Literature review and guide for optimal position in implant-based breast reconstruction.

Background and Objective: Identification of ideal candidates for prepectoral versus retropectoral implant-based breast reconstruction relies on careful preoperative risk assessment and intraoperative flap evaluation. Few guidelines exist to guide the surgeon's decision-making process when evaluating the preferred plane for implant placement. Methods: A literature review was performed to develop clinical decision-making algorithms for direct-to-implant (DTI) reconstruction with acellular dermal matrix (ADM) for patients undergoing prophylactic or therapeutic nipple-sparing mastectomy (NSM) based on patient characteristics, surgical techniques, and outcomes. Key Content and Findings: Prepectoral reconstruction is most suitable for patients with small breasts or macromastia with desire for breast reduction, low-grade ptosis, smaller implant sizes, those undergoing PMRT, and for those who aim to mitigate animation deformity and capsular contracture. Retropectoral reconstruction may be recommended for patients with larger breasts with no desire for size change requiring additional prosthesis support, and in patients who aim to reduce likelihood of rippling and need for subsequent fat grafting procedures to address contour abnormalities. Conclusions: Careful preoperative and intraoperative assessment of reconstruction options for patients undergoing implant-based breast reconstruction is necessary to mitigate complications and produce superior aesthetic outcomes. Decision algorithms may be used to determine ideal surgical techniques based on patient factors, like radiation history and planning, breast size and ptosis, and patient preferences.

A retrospective cohort study comparing reconstructive techniques and outcomes in post-mastectomy triple negative breast cancer patients.

Background: Up to 42% of all breast cancer patients undergo post-mastectomy reconstruction, however reconstructive techniques have not been widely studied in patients with triple negative breast cancer (TNBC). Reconstructive complications may delay adjuvant treatments; in TNBC, which inherently carries an increased risk of locoregional recurrence, this can greatly affect oncological outcomes. Therefore, we evaluate factors influencing choice of reconstructive techniques following mastectomy in TNBC patients and assess operative and oncologic safety outcomes. Methods: A single institution retrospective chart review identified TNBC patients who underwent post-mastectomy reconstruction between 2010 to 2020. Clinical characteristics collected included demographics, cancer history, reconstructive techniques [autologous-based reconstruction (ABR) vs. implant-based reconstruction (IBR)] and surgical and oncologic outcomes such as complications, recurrence, and mortality. Factors impacting whether patients underwent ABR versus IBR were assessed, as well as differences in outcomes between the two procedures. Statistical significance was defined as P<0.05. Results: During the 10-year period, 52.9% (n=127) of all post-mastectomy TNBC patients (n=240) underwent breast reconstruction, most frequently immediately after mastectomy (97.0%). Most patients underwent IBR compared to ABR (82.4% vs. 14.5%). Patients undergoing ABR were older than IBR patients (54.3 vs. 46.4 years; P=0.040) and had a higher body mass index (BMI; 30.0 vs. 26.1 kg/m2; P=0.007). Patients more often pursued ABR if they had a prior breast cancer history (36.8% vs. 16.7%; P=0.041) or experienced TNBC recurrence (26.3% vs. 9.3%; P=0.034), while primary TNBC patients more often opted for IBR. Reconstructive type did not impact complications (ABR 31.6% vs. IBR 16.8%, P=0.131), recurrence (ABR 15.8% vs. IBR 13.0%, P=0.719), or mortality (ABR 0.0% vs. IBR 6.5%, P=0.593) rates. Conclusions: Factors such as age, BMI, and breast cancer history impacted choice of reconstructive technique among TNBC women. No differences in complications, recurrence, or mortality occur in these high-risk patients regardless of reconstructive technique, highlighting that neither ABR nor IBR is superior in regard to surgical and oncologic safety in post-mastectomy TNBC patients.

Triple negative breast cancer and reconstruction: Predictors of recurrence, complications, and mortality.

BACKGROUND: Only 42% of all breast cancer patients undergoing mastectomy elect for breast reconstruction. OBJECTIVE: We evaluate factors impacting complications, recurrence, and mortality in triple-negative breast cancer (TNBC) patients undergoing reconstruction. METHODS: Reconstructive TNBC patients at a single institution from 2010 to 2020 were retrospectively reviewed. Patient demographics, cancer characteristics, reconstruction choice, and complications were collected. Statistical significance was defined at p < 0.05. RESULTS: A total of 131 patients were identified. Average age was 47.8 years, 50.4% were Caucasian and 36.4% were African American. Most patients had invasive ductal carcinoma (90.8%), and most underwent nipple-sparing (41.2%) or skin-sparing (38.9%) mastectomies. Twenty-one patients (16.0%) experienced postoperative complications. Patients with complications tended to be older (52.1 versus 46.9 years, p = 0.052). At mean follow-up of 52.1 months, 14.5% experienced cancer recurrence and 5.3% died. Deceased patients were significantly younger at diagnosis (42.2 versus 48.5 years, p = 0.008) and had a lower BMI compared to surviving patients (21.2 versus 26.9 kg/m2; p = 0.014). Patients younger than age 45 years had higher Ki-67 than those older than 45 years (80.0% versus 60.0%, p = 0.013). Outcomes in autologous- versus implant-based reconstruction were not significantly different. CONCLUSIONS: In TNBC post-mastectomy reconstruction patients, age and BMI were predictors of mortality while race, smoking history, reconstruction choice, or type of implant-based reconstruction had no significant effect on these outcomes. SYNOPSIS: The purpose of this study is to evaluate factors that impact complications, recurrence, and mortality in triple negative breast cancer (TNBC) patients undergoing reconstruction. We identified BMI, neoadjuvant chemotherapy, and age as predictors of complications, recurrence, and mortality in TNBC.

COVID-19 infection and large intestinal perforation: A case series.

INTRODUCTION: COVID-19 is a viral illness characterized primarily by respiratory symptoms. However, patients with COVID-19 infection may also present with gastrointestinal symptoms. Subsequent complications can be associated with high morbidity and mortality. METHODS: This is a retrospective observational study of three COVID-19 positive patients who developed large intestinal perforations and an analysis of their clinical characteristics, diagnosis, surgical treatment and outcomes. Three patients aged 45, 51 and 82 years old presented to our institution between November 2021 and March 2022 and were diagnosed with COVID-19 pneumonia requiring admission to the intensive care unit (ICU). All three patients received steroids and underwent surgery during their admission. None of our patients had prior history of bowel perforation or risks factors justifying their presentation. PRESENTATION OF CASES: Our first patient was found to have an ascending colon perforation and underwent right colon resection and end ileostomy. Our second patient was found to have a cecal perforation and underwent ileocecectomy with end ileostomy and mucus fistula creation. Our third patient was found to have a large cecal perforation and underwent right hemicolectomy and was left in discontinuity during the index operation. DISCUSSION: GI perforation is a less common but serious extra-pulmonary complication of COVID-19. The cases in the present study involve ascending colon perforations in the setting of active COVID-19 infection that occurred within two to five weeks after initial COVID-19 diagnosis. Given viral replication in GI cells, the local inflammatory effect of viral infection in the GI may play a role in bowel perforation. Providers should additionally be aware of the risk of perforation with steroids and immunomodulators. Immunosuppressive effects of these therapies may mask the classical signs of abdominal sepsis and lead to possible missed diagnoses. CONCLUSION: Gastrointestinal perforation is a rare but serious complication of COVID-19 infection. A high degree of clinical suspicion is necessary for timely diagnosis and management.

Risk-reducing surgery in PALB2 mutations carriers with breast cancer: a case series and literature review.

Background: Inherited germline mutations in PALB2 are known to predispose patients to a higher risk of breast, ovarian and pancreatic cancer with an estimated risk of developing breast cancer in over half of all affected women by age 80 years. Current guidelines for screening patients with PALB2 mutations include annual mammograms beginning at age 30 years and consideration of breast magnetic resonance imaging (MRI) and tomosynthesis. Existing evidence regarding risk-reducing surgery with mastectomy is insufficient to make a definitive recommendation to patients. In this case series, we describe the presentation and management of 5 patients with unilateral breast cancer and PALB2 mutations. To our knowledge, this is the first reported case series discussing the role of contralateral risk-reducing mastectomy (CRRM) in breast cancer patients with PALB2 mutations. The aim of our study was to evaluate the challenges in managing breast cancer risk in patients with PALB2 pathogenic variants with illustration through real-world clinical cases and a review of the literature. Methods: In this retrospective observational study, we present 5 patients with PALB2 mutations between the ages of 29 and 61 years who were diagnosed with breast cancer and underwent surgical management of their breast cancer at our institution between November 2020 and March 2022. Through their clinical courses and a literature review, we discuss the role of CRRM in breast cancer patients with PALB2 gene mutations. Results: Out of the 5 patients, 3 patients underwent CRRM and 2 patients chose unilateral surgery for their breast cancer and active surveillance for the contralateral breast. Of the 3 patients who underwent CRRM, 1 patient experienced a surgical complication from reconstruction on the prophylactic side. None of the patients developed any recurrences with an average length of follow up of 15.4 months. Conclusions: Based on our experience and the currently available literature, CRRM in patients with a PALB2 mutation should be performed on a case-by-case basis through a shared decision-making process taking into consideration overall risk, family history, patient preference and quality of life.

Reduction in tumor grade and Ki-67 in postmenopausal patient with node-positive invasive ductal carcinoma following combination hormone replacement therapy cessation: a case report.

Background: While praised for its benefits in treating symptoms related to menopausal changes, hormone replacement therapy (HRT) has been associated with an increased risk for hormone-dependent cancer development, particularly endometrial and breast. Few studies have elucidated the relationship between HRT cessation and hormone receptor-positive breast cancer proliferation. We report herein, to the best of our knowledge, the first case of 28.6% relative reduction in proliferation index marker Ki-67 in node-positive hormone receptor-positive breast cancer following HRT cessation. Case Description: We report an unusual case of a 64-year-old female patient with longstanding HRT for fifteen years who underwent immediate discontinuation after diagnosis of poorly differentiated invasive ductal carcinoma. We observed a reduction in tumor grade from poorly differentiated at time of biopsy to moderately differentiated at time of surgery following cessation of HRT, as well as a reduction in the tumor proliferation index (Ki-67) from 70% to 50%. The patient has remained recurrence-free at the one-year mark postoperatively with continued follow-up. Conclusions: This case highlights potential clinical benefits associated with HRT discontinuation in the postmenopausal population with preexisting hormone-dependent cancers with high proliferation index, as well as the usefulness of Ki-67 in measuring response to aromatase inhibition in this subpopulation of patients. Keywords: Hormone replacement therapy (HRT); breast cancer; tumor grade; Ki-67; case report.

Neoadjuvant therapy is associated with lower margin positivity rates after Pancreaticoduodenectomy in T1 and T2 pancreatic head cancers: An analysis of the National Cancer Database.

BACKGROUND: Neoadjuvant therapy (NAT) for T1/T2 pancreatic adenocarcinoma (PDAC) prior to pancreaticoduodenectomy remains controversial. We compared positive margin rates in patients with clinical T1&T2 tumors who did and did not receive NAT. METHODS: The National Cancer Database (NCDB) found clinical T1&T2 PDAC patients who underwent pancreaticoduodenectomy from 2004 to 2014. Univariate and multivariate regression determined factors associated with a positive margin and survival. RESULTS: 9795 patients underwent surgery for clinical T1 or T2 pancreatic head adenocarcinoma. 8472 patients had data regarding use of neoadjuvant and adjuvant therapies; of which, 774 (9.1%) received NAT and 435 (5.1%) received both chemotherapy and radiation therapy. NAT was found to lower positive margin rates from 21.8 to 15.5% (p < 0.0001) and when radiation was added this rate dropped to 13.4%. Positive margins were associated with worse overall survival (14.9 vs. 23.9 months; HR 1.702, p < 0.0001). CONCLUSIONS: NAT is associated with a reduced positive margin rate in patients with T1 and T2 tumors. These findings support ongoing and future clinical trials of NAT in T1 and T2, early stage PDAC to determine impacts on survival.