Oncoplastic breast conservation surgery is oncologically safe when compared to wide local excision and mastectomy.

BACKGROUND: Support for the oncological safety of oncoplastic breast conservation surgery (OBCS) is mostly based on evidence comparing recurrence rates after OBCS to wide local excision (WLE). However, OBCS is often indicated for larger cancers and oncological results should also be compared to patients treated with mastectomy. In this study we compared recurrence and survival following OBCS, mastectomy and WLE. METHODS: Patients treated with OBCS between 2009 and 2012 were identified from a prospectively maintained database. For comparison, consecutive patients treated with WLE or mastectomy with or without immediate reconstruction (Ms ± IR) over the same time period were identified. Histological variables of patients were compared using Fisher Exact or Chi squared tests, and recurrence and survival were compared using Kaplan-Meier and Cox regression survival analysis. RESULTS: 980 patients' data were analysed (OBCS: n = 104; WLE: n = 558; Ms ± IR: n = 318). Tumour size, grade, nodal status, ER, and PR expression of patients treated with OBCS were all significantly more adverse compared with patients treated with WLE (p < 0.001). These histological variables were similar in patients treated with Ms ± IR and OBCS. 5-year local recurrence rates were similar in all three groups (WLE: 3.4 per cent, OBCS: 2 per cent, Ms ± IR: 2.6 per cent; log rank = 0.973), while distant recurrence rates were higher after Ms ± IR and OBCS (Ms ± IR:13.1 per cent, OBCS:7.5 per cent, WLE:3.3 per cent; log rank: p < 0.001). CONCLUSION: OBCS is oncologically safe in patients even when histological results are similar to patients treated with Ms ± IR.

How to compare the oncological safety of oncoplastic breast conservation surgery - To wide local excision or mastectomy?

BACKGROUND: Comparative studies suggest that patients treated with oncoplastic breast conservation surgery (OBCS) have similar pathology to patients treated with wide local excision (WLE). However, patients treated with OBCS have never been compared to patients treated with mastectomy. The aim of this study was to identify which control group was comparable to patients undergoing OBCS. METHODS: Commonly reported histopathological variables of patients treated with OBCS, WLE or mastectomy ± immediate reconstruction (Ms ± IR) were compared using Fisher Exact or Chi squared tests. RESULTS: 1000 patients' data were analysed (OBCS: n = 119; WLE: n = 600; Ms ± IR: n = 281). Tumour size was significantly bigger after OBCS than WLE (p < 0.001), but similar to Ms ± IR (p = 0.138). Tumour grade was higher after OBCS than WLE (p < 0.001), but similar to Ms ± IR (p = 0.497). More axillary nodes were involved in patients with OBCS than WLE (p < 0.001), but comparable to Ms ± IR (p = 0.175). ER and PR expressions were lower after OBCS compared to WLE (p = 0.007, p = 0.009), but identical to Ms ± IR (p = 1, p = 0.904 respectively). Differences in application of systemic (neo)adjuvant therapy followed the above trend. CONCLUSION: Striking similarities found between OBCS and mastectomy patients' histopathological results are in sharp contrast with previously published data. This study suggests that oncological outcomes following OBCS should be compared to mastectomy besides WLE.

Oncoplastic breast conservation does not lead to a delay in the commencement of adjuvant chemotherapy in breast cancer patients.

INTRODUCTION: There is hardly any evidence that oncoplastic breast conservation surgery (OBCS) does not lead to a delay in the commencement of adjuvant chemotherapy. Although this is an integral part of overall oncological safety, no controlled studies have been published so far. Therefore, our aim was to determine whether OBCS led to a delay when compared to simple wide local excision (WLE), mastectomy (Ms) or mastectomy with immediate reconstruction (MsIR). METHODS: Breast cancer patients who required adjuvant chemotherapy after OBCS, WLE, Ms and MsIR were identified from prospectively maintained institutional databases. Time between multidisciplinary team decision to offer chemotherapy and delivery of first cycle of chemotherapy was measured and compared among the four groups of patients. RESULTS: time to chemotherapy of breast cancer patients (n = 169) treated with OBCS (n = 31) were 29 [16-58] days, while it was 29.5 [15-105] days after WLE (n = 66), 29 [15-57] days after Ms (n = 56) and 31 [15-58] days after MsIR (n = 16). A combined analysis involving all four groups demonstrated no statistically significant difference (p = 0.524). Similarly, inter-group analysis revealed no significant differences in between patients treated with OBCS compared to any of the three control groups (OBCS to WLE: p = 0.433; OBCS to Ms: p = 0.800; OBCS to MsIR: p = 0.405). CONCLUSION: OBCS seems as safe as WLE, Ms or MsIR in terms of delivery of adjuvant chemotherapy, and, therefore, should not adversely affect breast cancer outcome in this respect.

Breast reconstruction in the high risk patient with systemic connective tissue disease: a case series.

INTRODUCTION: The presence of severe underlying connective tissue disease may restrict the reconstructive options offered to a woman in the event of mastectomy. Putative concerns about reconstructive surgery include the effects of connective tissue disease and immunosuppression on wound healing and donor site morbidity, and increased risks of deranged clotting and thrombophilia after free tissue transfer. There is also the possibility of an unpredictable tissue reaction after oncological resection surgery and adjuvant radiotherapy. METHODOLOGY: Here we present a review of the current sparse evidence regarding reconstructive breast surgery in this challenging group of patients. In addition we present a series of six consecutive patients with a spectrum of connective tissue disorders including combinations of longstanding Systemic Lupus Erythematosis (SLE), Rheumatoid arthritis and Raynaud's Disease who underwent successful post-mastectomy reconstruction with an extended autologous latissimus dorsi flap, along with subsequent successful correction of asymmetry and/or nipple reconstruction. RESULTS: There is a paucity of literature on this subject perhaps suggesting that surgeons are reluctant to offer reconstruction or that uptake is poor in this group. Complications related to radiotherapy and free tissue transfer in patients with severe CTD is less than may be expected. The most common complications experienced by our patients with CTD after extended ALD breast reconstruction were persistent donor site seroma, wound dehiscence and delayed haematoma formation, reflecting the abnormal inflammatory response and deranged haemostatic cascade common to connective tissue disease. However, all six patients made a full recovery from surgery without residual donor site morbidity and with an acceptable aesthetic breast reconstruction. CONCLUSION: Careful peri-operative management is crucial in this group of patients, but good outcomes are possible using a variety of reconstructive techniques. This is the first reported series of patients with severe connective tissue disease who have been managed with extended ALD breast reconstruction. The majority of complications relate to the donor site but the favourable outcomes demonstrate that the extended ALD flap remains a reliable reconstructive option for this group.

Prospective trial of adipose-derived regenerative cell (ADRC)-enriched fat grafting for partial mastectomy defects: the RESTORE-2 trial.

AIMS: Women undergoing breast conservation therapy (BCT) for breast cancer are often left with contour defects and few acceptable reconstructive options. RESTORE-2 is the first prospective clinical trial using autologous adipose-derived regenerative cell (ADRC)-enriched fat grafting for reconstruction of such defects. This single-arm, prospective, multi-center clinical trial enrolled 71 patients post-BCT with defects ≤150 mL. METHODS: Adipose tissue was collected via syringe lipoharvest and then processed during the same surgical procedure using a closed automated system that isolates ADRCs and prepares an ADRC-enriched fat graft for immediate re-implantation. ADRC-enriched fat graft injections were performed in a fan-shaped pattern to prevent pooling of the injected fat. Overall procedure times were less than 4 h. The RESTORE-2 protocol allowed for up to two treatment sessions and 24 patients elected to undergo a second procedure following the six month follow-up visit. RESULTS: Of the 67 patients treated, 50 reported satisfaction with treatment results through 12 months. Using the same metric, investigators reported satisfaction with 57 out of 67 patients. Independent radiographic core laboratory assessment reported improvement in the breast contour of 54 out of 65 patients based on blinded assessment of MRI sequence. There were no serious adverse events associated with the ADRC-enriched fat graft injection procedure. There were no reported local cancer recurrences. Injection site cysts were reported as adverse events in ten patients. CONCLUSION: This prospective trial demonstrates the safety and efficacy of the treatment of BCT defects utilizing ADRC-enriched fat grafts.

Ten-year follow-up of skin-sparing mastectomy followed by immediate breast reconstruction.

BACKGROUND: The oncological safety of skin-sparing mastectomy (SSM) followed by immediate breast reconstruction (IBR) is debated owing to a presumed compromise in the completeness of mastectomy. Current evidence is poor as it is based mostly on short-term follow-up data from highly selected patients. METHODS: A prospectively maintained institutional database was searched to identify patients who underwent SSM and IBR between 1995 and 2000. A retrospective review of medical records was carried out, including only patients with ductal carcinoma in situ and invasive breast cancer. During this time all patients treated with mastectomy were offered IBR regardless of tumour stage. RESULTS: Follow-up data from 253 consecutive patients with IBR were reviewed. Patients with incomplete follow-up data and those undergoing SSM for recurrent disease following previous lumpectomy were disregarded, leaving 207 for analysis. Offering IBR to all women requiring mastectomy resulted in a large proportion of patients with advanced disease. During a median follow-up of 119 months, 17 (8·2 per cent) locoregional, six (2·9 per cent) local and 22 (10·6 per cent) distant recurrences were detected; the overall recurrence rate was 39 (18·8 per cent). Overall recurrence rate was associated with axillary lymph node metastasis (P = 0·009), higher stage (P < 0·001) and higher tumour grade (P = 0·031). The breast cancer-specific survival rate was 90·8 per cent (19 of 207 women died from recurrence). CONCLUSION: Based on these long-term follow-up data, SSM combined with IBR is an oncologically safe treatment option regardless of tumour stage.

Reduction mammaplasty and related impact on psychosexual function.

INTRODUCTION: Reduction mammaplasty brings an effective improvement, both from the physical and psychological points of view. However, psychosexual consequences are as yet poorly studied, although scars, impairment of sensibility, change in shape and asymmetry can have a negative effect on sexual life. AIM: These authors retrospectively reviewed 55 patients to verify the existence of a close relationship between this popular surgical procedure and psychosexual function. MATERIAL AND METHODS: All patients were compared to a group (51 healthy women) chosen from the hospital personnel. Both groups answered four psychological questionnaires (Short Form (SF)-36, Hamilton Anxiety Rating Scale (Ham-A), Hamilton Rating Scale for Depression (Ham-D), Female Sexual Function Index (FSFI)) anonymously, in addition to the scar-assessment test as a single physical test. Psychological tests aim to evaluate self-esteem, quality of life (SF-36) and sexual function in women (FSFI, a test based on Erectile Function Index of Male). High levels of anxiety and depression were used as exclusion criteria in our study (Ham-D and Ham-A). Statistical analysis was based on non-parametric correlation test adjusted for small groups and Spearman's rho test to verify the associations among sub-items scales. RESULTS: Almost all patients (98%) fulfilled the inclusion criteria for our study. Sexual function index was equal in both groups, but it still showed a higher quality of life in the control group. Nevertheless, the SF-36 value of the patients' group is still enough to allow for acceptable self-esteem. CONCLUSIONS: We can confirm that reduction mammaplasty does not impair sexual satisfaction or quality of life; moreover, we believe that this procedure can improve such indices. Further investigation will compare patient's values prior to and following surgery to put in evidence a stronger relationship between mammary reduction and sexual function.

Shoulder function following autologous latissimus dorsi breast reconstruction. A prospective three year observational study comparing quilting and non-quilting donor site techniques.

Latissimus dorsi harvest and axillary surgery can affect shoulder function. The effect of autologous latissimus dorsi flap (ALD) breast reconstruction and donor site quilting have been inadequately studied. A cohort of ALD flap breast reconstruction patients were assessed pre-operatively and at eight post-operative time-points (up to 3 years after reconstruction) using the self-administered Disabilities of the Arm, Shoulder and Hand (DASH) outcome measure, for which validated normative data is available. Patients with incidental shoulder conditions and bilateral reconstructions were excluded. This was a prospective, observational study with blinded data interpretation: 58 patients, 22 of whom had donor site quilting, were assessed. Groups were compatible demographically, in breast care management and in pre-operative DASH score (quilted 6.5, non-quilted 6.4; P=0.98). Scores were significantly increased at initial post-operative clinic review (mean 49, SD19; P<0.001), 6 week (29, SD20; P<0.001), and 3 month (19, SD19; P<0.01), thereafter remaining at a plateau value of approximately 15 (P>0.05). Seroma incidence was reduced in the quilted group (5% vs 70%). A strong, significant correlation was found between 3 month DASH score and long term function (r=0.66, P<0.0003); patients with DASH >20 fare significantly worse in the longterm (mean 20 point increase, SD5.0, P<0.001). Higher post-operative DASH scores correlated significantly with pre-operative DASH (r=0.58) and BMI (r=0.36). Adjuvant therapy had no effect on shoulder function. Axillary dissection had a weak correlation with a higher DASH score, but only at the 3-month post-operative time-point (r=0.32, P=0.03). ALD flap breast reconstruction generally results in a functionally insignificant increase (6.5 points) in longterm DASH score, although a small subset of patients do develop longterm impairment, and quilting does not appear to inhibit shoulder function.

The timing of autologous latissimus dorsi breast reconstruction and effect of radiotherapy on outcome.

INTRODUCTION: The optimal timing of breast reconstruction is controversial. Immediate breast reconstruction (IBR) has been gaining in popularity due to the aesthetic and psychological benefits, although its role is less certain when postoperative radiotherapy may be required. There is some evidence that long term cosmetic outcome of IBR using the autologous latissimus dorsi (ALD) flap may be impaired if the reconstruction is subjected to postoperative radiotherapy. We compared the long term cosmetic outcome and patient satisfaction between a group of patients who underwent IBR with postoperative radiotherapy and a group who underwent delayed ALD reconstruction. METHODS: Patients who underwent ALD breast reconstruction between 1997 and 2000 were invited to attend a research clinic. At the clinic up-to-date photographs were obtained and a quality of life questionnaire was completed. Cosmetic outcome was assessed by a panel of judges including surgeons, nurses and lay people. RESULTS: Thirteen patients who had IBR and postoperative radiotherapy and 11 patients who had delayed reconstruction attended for follow up. In the long term both groups fell within an acceptable cosmetic outcome range. However, there was a trend towards a better outcome in patients undergoing delayed reconstruction, with the volume and contour of the upper pole being most affected in the irradiated reconstructions. Patient satisfaction was similar between the two groups, however most patients in retrospect would have preferred an immediate reconstruction. CONCLUSIONS: Immediate ALD breast reconstruction, even in the setting of postoperative radiotherapy, yields satisfactory results. We continue to offer it to patients undergoing mastectomy operations, even when postoperative radiotherapy is likely to be required.

Do pre-operative abdominal exercises prevent post-operative donor site complications for women undergoing DIEP flap breast reconstruction? A two-centre, prospective randomised controlled trial.

The deep inferior epigastric perforator (DIEP) flap is the gold standard for breast reconstruction using abdominal tissue. Unlike the transverse rectus abdominis myocutaneous (TRAM) flap, no rectus abdominis muscle is removed with the flap, but intra-muscular scarring can still cause post-operative complications. Strong abdominal muscles have been advocated as a prerequisite for surgery, but without any evidence as to the potential benefits. This study aimed to investigate the effect of pre-operative abdominal exercises on inpatient pain levels, length of hospital stay, post-operative abdominal muscle strength and function following a DIEP flap.Ninety-three women undergoing delayed breast reconstruction with a DIEP flap between October 1999 and November 2000 were randomly allocated to either a control or exercise group. The exercise group performed pre-operative exercises using the Abdotrim abdominal exerciser. Pre-operatively, outcome measures included trunk muscle strength measured on an isokinetic dynamometer, SF-36, rectus muscle thickness measured using ultrasound, and submaximal fitness. Post-operative pain and length of hospital stay were recorded. Subjects were reassessed using the same outcome measures 1 year post-operatively. There was a statistically significant increase in static (isometric) muscle strength and thickness pre-operatively for the exercise group. One year following surgery, there was a significant decrease in dynamic (concentric and eccentric) flexion strength for both groups, although the clinical significance of this is questionable as the majority of women had returned to pre-operative fitness and the surgery had no impact on functional activities. The static flexion strength of the control group was reduced at 1 year, whereas it was maintained in the exercise group, although this was not statistically significant. One third of women in the control group complained of functional problems or abdominal pain post-operatively compared to one fifth of the exercise group. Overall, the DIEP flap had no major impact on abdominal muscle strength for either group, demonstrating its superiority over the TRAM flap. There was no statistically significant benefit to the exercise group of the pre-operative exercises 1 year following surgery. However, there was a subjective benefit, albeit statistically nonsignificant, in terms of reduced functional problems post-operatively and improved well-being prior to surgery.

Mucinous breast carcinoma.

A case of mucinous breast carcinoma is discussed in which several unusual features in presentation and difficulties in management are addressed.

The use of Munsell colour charts in nipple-areola tattooing.

Tattooing is an excellent, simple and quick option in nipple-areola reconstruction. Colour mismatch is one of the commonest problems with this procedure. Use of Munsell colour charts allows the premixing of common colours for different patient populations using pigments from various manufacturers. There are significant correlations between nipple colour and Fitzpatrick skin type and between nipple colour and parity. Three nipple-areola colours were more common than others and were found in 50% of patients; these can be premixed ready for use. Adjustment of premixed colours for individual patients can be performed prior to tattooing, speeding up the procedure. Accurate recording of colours also facilitates audit.

How many procedures to make a breast?

The construction of a new breast after mastectomy involves fashioning the breast mound and creating a projecting nipple and a coloured areola. This should involve three episodes for a patient, but is this the experience of patients embarking on breast reconstruction? We identified 177 patients who had undergone breast reconstruction between 1 September 1997 and 31 March 1999. The clinical records for 164 of these patients were found and the data summarised. The techniques, complications and other ancillary procedures experienced by this group of patients are presented. Multiple procedures are likely to be required to complete breast reconstruction, and the patient should be so counselled from the outset. Particular problems may be encountered with each technique and this should be borne in mind when selecting a procedure for each patient, especially in the context of immediate reconstruction where avoiding any delay to adjuvant treatment is a consideration.

Expanding silicone granuloma.

Complications of breast augmentation using silicone implants have been the subject of much discussion. We report a single case of a silicone granuloma, which has exhibited unusual behaviour in that it has grown rapidly and significantly. Whilst silicone granulomata have been reported on many occasions in the past, to our knowledge this is the first report of a rapidly growing example.

Avulsion of vascular anastomosis in free-flap breast reconstruction.

We report a case of anastomotic avulsion following a free deep inferior epigastric perforator (DIEP) flap reconstruction immediately after mastectomy for carcinoma of the breast. This occurred on the 5th postoperative day when the patient was allowed a shower and abducted her shoulders to wash her hair. The aim of this report is to make readers aware of such a possibility, and we suggest exercising caution in early mobilisation of the upper limb after free-flap breast reconstruction.

Cross-leg pedicled free scapular flap for neuropathic foot ulcer: case report.

A case is reported of the treatment of a chronic neuropathic ulcer on the lateral aspect of the foot with osteomyelitis. Extensive debridement and free scapular flap transfer were performed. Because the leg had only one patent vessel, the anterior tibial artery, which was unsuitable for anastomosis, the vascular anastomosis of the flap was performed to the posterior tibial vessel of the contralateral leg, which was used as a termporary carrier. The vascular pedicle was divided after 3 weeks, and the flap survived completely. This case report extends the indications of the cross-leg free flap for complex defects on a single-vessel foot.

Deep inferior epigastric perforator flap in breast reconstruction: experience with the first 50 flaps.

Abdominal wall function is a major concern for plastic surgeons performing breast reconstruction with TRAM flaps. The deep inferior epigastric perforator (DIEP) free flap spares the whole rectus abdominis muscle, includes skin and fat only, and therefore, preserves adequate abdominal wall competence. Between January of 1995 and May of 1997, a total of 50 breast reconstructions in 42 patients were performed by using the DIEP flap. Eight patients had bilateral procedures. Five breast reconstructions were immediate and 45 were delayed. All patients were collected prospectively and no patients were excluded from this study. The average age of patients was 47 years (range, 22 to 59 years) and the average weight was 65 kg (range, 51 to 103 kg). Seventy percent of patients had one or more risk factors for TRAM flap reconstruction. The mean postoperative follow-up period was 13 months (range, 3 to 30 months). Twenty consecutive patients (17 single and 3 bilateral DIEP flap breast reconstructions) within this group underwent evaluation of their abdominal wall function preoperatively and then 3 and 6 months postoperatively by using Lacote's muscle grading system. Average flap harvesting time was 120 minutes and average blood loss was 420 cc. Total flap loss and partial necrosis occurred in one (2 percent) and three flaps (6 percent), respectively. Abdominal wound infection occurred in seven patients (17 percent). Unfortunately, one patient died of adult respiratory distress syndrome on the seventh postoperative day. Fat necrosis was found in three flaps (6 percent). Postoperative abdominal wall examination did not reveal any hernia, but bulging was found in two patients (5 percent). All patients were able to resume their daily activities. Abdominal wall function tests in the series of 20 patients showed that all patients had reached or even improved their preoperative level of upper and lower rectus muscle function 6 months after the operation. The external oblique muscles were the most affected by the procedure of flap harvesting, but only two patients (10 percent) were found to have a measurable impairment after 6 months. Patient satisfaction with the reconstructed breast and the donor site was rated high. The free DIEP flap is, therefore, a reliable and valuable method of breast reconstruction. The donor site morbidity was decreased, and the more tedious flap dissection did not affect the overall outcome.