Florence Didier

The nipple-sparing mastectomy: Early results of a feasibility study of a new application of perioperative radiotherapy (ELIOT) in the treatment of breast cancer when mastectomy is indicated

Background Breast cancer surgery has become less and less mutilating, however a mastectomy is required in the case of multicentric, large tumors or recurrences after conservative treatment. The removal of the nipple areola complex during the mastectomy dramatically increases the feeling of mutilation. To reduce this negative psychological impact, in cancers located outside of the central area of the breast, we propose a new type of nipple-sparing mastectomy associated with intraoperative electron beam radiotherapy (ELIOT) delivered on the region of the areola. The nipple-sparing mastectomy is performed leaving 5 mm of glandular tissue behind the nipple areola complex to preserve its blood supply. The reconstruction is immediately performed with a prosthesis or an autologous flap. Patients and Methods Twenty-five patients were included in the study; two of them had a bilateral nipple-sparing mastectomy. Results Pathological examinations demonstrated the presence of 19 infiltrating carcinomas and 8 ductal carcinoma in situ. Two patients had a superficial skin areolar slough followed by spontaneous healing. One necrosis of the areola occurred due to extensive retroareolar dissection. In the early follow-up, the color of the areola was preserved. All patients except one expressed their satisfaction of having kept their areola. Conclusions These preliminary results are encouraging but they require further studies to evaluate the long-term results, the local recurrence rate and the psychological impact.

Nipple-sparing mastectomy—is it worth the risk?

Nipple-sparing mastectomy (NSM) is a surgical protocol designed to reduce the disabling psychological effects of radical or skin-sparing mastectomy. The preservation of the nipple–areola complex produces a more-natural result of the breast reconstruction, but this preservation is suspected of increasing tumor local recurrence. To reduce this risk, different approaches have been proposed: restrict the inclusion criteria and/or add localized radiation therapy. The local recurrence rate in recent series of patients receiving NSM is comparable with the local recurrence rate in modified radical or skin-sparing mastectomies. Today, the quality of the subcutaneous mastectomy technique allows for a more radical glandular removal, especially in the retroareolar area; therefore, local recurrence is observed in 3–6% of patients at 5 years, consistent with traditional mastectomy.

A double-blind, randomised, vehicle-controlled clinical study to evaluate the efficacy of MAS065D in limiting the effects of radiation on the skin: interim analysis

Our aim was to assess the efficacy of MAS065D, a non-steroidal water-in-oil cream, in preventing and limiting skin reactions caused by radiation therapy (RT). 40 women treated with conservative breast cancer surgery followed by radiotherapy, were randomised to receive MAS065D (22 pts) or vehicle (18 pts). Radiotherapy was delivered in 20 fractions: 2.25 Gy to the whole breast plus a concomitant boost of 0.25 Gy to the tumour bed up to a total dose of 50 Gy. Evaluations of skin toxicity, erythema, and subjective symptoms were carried out weekly and 3 weeks after treatment completion. A statistically significant difference between vehicle and MAS065D groups was recorded regarding the maximum severity of skin toxicity (p < 0.0001), burning within the radiation field (p = 0.039) and desquamation (p = 0.02), in favour of the latter. We conclude that MAS065D may be considered a safe and effective treatment in the prevention and minimization of skin reactions and associated symptoms.

Impact of medical discipline and observer gender on cosmetic outcome evaluation in breast reconstruction using transverse rectus abdominis myocutaneous (TRAM) flap and radiotherapy

BACKGROUND Despite the complication rate, the majority of studies report a satisfactory cosmetic outcome in patients undergoing transverse rectus abdominis myocutaneous (TRAM) flap breast reconstruction both before and after radiotherapy (RT). The lack of a universal agreement on the use of a validated scale for cosmetic assessment in clinical practise leads to subjective criteria of evaluation and causes a great deal of interobserver variability. This study investigates whether there is any difference in the evaluation of cosmesis according to gender and specialisation of the observer. METHODS Fifty-two photographs of the patients who had undergone TRAM reconstruction for breast cancer, divided into three groups according to the treatment (TRAM only, TRAM→RT, RT→TRAM), were evaluated by 21 specialists, 10 male and 11 female from radiotherapy, breast surgery and plastic reconstructive surgery. Cosmetic outcome was classified using the four-category Harvard scale: a score of excellent/good was considered acceptable. RESULTS The overall rate of good/excellent ratings was 66.6%, which was lower than the score reported in the literature. A significantly worse score was registered in the TRAM→RT group compared with the other groups. The probability for male physicians to award a positive judgement is 24% higher than that of female ones. In general, there is a decent agreement among the judgement raters. CONCLUSIONS No statistically significant difference in cosmetic evaluation was noted overall between male physicians and female ones. However, within each specialisation, the difference between the two genders was great. Breast surgeons gave the worst opinion, and among them female surgeons judged most severely, whereas plastic surgeons gave the best opinion, and among them females provided the highest favourable judgement.

Stress Exposure in Significant Relationships Is Associated with Lymph Node Status in Breast Cancer.

Objective Life stress exposure may impact on health and disease. Previous literature showed that stressful life events are associated with cancer incidence, survival and mortality. In animal models, patterns of maternal care have been shown to critically affect stress sensitivity and immunity trajectories later in life, by modifying DNA methylation during critical periods early in life. However, the role of parental care in breast cancer progression and survival has only limitedly been explored. Here, we investigated whether these factors may be linked to biological prognostic variables. Methods One hundred twenty-three women hospitalized for surgery of primary breast cancer completed a questionnaire assessing parental bonding. Stressful events throughout the life span were also assessed. Results We found that the absence of optimal parental relationships is significantly associated with an increased risk of lymph node involvement, adjusting for confounders, while cumulative stress in the area of sentimental relationships is borderline significantly associated with the same prognostic factor. Conclusions Our results suggest that parental bonding and sentimental relations may have a role in breast cancer progression. These variables represent an important evolutionary aspect which may modulate cancer progression through psycho-physiological stress pathways and influence the immune system.

Memories of paternal relations are associated with coping and defense mechanisms in breast cancer patients: an observational study

BackgroundBreast cancer diagnosis and treatment represent stressful events that demand emotional adjustment, thus recruiting coping strategies and defense mechanisms. As parental relations were shown to influence emotion regulation patterns and adaptive processes in adulthood, the present study investigated whether they are specifically associated to coping and defense mechanisms in patients with breast cancer.MethodsOne hundred and ten women hospitalized for breast cancer surgery were administered questionnaires assessing coping with cancer, defense mechanisms, and memories of parental bonding in childhood.ResultsHigh levels of paternal overprotection were associated with less mature defenses, withdrawal and fantasy and less adaptive coping mechanisms, such as hopelessness/helplessness. Low levels of paternal care were associated with a greater use of repression. No association was found between maternal care, overprotection, coping and defense mechanisms. Immature defenses correlated positively with less adaptive coping styles, while mature defenses were positively associated to a fighting spirit and to fatalism, and inversely related to less adaptive coping styles.ConclusionsThese data suggest that paternal relations in childhood are associated with emotional, cognitive, and behavioral regulation in adjusting to cancer immediately after surgery. Early experiences of bonding may constitute a relevant index for adaptation to cancer, indicating which patients are at risk and should be considered for psychological interventions.

Do Early Breast Cancer Patients with Only Sentinel Lymph Node Biopsy Experience Lower Psychological Morbidity Over Time

To the Editor: Although many overall quality of life (QOL) studies comparing patients with early breast cancer who underwent axillary lymph node dissection (ALND) versus sentinel lymph node biopsy (SLNB) have already been performed and have shown a benefit for SLNB (1–4), there are few data available regarding the specific impact of SLNB on psychological morbidity over time (5–7). We therefore decided to assess whether or not having only SLNB, a very conservative procedure, could influence how patients perceived the disease, i.e., their awareness of its seriousness, thus minimizing anxiety levels. In a prospective, longitudinal study, we compared QOL and psychological morbidity in a consecutive series of newly diagnosed primary-breast-cancer patients who underwent primary breast surgery following internal guidelines: quadrantectomy and SLNB with or without subsequent ALND according to the result of intraoperative examination of the sentinel node: the patient had ALND only if the SLNB was positive. Study eligibility criteria were as follows: invasive early breast cancer (stages I or II); breastconserving surgery; SLNB performed during surgery; patient age greater than or equal to 18 years. The SLNB technique used at IEO (European Institute of Oncology) has been previously described (1). Quality of life and psychological morbidity were assessed using the Functional Assessment of Cancer Therapy-Breast quality of life (FACT-B) and the Hospital Anxiety and Depression Scale, at baseline, 1 day before and 3, 6, 9, 12, and 18 months after surgery. Between November 2005 and February 2007, 280 patients were screened. Of the 234 assessed patients who had quadrantectomy and sentinel node biopsy (SLNB), 62 had ALND. Among patients characteristics no significant differences were detected for any patients except for age and for a higher percentage of chemotherapy treatments in the ALND subgroup (32 [50.0%] versus 29 [17.0%]; p < 0.001). The FACT-B total score showed that women undergoing ALND had a significant, more rapid worsening of QOL at 3 months (p = 0.01). Overall, improvement of global QOL occurred over time in both cohorts and multivariate statistical analysis showed that changes were correlated with time (p < 0.001). Changes in global QOL were not correlated with the type of surgery (p = 0.09), chemotherapy (p = 0.74) or age (p = 0.75). When we analyzed two of FACT-B subscales, namely the Breast Cancer subscale (BCS) and the Emotional Well-Being subscale (EWB) (see Fig. 1), we observed significantly lower scores and a significantly faster deterioration of QOL at 3 months in the ALND subgroup. A multivariate analysis showed a significant correlation of EBW scores with time (p < 0.001). The anxiety subscale indicated particularly high levels of anxiety and low scores regarding depression in both cohorts and no significant differences were registered. Both subscales decreased significantly (p < 0.001) over time becoming nearly stable from 6 months onward. Changes were correlated with time, but not with the type of surgery. The multivariate analysis did not detect any statistically significant factors affecting the decrease over time (Depression: p = 0.67 for surgery, p = 0.97 for chemotherapy, p = 0.82 for age, and p = 0.36 for the interaction term surgery x time. Anxiety: p = 0.60 for surgery, p = 0.35 for chemotherapy, p = 0.09 for age and p = 0.19 for surgery x time interaction). Compared with previous QOL studies, our study provides significant, interesting information regarding one dimension of QOL analyzed by FACT-G, but not mentioned by other authors (7): emotional well-being. Address correspondence and reprint requests to: Florence Didier, MA, Psycho-Oncology Unit (Department of Medicine), European Institute of Oncology, Via Ripamonti, 435, 20141 Milan, Italy, or e-mail: florence.didier@ieo.it.