Kouichi Sakaguchi

Section 5. Breast: Video-assisted total glandectomy and immediate reconstruction for breast cancer

This paper describes a new surgical technique and our clinical experience with video-assisted endoscopic total glandectomy via a middle axillary incision followed by immediate reconstruction with latissimus dorsi muscle flap (LDMF) performed in 17 patients with bigger, multiple tumors or extensive ductal spread of breast cancer. The novel techniques in this procedure are as follows: (1) By securing patients in a semi-lateral position and suspending the upper extremity, either supine or semi-lateral position can be easily achieved by simply rotating the operating table, resulting in a wider working space from the axillary to hip area. (2) By applying a retractor for skin flap traction, endoscopic glandectomy and reconstruction become safe and reliable. As a result, the mean number and size of tumors were 1.2 and 4.12 cm, respectively. Surgical margins of all the cases were pathologically negative and there were no recurrences observed during 14 months follow-up to date. Esthetic results have been satisfactory and the surgical wounds were not visible from the front in any case. Compared to mastectomy, this procedure shows the same therapeutic results, but offers a greater esthetic and psychological advantage to all the patients.

Preventive effects on seroma formation with use of the harmonic focus shears after breast reconstruction with the latissimus dorsi flap

Abstract Background: Postoperative seroma is the most common complication of latissimus dorsi (LD) flap surgery for breast reconstruction. The use of EC for elevation of the flap might cause additional risk for seroma formation by injuring surrounding lymph vessels due to heat dispersion. There is a possibility that seroma formation can be prevented by using alternative devices such as harmonic focus (HF) shears that can dissect the tissue simultaneously with sealing the lymph vessels. Methods: Forty-eight patients who underwent breast reconstruction with LD flaps since August 2011 up to April 2015 were enrolled. They were retrospectively split into two groups: 24 in group HF, 24 in group EC (conventional electrocautery). The primary outcome measures were rate of seroma formation and total volume of drain discharge and indwelling period of drainage at the anterior chest and donor site. Secondary outcome measures were length of hospital stay and duration of surgery. Results: The incidence of seroma was 45.8% in the EC group and 20.8% in the HF group. The total volumes of the drain discharge and indwelling period of drainage in the back (donor site) were significantly decreased in the HF group. The length of the hospital stay and surgical time was significantly shorter for the HF group. Conclusions: The use of HF shears on the LD flap donor site is helpful for reducing seroma formation, the length of the drainage period, the surgical time, and the length of the hospital stay.

Dynamic Contrast-enhanced Magnetic Resonance Imaging for Patients with Breast Cancer Receiving First-line Bevacizumab and Paclitaxel.

Background: Bevacizumab plus paclitaxel shows promise for metastatic disease; however, there is no predictive biomarker. Dynamic contrast-enhanced (DCE) magnetic resonance imaging (MRI) is widely used to evaluate the efficacy of anti-angiogenic therapies. Patients and Methods: Patients with locally advanced/metastatic breast cancer who had not received any prior chemotherapy or hormone therapy were included. DCE-MRI was conducted at baseline and after one and two cycles of bevacizumab and paclitaxel. The percentage change in the volume transfer constant (ΔKtrans) and the correlation of ΔKtrans with tumour regression and time to progression (TTP) were evaluated. Results: The mean ΔKtrans from baseline after one and two cycles was −51.4% and −55.1%, respectively. Patients with ΔKtrans ≥50% displayed more tumour regression than those with ΔKtrans <50%; TTP was not significantly different. Conclusion: We demonstrate a decrease in blood permeability following bevacizumab and paclitaxel using DCE-MRI and a correlation between ΔKtrans and tumour regression.

Retention of a reconstructed nipple using a C-V flap with different layer thicknesses in the C-flap

Abstract Background: The C-V flap for nipple reconstruction is now one of standard surgical techniques. But decreased projection is still a problem. In recent years, it has been suggested that projection can be more easily maintained when raising of the C-flap is performed with a split thickness dermis. In this study, we examined whether decrease of projection can be prevented by raising of a C-flap with a split dermis rather than with full dermis. Methods: A total of 49 consecutive patients who underwent reconstruction of a nipple using the C-V flap technique were enrolled. The patients included 22 who underwent surgery using a C-flap with a full thickness dermis (Group F), and 27 who underwent surgery with raising of a flap with a split thickness dermis (Group S). The size of the reconstructed nipple was measured at 2 weeks, 6 months and 1 year postoperatively for comparison between Groups F and S. Results: Partial necrosis of the C-flap end occurred in 4 subjects in only Group S. The decrease in projection after 1 year postoperatively in Group S was significantly lower than that in Group F. In contrast, the teat base size in Group F tended to be greater than that in Group S, suggesting a tendency for an expanded base using a flap with a full dermis. Conclusions: Our results indicated that it is recommended to use a C-flap with a split dermis for cases with high projection of the nipple on the contralateral side.

Docetaxel and cyclophosphamide as neoadjuvant chemotherapy in HER2- primary breast cancer.

141 Background: Recently, docetaxel plus cyclophosphamide (TC) has been established as a standard regimen for adjuvant chemotherapy in HER2- operable breast cancer. However, the efficacy and tolerability of TC as neoadjuvant chemotherapy (NAC) remains unclear. We performed a prospective study of TC NAC in HER2- primary breast cancer. METHODS Eligible patients had HER2- invasive breast cancer that measured more than 1cm, less than 7cm and N0~N1 clinically between July, 2011 and February, 2014. Four cycles of TC(75 and 600 mg/m2) were administered intravenously every 3 weeks as NAC. We investigated the pathological complete response(pCR) of primary breast tumors. pCR was defined as no histological evidence of invasive carcinoma, or the appearance of only ductal carcinoma in situ. The cut-off value of Ki67 index between luminal A and luminal B was defined 20%. RESULTS We enrolled 52 patients. The completion rate for 4 cycles of TC was 94.2% ( 49 of 52). Relative dose intensity was 99.1% for TC therapy. Forty nine patients were classified according to breast cancer subtype before the estimation. Overall pCR rate was 16.3 %( 8 of 49 ) . pCR rate for patients with luminal A ( ER+, Ki67 low and HER2- ), luminal B ( ER+, Ki67 high and HER2- ) and triple negative ( ER- and HER2- ) were 0%( 0 of 12 ), 4.3 %( 1 of 23 ) and 50.0 %( 7 of 14 ), respectively pCR was achieved in almost triple negative patients. CONCLUSIONS The pCR rate of TC was not so high, regardless of the high completion rate. In this study, TC was effective against triple negative subtype, showing a high pCR rates, compared with luminal subtype. In conclusion, the efficacy of TC NAC in HER2- primary breast cancer is limited, and triple negative subtype might be the good target. CLINICAL TRIAL INFORMATION UMIN000013261.

Prognosis of Japanese breast cancer based on hormone receptor and HER2 expression determined by immunohistochemical staining

1122 Background: We classified Japanese breast cancer patients based on estrogen receptor (ER), progesterone receptor (PR) and HER2 protein expression and compared their prognoses. Methods: Background and prognostic factors were compared among 600 patients with breast cancer who were assigned to groups as follows: luminal A (ER+ and/or PR+ and HER2-; n = 431; 71.8%), luminal B (ER+ and/or PR+ and HER2+; n =27; 4.5%), HER2 subtype (ER-, PR- and HER2+; n = 39; 6.5%) and basal-like breast cancer (BBC) (ER-, PR- and HER2-; n = 103; 17.2%). Results: There were no differences among the groups regarding to age, menopausal state, size of tumors, and axillary metastasis. Disease-free survival rates were significantly lower for the luminal B, HER2 subtype and BBC, than for the luminal A subtype. Cancer tended to recur earlier and overall survival was significantly lower for the BBC, than that for the luminal A and HER2 subtype. Luminal B and HER2 subtype revealed same overall survival rate as luminal A. Conclusions...