Jayant P. Agarwal

Effect of Breast Conservation Therapy vs Mastectomy on Disease-Specific Survival for Early-Stage Breast Cancer

IMPORTANCE To our knowledge, there are no recent studies that directly compare survival after breast conservation therapy (BCT) vs mastectomy. OBJECTIVE To compare the breast cancer-specific survival rates of patients undergoing BCT, mastectomy alone, or mastectomy with radiation using a contemporary cohort of patients. DESIGN, SETTING, AND PARTICIPANTS We performed univariate, multivariate logistic regression, and propensity analyses to compare the hazard of death for female patients with early-stage invasive ductal carcinoma treated with BCT, mastectomy alone, or mastectomy with radiation during the period from 1998 to 2008. The data were extracted from the Surveillance, Epidemiology, and End Results database. Early-stage breast cancer was defined as having a tumor size of 4 cm or smaller with 3 or less positive lymph nodes. EXPOSURE Breast conservation therapy, mastectomy alone, or mastectomy with radiation. MAIN OUTCOMES AND MEASURES Hazard of death due to breast cancer for patients undergoing BCT, mastectomy alone, or mastectomy with radiation. RESULTS A total of 132,149 patients were included in this analysis. Breast conservation therapy was used to treat 70% of patients, mastectomy alone was used to treat 27% of patients, and mastectomy with radiation was used to treat 3% of patients. The 5-year breast cancer-specific survival rates of patients who underwent BCT, a mastectomy alone, or a mastectomy with radiation were 97%, 94%, and 90%, respectively (P < .001); the 10-year breast cancer-specific survival rates were 94%, 90%, and 83%, respectively (P < .001). Multivariate analysis showed that women undergoing BCT had a higher survival rate than those undergoing mastectomy alone (hazard ratio, 1.31; P < .001) or mastectomy with radiation (hazard ratio, 1.47; P < .001). When propensity score stratification was used, the effect of treatment method on survival was similar. CONCLUSIONS AND RELEVANCE Patients who underwent BCT have a higher breast cancer-specific survival rate compared with those treated with mastectomy alone or mastectomy with radiation for early-stage invasive ductal carcinoma. Further investigation is warranted to understand what may be contributing to this effect.

An analysis of immediate postmastectomy breast reconstruction frequency using the surveillance, epidemiology, and end results database

Abstract:  Mastectomy is used to treat one third of the nearly 180,000 women diagnosed with breast cancer in the United States annually. In this study, we use population‐level data from multiple years of the Surveillance, Epidemiology, End Results (SEER) database to further define patient, tumor, and geographic characteristics associated with immediate and early‐delayed breast reconstruction. Population level de‐identified data for the years 1998 to 2002 were extracted from the National Cancer Institute’s (NCI) SEER cancer database. All female patients who were treated with mastectomy for a diagnosis of ductal and/or lobular breast cancer (including Paget disease) were included. The primary end point of interest was odds of reconstruction. Multivariate analysis was performed to control for patient demographic and oncologic characteristics. A total of 52,249 patients met the inclusion criteria. Reconstruction was performed in 8,446 patients (16.2%). Odds of reconstruction varied by region from 0.60 (Seattle) to 2.81 (Atlanta). African Americans were noted to have a significantly lower likelihood of reconstruction when compared with Caucasian patients (OR 0.60 versus 1.00). Patients living in nonmetropolitan regions were also significantly less likely to undergo reconstruction. Receipt of radiation therapy was also negatively correlated with likelihood of reconstruction. In this multicenter, multiyear analysis of factors associated with immediate or early‐delayed reconstruction after mastectomy, we demonstrate that younger age, white race, metropolitan locale, and lower stage disease were all independently associated with higher likelihood of reconstruction. This information provides insight into breast reconstruction utilization and will help guide future studies to understand how these factors affect patient and physician decision‐making.

The BREASTrial: Stage I. outcomes from the time of tissue expander and acellular dermal matrix placement to definitive reconstruction

Background: Use of acellular dermal matrix in tissue expander breast reconstruction has become a popular adjunct to the total submuscular technique. The question remains as to which matrix, if any, is ideal for breast reconstruction. Methods: A randomized trial was conducted to analyze outcomes of immediate staged tissue expander breast reconstruction using either AlloDerm or DermaMatrix. The impact of obesity, radiation, and chemotherapy on complications and biointegration of matrix was investigated. The trial was divided into three stages, with stage I results reported here. Results: One hundred twenty-eight patients (199 breasts) were randomized equally over 2.5 years. Most patients were white, healthy nonsmokers. The overall complication rate was 36.2 percent; half of the complications were minor. The AlloDerm and DermaMatrix groups had similar rates of complications (33.6 percent versus 38.8 percent; p = 0.52), consisting mostly of skin necrosis (17.8 percent versus 21.4 percent; p = 0.66) and infections (13.9 percent versus 16.3 percent; p = 0.29), both of which led to tissue expander losses (5 percent versus 11.2 percent; p = 0.11). The AlloDerm group required less time for completion of expansion (42 days versus 70 days; p < 0.001). Obesity was associated with poor matrix biointegration and a longer drain time, both of which were associated with higher complication rates. Conclusion: The Breast Reconstruction Evaluation Using Acellular Dermal Matrix as a Sling Trial is the largest randomized trial to date in matrix breast reconstruction and emphasizes the importance of careful patient and allograft selection to minimize complications. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

The Retrograde Limb of the Internal Mammary Vein: An Additional Outflow Option in Diep Flap Breast Reconstruction

Background: The deep inferior epigastric perforator (DIEP) flap has become an increasingly popular option for postmastectomy reconstruction. The purpose of this study was to evaluate the retrograde limb of the internal mammary vein as a recipient vein in DIEP breast reconstruction. Methods: Fifteen consecutive DIEP flaps in 13 patients were transferred with anastomosis of one DIEP vena comitans to the antegrade internal mammary vein and the other DIEP vena comitans to the retrograde internal mammary vein. The deep inferior epigastric artery was anastomosed to the antegrade internal mammary artery. Blood flow through the retrograde internal mammary vein was evaluated with intraoperative duplex ultrasound. Results: Thirty venous anastomoses in 15 DIEP flaps for breast reconstruction were performed over a 4-month period to investigate the retrograde limb of the internal mammary vein as a potential recipient vein. No evidence of intraoperative venous congestion was seen. Retrograde blood flow was demonstrated using intraoperative duplex imaging and clinical examination. All 15 flaps were successful. Conclusions: The retrograde limb of the internal mammary vein is an option as a recipient vein in DIEP breast reconstruction. This outflow option may prove useful in cases with intraoperative congestion in a single vein flap, in cases with co-dominant superficial and deep venous systems, and in cases in which double-pedicle free flaps are used for unilateral breast reconstruction.

Double pedicle deep inferior epigastric perforator/muscle-sparing TRAM flaps for unilateral breast reconstruction

Background:Utilizing both rectus abdominis muscles for unilateral breast reconstruction poses significant risks for hernia or bulge formation and decreased abdominal wall strength. We have used the fascial sparing double pedicle deep inferior epigastric artery perforator (DIEP)/DIEP or DIEP/muscle sparing TRAM (MS-TRAM) flap to overcome the disadvantages of the conventional bilateral TRAM or bilateral free TRAM flaps. Methods:Between January 1996 and March 2005, 14 double pedicle free DIEP/DIEP or DIEP/MS-TRAM flaps were performed in 14 patients for unilateral breast reconstruction. The abdominal wall was closed without mesh in all cases. Results:Evaluation of results was conducted through a retrospective chart review and questionnaire. The average hospital stay was 5.4 days. The follow-up period ranged from 9 months to 10 years. There was no flap loss. There were no hernias, although 1 obese patient had lower abdominal wall bulging. Questionnaire was returned by 11 out of 14 patients, with an average rating of 4.5 (1–5), with all but 1 who would recommend it to others. None of the 11 patients had postoperative abdominal pain or back pain, and 9/11 patients returned to daily activities and/or sports. All patients that worked preoperatively returned to work postoperatively. Conclusions:Double pedicle free flaps for unilateral breast reconstruction are a safe option when autologous breast reconstruction is desired, but the volume of tissue required to build a breast exceeds the amount that could be transferred on a single pedicle flap. The double pedicle DIEP (DIEP/DIEP) and/or MS-TRAM (DIEP-MS-TRAM) flap offers good symmetric results for unilateral breast reconstruction and can minimize abdominal wall morbidity.

Therapeutic nipple-sparing mastectomy: trends based on a national cancer database.

BACKGROUND Current reports on nipple-sparing mastectomy (NSM) are limited to single-institution series. We use the National Cancer Institutes Surveillance, Epidemiology, and End Results database to report on the national experience with NSM. METHODS Population-level deidentified data were extracted from the Surveillance, Epidemiology, and End Results database. All female breast cancer patients treated with NSM from 2005 to 2009 were included. Case analysis was performed with respect to demographic and oncologic characteristics. RESULTS Four hundred forty-nine patients underwent therapeutic NSM; this number increased from 66 patients in 2005 to 133 in 2009. Patients were distributed across 16 regions, although nearly 50% were from a region of California. Tumor diameter was <2 cm in 224 patients (50%). Lymph nodes were positive in 59 patients (13%), while radiation was delivered to 74 patients (16%). CONCLUSIONS NSM use has been increasing over the past several years. A majority of patients have tumor size <2 cm, although the number of patients with tumor size ≥2 cm has increased over time. Further population-based studies of NSM may benefit from collection of oncologic data such as tumor-to-nipple distance and tumor location.

A Population-Based Study of Breast Cancer-Specific Survival Following Mastectomy and Immediate or Early-Delayed Breast Reconstruction

Abstract:  Immediate breast reconstruction allows for improved patient psychosocial outcomes after mastectomy. We used the Surveillance, Epidemiology, and End Results (SEER) database to study the breast cancer‐specific survival of patients treated with immediate or early‐delayed breast reconstruction after mastectomy. Population‐level de‐identified data was abstracted from the SEER database. All female patients treated with mastectomy for a diagnosis of ductal and/or lobular breast cancer between 1998 and 2002 were included. Breast cancer‐specific survival was reported as hazard ratios using multivariate analysis to control for patient demographic and oncologic covariates. Demographic covariates included age, race, marital status, income, education, and county metropolitan status; oncologic covariates included tumor stage, histology, grade, lymph node status, hormone receptor status, receipt of radiation therapy, and unilateral or bilateral mastectomy. A total of 52,249 patients were included in the study. Patients treated with mastectomy and reconstruction had a significantly lower hazard of death (HR 0.73, p < 0.0001) compared with patients treated with mastectomy only. Black patients had a significantly increased hazard of death (HR 1.42, p < 0.0001) compared with white patients. Receipt of radiotherapy did not significantly associate with hazard of death (HR 1.03, p = 0.3494). Additionally, bilateral mastectomy did not significantly associate with hazard of death (HR 0.98, p = 0.763). Our analysis shows that patients who undergo breast reconstruction after mastectomy have a higher breast cancer‐specific survival than those undergoing mastectomy alone, when controlling for demographic and oncologic covariates. Further research is required to understand the nature of this relationship.

Free-flap reconstruction in the doubly irradiated patient population.

Background: The standard of care for previously irradiated, unresectable, recurrent head and neck cancer has been chemotherapy alone. High-dose reirradiation with concomitant chemotherapy represents a more aggressive approach to these tumors and has afforded encouraging results with an increased fraction of long-term survivors. After reirradiation, these patients commonly present with extensive tissue loss, nonhealing wounds, contractures, and fistulas, and free-flap reconstruction is often necessary to correct the perils of oncologic treatment. Methods: A 9-year retrospective review of 35 patients who required surgical intervention following a second round of chemoradiation was performed. Thirty-three free flaps were performed on 24 patients, and total radiation given before free tissue transfer ranged from 100 to 200 Gy. Indications for free-flap reconstruction included soft-tissue necrosis (15 of 33), tumor ablation (seven of 33), osteoradionecrosis (six of 33), oral incompetence (three of 33), tracheal perforation (one of 33), and esophageal stricture (one of 33). Results: Free tissue transfer was successful in 94 percent (31 of 33) of flaps, with an overall major complication rate of 66 percent (23 of 35). Wound dehiscence (15 percent), infection (15 percent), hematoma (12 percent), fistula formation (12 percent), partial flap necrosis (9 percent), and total flap necrosis (6 percent) were the most commonly seen complications. Conclusions: Although complications are common, free tissue transfer offers the difficult reirradiated patient a successful means of wound rehabilitation. The ultimate success of closing these wounds allows for aggressive oncologic treatment, which possibly will facilitate improved survival in this patient population that struggles with a dismal overall prognosis.

Psychosocial distress is prevalent in head and neck cancer patients

The purpose of this study is to evaluate the levels of psychological distress in head and neck cancer patients using a validated screening tool. We aim to characterize distress in this cancer population and understand the factors driving distress levels.

Further validation for use of the retrograde limb of the internal mammary vein in deep inferior epigastric perforator flap breast reconstruction using laser-assisted indocyanine green angiography.

We have previously described the use of the retrograde limb of the internal mammary vein (IMV) as an additional venous outflow tract in deep inferior epigastric perforator (DIEP) flap reconstruction. In the current study, we use the Novadaq SPY ((R)) system, a novel intraoperative angiographic method, to further validate the use of the retrograde limb of the IMV. The Novadaq SPY ((R)) system laser source was used with indocyanine green angiography to evaluate the arterial, anterograde venous, and retrograde venous anastomoses of 15 patients undergoing DIEP flap breast reconstruction. The number of perforators used, patient age, exposure to radiation, coupler size, and incidence of intraoperative congestion were recorded. All flaps survived, and there were no cases of intraoperative congestion. The average time required to perform the additional retrograde anastomosis was 12 minutes. Flow of indocyanine green not only revealed patency of our anastomoses but it confirmed unobstructed flow through the retrograde limb of the IMV. Our study further validates that the retrograde limb of the IMV does in fact achieve flow away from the DIEP flap and can therefore be used as an additional or alternative outflow tract in DIEP flap breast reconstruction surgery.