Anne C. O’Neill

Implications of Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL) for Breast Cancer Reconstruction: An Update for Surgical Oncologists

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is a rare disease that has been diagnosed in an extremely small proportion of women with breast implants. The pathogenesis of this disease is currently poorly understood, but it appears to be related to textured implants. Recent high-profile media coverage of this rare clinical entity is likely to cause considerable anxiety for breast cancer patients who have undergone alloplastic breast reconstruction. The purpose of this review is to provide surgical oncologists with an evidence-based overview of the incidence, diagnosis, and management of BIA-ALCL with a particular emphasis on breast reconstruction cases. It is essential that surgical oncologists are familiar with BIA-ALCL, because although it is extremely rare, early recognition and surgical resection will be curative in many cases.Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is a rare disease that has been diagnosed in an extremely small proportion of women with breast implants. The pathogenesis of this disease is currently poorly understood, but it appears to be related to textured implants. Recent high-profile media coverage of this rare clinical entity is likely to cause considerable anxiety for breast cancer patients who have undergone alloplastic breast reconstruction. The purpose of this review is to provide surgical oncologists with an evidence-based overview of the incidence, diagnosis, and management of BIA-ALCL with a particular emphasis on breast reconstruction cases. It is essential that surgical oncologists are familiar with BIA-ALCL, because although it is extremely rare, early recognition and surgical resection will be curative in many cases.

Predicting Complications in Immediate Alloplastic Breast Reconstruction: How Useful Is the American College of Surgeons National Surgical Quality Improvement Program Surgical Risk Calculator?

Background: Complications following immediate breast reconstruction can have significant consequences for the delivery of postoperative chemotherapy and radiation therapy. Identifying patients at higher risk of complications would ensure that immediate breast reconstruction does not compromise oncologic treatment. The American College of Surgeons National Surgical Quality Improvement Program Surgical Risk Calculator is an online tool in the public domain that offers individualized preoperative risk prediction for a wide range of surgical procedures, including alloplastic breast reconstruction. This study evaluates the usefulness of this tool in patients undergoing immediate breast reconstruction with tissue expanders at a single institution. Methods: Details of 278 patients who underwent immediate breast reconstruction with tissue expander placement were entered into the calculator to determine the predicted complication rate. This was compared to the rate of observed complications on chart review. The predictive model was evaluated for calibration and discrimination using the statistical measures used in the original development of the calculator. Results: The predicted rate of complications (5.2 percent) was significantly lower that the observed rate (16.2 percent; p < 0.01). The Hosmer-Lemeshow test confirmed lack of fit of the model. The C statistic was 0.62 and the Brier score was 0.173, indicating that the model had poor predictive power and could not discriminate between those who were at risk for complications and those who were not. Conclusions: The American College of Surgeons National Surgical Quality Improvement Program universal Surgical Risk Calculator underestimated the proportion of patients that would develop complications in this cohort. In addition, it was unable to effectively identify individual patients at increased risk, suggesting that this tool would not make a useful contribution to preoperative decision-making in this patient group.

Restoring wholeness: Women’s embodied experiences in considering post-mastectomy delayed breast reconstruction

Abstract This qualitative inquiry reports on the embodied experience of women with breast cancer considering post-mastectomy delayed breast reconstruction (DBR). In a pilot randomized controlled trial evaluating an educational workshop on decision-making about DBR, a purposeful sample of eight women participated in telephone semi-structured interviews. The concept of embodiment guided thematic analysis. The decision whether to undergo DBR involved four embodiment-related themes: living with an altered body, losing a sense of self, taking charge to reclaim the body and self, and rebuilding the body and self. Embodiment thus played a significant role in women’s decision-making. Other psychosocial factors, however, may compete with embodiment motivations. Healthcare providers can help support women to see breast reconstruction as a legitimate means to restore their body and sense of self.

Superficial Soft-Tissue Sarcomas Rarely Require Advanced Soft-Tissue Reconstruction following Resection

Objective: Soft-tissue sarcomas are most frequently located deep within myofascial compartments. Superficial soft-tissue sarcomas (S-STS) are relatively less common and may be managed differently than deep sarcomas because generous resection margins are often possible without sacrificing critical structures. We sought to investigate the frequency and types of soft-tissue reconstructive procedures that are required following excision of S-STS. Methods: We reviewed 457 consecutively treated patients with S-STS with a minimum 2-year follow-up from our prospectively maintained database between 1989 and 2009. Results: Mean follow-up was 10.5 years (range, 2–23). Four hundred twenty-one tumors (91%) were excised with negative margins, 38 (8.3%) had microscopically positive margins, and three (0.7%) had grossly positive margins. One patient required an amputation. In 271 (58%) patients, the wounds were closed primarily. In comparison, 93 patients (20%) required a rotation flap, 70 (15%) required a split-thickness skin graft, and 23 (5%) underwent a free tissue transfer (ie, advanced reconstructive procedure). The overall complication rate was 12%, although 43% of patients undergoing free tissue transfer developed complications (P = 0.04). An unplanned excision before referral to our center was a risk factor for local recurrence (P = 0.03) when residual tumor was recovered in the reexcision specimen pathologically. Conclusions: Although concern about the morbidity associated with a free tissue transfer (ie, advanced reconstructive procedure) may potentially limit the adequacy of resection in some patients with S-STS, the results of this study showed that the majority of patients had complete excisions with negative margins and primary closure. Obtaining a negative margin when excising a known or suspected S-STS rarely requires an advanced reconstructive procedure and almost never results in loss of limb.

Preoperative Computed Tomographic Angiogram Measurement of Abdominal Muscles Is a Valuable Risk Assessment for Bulge Formation after Microsurgical Abdominal Free Flap Breast Reconstruction

Background: A major shortcoming associated with abdominal tissue breast reconstruction is long-term abdominal wall morbidity. Although abdominal muscle size on computed tomographic angiography has been correlated with morbidity following many abdominal operations, it has not been studied for breast reconstruction. Therefore, the authors evaluated the association between preoperative computed tomography angiography–derived measurements of abdominal core muscles and postoperative abdominal wall morbidity after abdominal tissue breast reconstruction. Methods: In this retrospective matched case-control study of women who underwent microsurgical abdominal flap breast reconstruction at one institution between January 2011 and June 2015, the authors evaluated all cases of postoperative bulge/hernia, matched by type of abdominal flap and body mass index in a ratio of 1:2 to controls without bulge/hernia. The authors obtained morphometric measurements of abdominal core muscles on preoperative computed tomographic angiographs. Using univariable and multivariable logistic regressions, the authors examined the effects of clinical risk factors and computed tomographic angiography morphometric measurements on postoperative bulge/hernia formation. Results: Of the 589 patients who underwent abdominal free flap breast reconstruction, symptomatic bulges/hernias were identified in 35 patients (5.9 percent). When compared to the 70 matched controls, multivariable analysis showed that decreased area of rectus abdominis muscle (OR, 0.18; p < 0.01) and increased inter-rectus abdominis distance (OR, 1.14; p < 0.01) on computed tomographic angiography were significant risk factors associated with postoperative bulge/hernia. Conclusion: Preoperative computed tomographic angiography allows objective measurements of the patient’s abdominal muscle anatomy that provide valuable prognostic information on the risk of bulge/hernia formation following abdominally based microsurgical breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Response to “Complications in DIEP Flap Breast Reconstruction after Mastectomy for Breast Cancer: A Prospective Cohort Study Comparing Unilateral and Bilateral Reconstructions”

We read with interest the excellent article by Wade et al. that described their experiences with DIEP flap microvascular breast reconstruction. In particular, we commend their efforts to address the lack of prospective studies in this field. The authors prospectively report the outcomes of 565 DIEP flap reconstructions performed in 468 patients during a 6-year period. They observed a 0.81% flap failure rate in unilateral reconstructions compared with 5.15% in bilateral cases. They attribute this sixfold increase in failure to the obligate need to use both sides of the abdomen in bilateral reconstructions. This precludes conversion to the contralateral hemi abdomen in cases where the perfusion or venous drainage of the primary flap is found to be inadequate. The authors do not state how frequently this conversion becomes necessary in their unilateral cases, but they report that 10% of patients require supplemental venous drainage using the superficial system, suggesting that the selected perforators are frequently inadequate. We concur with the opinion of Schaverien and Butler that a thorough understanding of perforator anatomy and dynamics is essential to the success of DIEP flap reconstruction. At our institution, we have considerable experience with bilateral DIEP flaps, because they account for 46% of our microvascular breast reconstructions. As we have previously published, we have an overall flap failure rate of 0.8%, and we have not observed any significant increase in postoperative microvascular problems, including total or partial flap failure, in bilateral cases compared with unilateral reconstructions [odds ratio (OR) 1.0; 95% confidence interval (CI) 0.5–1.8; p = 1]. Central to this is our systematic approach to perforator assessment and selection. As we have previously described, we adhere to an intraoperative algorithm that allows a methodical approach to perforator selection based largely on the diameter of the perforating vein. In cases where perforators do not meet our minimum criteria, we consider conversion to a muscle-sparing transverse rectus abdominis muscle flap (MS-TRAM). Our previous publications have indicated that this is necessary in approximately 10% of flaps. We note with interest that Wade et al. did not perform any MS-TRAM flaps during their study period. In addition, they have not elaborated on their intraoperative decisionmaking process with regard to perforator selection. While we admire their endeavor to harvest DIEPs in all cases and minimize donor site morbidity, our experience and that of others would suggest that this cannot always be achieved safely. Judicious conversion to MS-TRAM flap should be considered in selected cases. This is particularly important in bilateral reconstructions where both hemi-abdomens must be harvested. The MSTRAM flap allows multiple perforators to be included in the flap and therefore will improve perfusion and drainage in cases where no single perforator is considered adequate for flap survival. A structured approach to perforator assessment and selection is particularly important in bilateral reconstructions where both hemi-abdomens must be harvested. Society of Surgical Oncology 2017

Unfavorable Results After Free Tissue Transfer to Head and Neck: Lessons Based on Experience from the University of Toronto

The purpose of the current article is to provide an overview of the functional and aesthetic unfavorable results of head and neck reconstruction, and provide suggestions on how to address these issues. Understanding the consequences of an unsuccessful reconstruction provides the foundation for proper planning and personalized approach to reconstruction of lost structures.