where all women operated with mastectomy 2000, 2005, 2010 were identified (N = 5853). Geographical differences in type of BR were investigated using heatmaps. Distribution of continuous variables were compared using the Mann-Whitney U test, categorical variables were compared using the chi-square test. RESULTS: Mean age at survey was 69 years (SD=±11.4) and response rate was 50%, responders were on average six years younger than the non-responders and had a more favourable tumor stage (both p < 0.01). Of the 2904 responders, 31% (895/2904) had received a BR: implant-based in 58% (516/895)autologous in 31% (281/895). BR was immediate in 20% (176/895) and delayed in 80% (719/895) women. Women with BR were on average one year older, more often had a normal BMI, reported to be married or had a partner, had a higher educational level and a higher annual income when compared to those without BR (all p < 0.001). The independent factors of not receiving BR were older age and given radiotherapy. CONCLUSIONS: To our knowledge, this is the first national long-term follow-up study on women undergoing mastectomy with and without BR. Around 30% of the survey responders have had a BR with a significant geographical variation highlighting the importance of information, availability and standardisation of indications for BR.

Bilateral Free Flap Breast Reconstruction Outcomes: Do Abdominal Scars Affect Bilateral Flaps?

BACKGROUND: The incidence of bilateral mastectomies is increasing along with the rates of breast reconstructions. A substantial number of patients will present with abdominal scars after Cesarean section, laparoscopy, laparotomy, and so on. The aim of this study was to evaluate the impact of prior abdominal scars on complication rates in abdominal bilateral free flap breast reconstruction. METHODS: All consecutive patients with autologous free flap breast reconstruction between 2007 and 2014 were eligible. The relevant demographic and clinical data were prospectively collected into a study-specific database. Complications and reoperations were prospectively registered after postoperative outpatient visits. RESULTS: Overall, 493 patients underwent abdominally based breast reconstruction during the study period: unilateral (n = 250; 50.7%) or bilateral (n = 243; 49.3%). In the bilateral group, the abdominal scar locations were Pfannenstiel (n = 73; 30.1%), midline (n = 16; 6.6%), lower oblique (n = 17; 7.0%), upper oblique (n = 5; 2.1%), and laparoscopic (n = 69; 28.4%). Four (1.7%) flap failures (including 1 converted to a pedicled transverse rectus abdominis flap) were registered, all occurring in patients from the scar group: 3 with Pfannenstiel incision and 1 patient with prior laparoscopy. Pfannenstiel scar was associated with higher risk of hematoma at the recipient site when compared with no scar group (13.7% versus 2.2%; P = 0.006). Partial flap necrosis, infection, and seroma occurred in 14 (5.9%), 8 (3.4%), and 5 (2.1%) patients, respectively, and no differences between the scar groups were identified. CONCLUSION: Surgical outcomes of bilateral reconstructions in patients with abdominal scars are generally comparable with ones in patients without prior surgery; however, some problems have been identified. These procedures might have some intraoperative considerations and often require increased operative times. Apart from the traditional preoperative computed tomography angiography, intraoperative imaging (e.g., fluorescence angiography) may be advocated in patients with abdominal scars.

Preoperative psychosocial characteristics may predict body image and sexuality two years after risk-reducing mastectomy: a prospective study.

BACKGROUND: Risk-reducing mastectomy (RRM) in patients at high risk has become more available and the rates of both bilateral (BRRM) and contralateral (CRRM) procedures are increasing. For women opting for RRM, psychosocial well-being, body image and sexuality are known to be important patient-reported outcomes. The aim of the present study was to investigate baseline health-related quality of life (HRQoL) and emotional distress (anxiety and depression) as predictors of body image and sexuality two years after RRM in women undergoing CRRM and BRRM. METHODS: This is a prospective cohort study including consecutive women opting for BRRM and breast cancer patients considering CRRM at Karolinska University Hospital during 1998-2010. The women were given a set of questionnaires to be completed at baseline before RRM (The Medical Outcomes Study 36-Item Short Form, The Hospital Anxiety and Depression Scale, and The Sexual Activity Questionnaire) and two years after RRM (all the above-mentioned questionnaires along with The Body Image Scale). Mean scores for all questionnaires were analysed using linear regression models and adjusted for age at RRM as well as calendar year. RESULTS: In total, 253 patients consented to participate in the study. Response rate at baseline and 2 years was 88% and 71%, respectively. In the BRRM group (healthy women), preoperative HRQoL and emotional distress were associated with body image and sexual problems two years after the procedure. No similar associations were found for the patients with breast cancer who underwent CRRM. CONCLUSIONS: The current study suggests that preoperative HRQoL and emotional distress may predict body image and sexual problems two years after RRM in healthy women, but not in breast cancer patients. Baseline psychosocial characteristics may be useful to identify women at risk for long-term body image and sexual problems following BRRM, but not among breast cancer patients opting for CRRM.

An unusual case of a ruptured Poly Implant Prothèse breast implant associated with xanthoma.

A suspicious breast mass was intra-operatively found in a female patient previously operated for breast augmentation with the Poly Implant Prothèse (PIP) implants. The neoplasm was verified as xanthoma and an asymptomatic microrupture of PIP was also detected. This report discusses possible association of breast xanthoma with PIP implant rupture.

Predictors of Reoperations in Deep Inferior Epigastric Perforator Flap Breast Reconstruction.

BACKGROUND: The deep inferior epigastric perforator (DIEP) procedure is regarded a safe option for autologous breast reconstruction. Reoperations, however, may occur, and there is no consensus in the literature regarding the risk factors. The aim of this study was to identify factors associated with reoperations in DIEP procedure. PATIENTS AND METHODS: A retrospective study of consecutive patients undergoing DIEP breast reconstruction 2007 to 2014 was performed and included a review of 433 medical charts. Surgical outcome was defined as any unanticipated reoperation requiring return to the operating room. Multivariate regression analysis was utilized to identify predictors of reoperation. The following factors were considered: age, body mass index, comorbidity, childbearing history, previous abdominal surgery, adjuvant therapy, reconstruction laterality and timing, flap and perforator characteristics, and number and size of veins. RESULTS: In total, 503 free flaps were performed in 433 patients, 363 (83.8%) unilateral and 70 (16.2%) bilateral procedures. Mean age was 51 years; 15.0% were obese; 13.4% had hypertension; 2.3% had diabetes; 42.6% received tamoxifen; 58.8% had preoperative radiotherapy; 45.6% had abdominal scars. Reoperation rate was 15.9% (80/503) and included flap failure, 2.0%; partial flap loss, 1.2%; arterial thrombosis, 2.0%; venous thrombosis, 0.8%; venous congestion, 1.2%; vein kinking, 0.6%. Other complications included bleeding, 2.2%; hematoma, 3.0%; fat necrosis, 2.8%, and infection, 0.2%. Factors negatively associated with reoperation were childbearing history (odds ratio [OR]: 3.18, P = 0.001) and dual venous drainage (OR: 1.91, P = 0.016); however, only childbearing remained significant in the multivariate analyses (OR: 4.56, P = 0.023). CONCLUSIONS: The history of childbearing was found to be protective against reoperation. Number of venous anastomoses may also affect reoperation incidence, and dual venous drainage could be beneficial in nulliparous patients.

Associations between Reoperations and Psychological Factors after Contralateral Risk-Reducing Mastectomy: A Two-Year Follow-Up Study.

Introduction. The aim of the study was to investigate associations between reoperations after contralateral risk-reducing mastectomies (CRRM) and emotional problems, body image, sexuality, and health related quality of life (HRQoL) in women with breast cancer and hereditary high risk. Patients and Methods. Patients scheduled for CRRM with breast reconstruction between 1998 and 2010 completed questionnaires, comprised of SF-36, the Hospital Anxiety and Depression Scale, the Body Image Scale, and the Sexual Activity Questionnaire, preoperatively and two years after CRRM. Data on reoperations was collected from medical charts. Results. A total of 80 women participated, with a response rate of 61 (76%) preoperatively and 57 (71%) at the two-year follow-up. At the two-year assessment, 44 (55%) patients had undergone ≥1 reoperation (reoperation group), whereas 36 (45%) had not (no reoperation group). No statistically significant differences between the groups were found for HRQoL, sexuality, anxiety, or depression. A higher proportion of patients in the "reoperation group" reported being dissatisfied with their bodies (81% versus 48%, p = 0.01). Conclusion. The results suggest associations between reoperation following CRRM with breast reconstruction and body image problems. Special attention should be paid to body image problems among women who are subject to reoperations after CRRM.

Cardiovascular complications secondary to Graves' disease: a prospective study from Ukraine.

BACKGROUND: Graves' disease (GD) is a common cause of hyperthyroidism resulting in development of thyrotoxic heart disease (THD). OBJECTIVES: to assess cardiovascular disorders and health related quality of life (HRQoL) in patients with THD secondary to GD. PATIENTS AND METHODS: All patients diagnosed with THD secondary to GD between January 2011 and December 2013 were eligible for this study. Clinical assessment was performed at baseline and at the follow-up visit after the restoring of euthyroid state. HRQoL was studied with a questionnaire EQ-5D-5L. RESULTS: Follow-up data were available for 61 patients, but only 30 patients with THD secondary to GD were consented to participate in investigation of their HRQoL. The frequency of cardiovascular complications was significantly reduced as compared before and after the antithyroid therapy as follows: resting heart rate (122 vs. 74 bpm), blood pressure: systolic (155 vs. 123 mm Hg), diastolic (83 vs. 66 mm Hg), supraventricular premature contractions (71% vs. 7%), atrial fibrillation (72% vs. 25%), congestive heart failure (69% vs. 20%), thyrotoxic cardiomyopathy (77% vs. 26%), all p<0.01. Anti-TSH receptor antibodies were determined as independent predictor of left ventricular geometry changes, (b-coefficient = 0.04, 95%CI 0.01-0.07, p = 0.02). HRQoL was improved in all domains and self-rated health increased from 43 to 75 units by visual analogue score (p<0.001). CONCLUSIONS: Restoring of euthyroid state in patients with GD is associated with significant elimination of cardiovascular disorders and improvement of HRQoL. To our knowledge this is the first study evaluating Ukrainian patients with THD secondary to GD with focus on HRQoL.

Physical therapy after prophylactic mastectomy with breast reconstruction: a prospective randomized study.

INTRODUCTION: The rate of prophylactic mastectomies (PM) is increasing. Patients generally report high levels of health related quality of life and satisfaction after the procedure, whereas body image perception and sexuality may be negatively affected. The aim of the study was to evaluate the interest in physical therapy as a means of improving body image and sexuality in women after PM. PATIENTS AND METHODS: Patients undergoing PM at Karolinska University Hospital between 2006 and 2010 were eligible. The following patient-reported outcome measures were used at study baseline and 2 years postoperatively: the body image scale (BIS), the sexual activity questionnaire (SAQ), the short-form health survey (SF-36), the hospital anxiety and depression scale (HAD), and a study specific "pain/motion/sensation scale". RESULTS: Out of 125 patients invited to participate in this prospective randomized study, 43 (34%) consented and were randomized into the intervention (n = 24, 56%) or control (n = 19, 44%) groups. There were no statistically significant between-group differences found with respect to BIS, SAQ, SF-36, HAD, and "pain/motion/sensation". Two years postoperatively, more than half of the patients in both groups reported problems like feeling less attractive, less sexually attractive, their body feeling less whole, and being dissatisfied with their body. A majority marked a decreased sensation in breast area. CONCLUSION: The interest in a physiotherapy intervention was limited among women who had undergone PM. The intervention did not show any substantial effects. A large proportion of patients reported specific body image related and pain/motion/sensation problems postoperatively.

No difference in dose distribution in organs at risk in postmastectomy radiotherapy with or without breast implant reconstruction.

The aim of this study was to quantify the variation in doses to organs at risk (ipsilateral lung and heart) and the clinical target volume (CTV) in the presence of breast implants. In this retrospective cohort study, patients were identified through the National Breast Cancer Register. Consecutive breast cancer patients undergoing mastectomy between 2009 and 2011 and completing a full course of postmastectomy radiotherapy (PMRT) were eligible. All included patients (n = 818) were identified in the ARIA© oncology information system and further stratified for immediate breast reconstruction (IBR+, n = 162) and no immediate breast reconstruction (IBR-, n = 656). Dose statistics for ipsilateral lung, heart and CTV were retrieved from the system. Radiation plans for patients with chest wall (CW) only (n = 242) and CW plus lymph nodes (n = 576) irradiation were studied separately.The outcome variables were dichotomized as follows: lung, V(20Gy) ≤ 30% vs. V(20Gy) > 30%; heart, D(mean) ≤ 5 Gy vs. D(mean) > 5 Gy; CTV, V95% ≥ median vs. V95% < median.In the univariate and multivariate regression models no correlation between potential confounders (i.e. breast reconstruction, side of PMRT, CW index) and the outcome variables was found. Multivariate analysis of CW plus lymph nodes radiation plans, for example, showed no association of breast reconstruction with dosimetric outcomes in neither lung nor heart- lung V(20Gy) (odds ratio [OR]: 0.6, 95%CI, 0.4 to 1.0, p = 0.07) or heart D(mean) (OR: 1.2, 95%CI, 0.5 to 3.1, p = 0.72), respectively.CTV was statistically significantly larger in the IBR+ group (i.e. included breast implant), but no correlation between the implant type and dosimetric characteristics of the organs at risk was revealed.In the current study, the presence of breast implants during postmastectomy radiotherapy was not associated with increased doses to ipsilateral lung and heart, but CTV definition and its dosimetric characteristics urge further evaluation.

Breast reconstruction and treatment algorithm for patients with complications after polyacrylamide gel injections: a 10-year experience.

BACKGROUND: An algorithm for breast reconstruction for patients with complications after polyacrylamide gel (PAAG) injections is presented, and the outcomes of surgery using the adopted treatment protocol are evaluated. METHODS: We reviewed the clinical records of consecutive patients who were treated for PAAG complications with breast reconstruction at two surgical centers between 2000 and 2010 (n=154). All patients had one or more complications from PAAG injections and underwent gel removal and breast reconstruction with implants. One hundred women who underwent conventional breast augmentation with implants matching the study cohort comprised a reference group. RESULTS: Of the total of 154 patients, 121 (79%) women had no signs of acute inflammation and underwent a single-stage surgery comprising gel removal and immediate breast reconstruction (group I). The remaining 33 (21%) patients had signs of acute inflammation (group II) and underwent two-stage surgery with delayed reconstruction. Subgroup analysis of group I revealed that submuscular implant placement was associated with a lower probability of capsular contracture (CC) than was subglandular placement (17 vs. 36%, p<0.05). The rate of CC in patients with textured implants (n=81) was 24.8%, whereas no CC was registered among patients with micropolyurethane surface implants (n=40). The rate of early surgical complications in group I, group II, and the reference group was 39, 51.5, and 9%, respectively. The probability of reoperation after breast reconstruction in group I and in group II was 34 and 42%, respectively. CONCLUSION: Complications and subsequent breast reconstruction in patients after PAAG injection pose a challenge to the surgeon; however, satisfactory results can be achieved in the majority of patients. The reconstruction algorithm described here may serve as a useful tool for breast surgeons dealing with PAAG complications. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Contralateral prophylactic mastectomy in breast cancer patients with a family history: a prospective 2-years follow-up study of health related quality of life, sexuality and body image.

INTRODUCTION: Contralateral prophylactic mastectomy (CPM) is the most effective option to prevent the occurrence of a second breast cancer in hereditary breast cancer patients. This study aimed to prospectively evaluate health-related quality of life (HRQoL), anxiety and depression, sexuality and body image in breast cancer patients with a family history undergoing CPM with immediate breast reconstruction. PATIENTS AND METHODS: In total, 60 of 69 eligible patients agreed to participate in the study. Four validated questionnaires were used: the SF-36, the Hospital Anxiety and Depression Scale (HAD), the Body Image Scale (BIS), and the Sexual Activity Questionnaire (SAQ). Forty-five patients (75%) responded before CPM, 49 (82%) at 6 months, and 45 (75%) at 2 years after CPM. RESULTS: Overall, the patients showed a satisfactory HRQoL 2 years after CPM, similar to women in the general population. There were no differences in HRQoL, anxiety, depression or sexuality before and after CPM. However, more than half of the women reported at least one body image problem 2 years postoperatively. CONCLUSION: No adverse effects on HRQoL, anxiety, depression or sexuality were observed. However, some aspects of body image were negatively affected after CPM. These findings could be used in preoperative counselling of breast cancer patients opting for CPM.

Breast reconstruction in patients with personal and family history of breast cancer undergoing contralateral prophylactic mastectomy, a 10-year experience.

BACKGROUND: The purpose of this study was to evaluate the clinical course of breast reconstruction in patients with personal and family history of breast cancer undergoing contralateral prophylactic mastectomy (CPM) and elucidate the association between reoperation risk and adjuvant treatment. METHODS: A descriptive retrospective study of a consecutive series of breast cancer patients who underwent CPM with breast reconstruction at Karolinska University Hospital between 1998 and 2008 was performed. Reoperation was chosen as an outcome variable assessing morbidity and thus documented for each patient and for each reconstructed breast. Regression analyses were performed to evaluate the risk of reoperation after bilateral breast reconstruction. RESULTS: Ninety-one patients underwent CPM during the study period. Their mean age at CPM was 45.3 years (SD =9.4). No contralateral breast cancer was diagnosed after CPM during the median follow-up period of 3.9 years. All women, but two, received an implant based breast reconstruction. The majority (n =75, 82%) underwent CPM with concurrent bilateral breast reconstruction. Overall, after bilateral breast reconstruction 45/75 (60%) required at least one reoperation on the CPM side (n =2, 3%), therapeutic mastectomy (TM) side (n =17, 23%) or both sides (n =26, 33%). In the paired analyses, the probability of reoperation was significantly higher after TM reconstruction as compared to CPM (0.57 vs. 0.37, p =0.001). The mean number of reoperations required for completion of TM and CPM reconstruction was 0.84 and 0.49, respectively (p =0.003). Among all potential risk factors, only radiotherapy was associated with reoperation after bilateral breast reconstruction (odds ratio [OR]: 4.2, 95% CI, 1.3 to 13.6, p =0.015). CONCLUSIONS: Breast reconstruction in patients with personal and family history of breast cancer is a complex operation. This study found that the clinical course after bilateral breast reconstruction was predominantly affected by reoperations on the TM side and given radiotherapy was associated with reoperation. Further studies are necessary to examine the possible predictors of unanticipated reoperations in candidates for CPM with breast reconstruction.

Polyacrylamide gel injections for breast augmentation: management of complications in 106 patients, a multicenter study.

BACKGROUND: Polyacrylamide gel (PAAG) was first manufactured in Ukraine in the late 1980s and introduced as a biomaterial for "breast augmentation without surgery." Since it is prohibited in most countries, PAAG injections are rare nowadays, but their consequences and long-term complications can be crucial. METHODS: We identified 106 patients consecutively operated on for PAAG complications at three teaching Ukrainian hospitals between 1998 and 2009. All relevant sociodemographic, clinical, and treatment characteristics were collected. Forty-five (42%) patients were available for clinical follow-up. RESULTS: The majority (88%) had had bilateral PAAG injections. The mean volume of injected PAAG was 230 ml/breast (range = 50-400). Mean age at injection was 29 years (range = 17-49) and the mean time from the injection to complications was 6.1 years (SD = 4.1). Symptoms preceding debridement were pain in 85 patients (80%), breast hardening in 79 (74%), breast deformity in 77 (73%), lumps in 57 (54%), gel migration in 39 (37%), fistulas in 17 (16%), and gel leakage in 12 (11%). The surgical interventions in 199 breasts included gel evacuation alone in 107 (54%) or in combination with partial mastectomy in 65 (33%), partial mastectomy and partial pectoralis muscle resection in 12 (6%), or subcutaneous mastectomy in 15 (7%). Of the 199 operated breasts, 86 (43%) immediate and 58 (29%) delayed implant-based breast reconstructions were performed. CONCLUSION: Injections of PAAG can cause irreversible damage to the breast necessitating complex debridement procedures, even mastectomy and breast reconstruction. Despite numerous surgical interventions, gel remnants are still found on subsequent breast imaging. Although PAAG is prohibited in many countries, different types of injections with unknown long-term effects are currently being used. Making the public aware of the problems of injectables for breast augmentation is warranted.