Mary Jane Houlihan

Skin-sparing mastectomy and immediate reconstruction : Oncologic risks and aesthetic results in patients with early-stage breast cancer

&NA; Skin‐sparing mastectomy has been advocated as an oncologically safe approach for the management of patients with early‐stage breast cancer that minimizes deformity and improves cosmesis through preservation of the skin envelope of the breast. Because chest wall skin is the most frequent site of local failure after mastectomy, concerns have been raised that inadequate skin excision could result in an increased risk of local recurrence. Precise borders of the skin resection have not been well established, and long‐term local recurrence rates after skin‐sparing mastectomy are not known. The purpose of this study was to evaluate the oncologic safety and aesthetic results for skin‐sparing mastectomy and immediate breast reconstruction with a latissimus dorsi myocutaneous flap and saline breast prosthesis. Fifty‐one patients with early‐stage breast cancer (26 with ductal carcinoma in situ and 25 with invasive carcinoma) undergoing primary mastectomy and immediate reconstruction with a latissimus flap were studied from 1991 through 1994. For 32 consecutive patients, skin‐sparing mastectomy was defined as a 5‐mm margin of skin designed around the border of the nipple‐areolar complex. After the mastectomy, biopsies were obtained from the remaining native skin flap edges. Patients were followed for 44.8 months. Histologic examination of 114 native skin flap biopsy specimens failed to demonstrate breast ducts in the dermis of any of the 32 consecutive patients studied. One of 26 patients with ductal carcinoma in situ had metastases to the skin of the lateral chest wall and back. Four other patients, one with stage I disease and three with stage II‐B disease, had recurrent breast carcinoma. The stage I patient had a local recurrence in the subcutaneous tissues near the mastectomy specimen. Two patients suffered axillary relapse, and one had distant metastases to the spine. The findings of this study support the technique of skin‐sparing mastectomy as an oncologically safe one, based on an absence of breast ductal epithelium at the margins of the native skin flaps and a local recurrence rate of 2 percent after 45 months of follow‐up. Although these results need to be confirmed with greater numbers of patients and longer follow‐up, skin‐sparing mastectomy and immediate breast reconstruction may be considered an excellent alternative treatment to breast conservation for patients with ductal carcinoma in situ and early‐stage invasive breast cancer. (Plast. Reconstr. Surg. 102: 49, 1998.)

Axillary lymph nodes and breast cancer. A review

Background. The value of surgical staging and treatment of the axillary lymph nodes with either surgery or radiotherapy in the initial management of patients with Stage I or II invasive breast cancer is controversial.

High body mass index and smoking predict morbidity in breast cancer surgery: a multivariate analysis of 26,988 patients from the national surgical quality improvement program database.

Objective:The purpose of this study was to examine the incidence of complications of breast cancer surgery in a multi-institutional, prospective, validated database and to identify preoperative risk factors that predispose to these complications. Background:There is an increased emphasis on clinical outcomes to improve the quality of surgical care. Although mastectomy and breast conserving surgery have low risk for complications, few US studies have examined the incidence of these complications in large, multicenter patient populations. The broad scale of the National Surgical Quality Improvement Program (NSQIP) data set facilitates multivariate analysis of patient characteristics that predispose to development of postoperative complications in breast cancer surgery. Methods:A prospective, multi-institutional study of patients undergoing mastectomy and breast conserving surgery was performed from the National Surgical Quality Improvement Program from 2005 to 2007. Study subjects were selected as a random sample of patients at more than 200 participating community and academic medical centers. Thirty-day morbidity was prospectively collected and the incidence of postoperative complications was determined, with particular emphasis on superficial and deep surgical site infections. Multivariate logistic regression was performed to identify independent risk factors for postoperative wound infections in each. Results:A total of 26,988 patients were identified who underwent mastectomy (N = 10,471) and breast conserving surgery (N = 16,517). As expected, the overall 30-day morbidity rate for all procedures was low (5.6%), with significantly higher morbidity for mastectomies (4.0%) than breast conserving surgery (1.6%, P < 0.001). The most common complications in all procedures were superficial surgical site infections and deep surgical site infections. Independent risk factors for development of any wound infection in patients undergoing mastectomy were a high body mass index, smoking, and diabetes (ORs = 1.8, 1.6, 1.8). In patients who had a lumpectomy, a high body mass index, smoking, and a history of surgery within 90 days prior to this procedure (ORs = 1.7, 1.9, 2.0) were independent risk factors. Conclusions:Although complication rates in breast cancer surgery are low, wound infections remain the most common complication. A high body mass index and current tobacco use were the only independent risk factors for development of a postoperative wound infection across all procedures. This study highlights the benefit of a multi-institutional database in assessing risk factors for adverse outcomes in breast cancer surgery.

Nipple-sparing mastectomy: evaluation of patient satisfaction, aesthetic results, and sensation.

The purpose of this study is to describe our experience with nipple-sparing mastectomy and immediate reconstruction, with particular attention to patient satisfaction, aesthetic results, and nipple sensation. Immediate reconstruction was performed on 17 breasts in 10 patients, using either implants or autologous tissue flaps. Assessment of outcomes was performed through patient interviews, a self-reported patient satisfaction survey and review of postoperative photographs. Short-term complications included partial loss of the nipple-areolar complex requiring debridement (n = 3) and removal of the nipple-areolar complex (n = 2) for occult ductal carcinoma in situ. While all patients with completed breast reconstructions were satisfied with their general reconstructive experience, 6 of 9 patients were aesthetically satisfied with their breast reconstruction. Postoperative nipple sensation was reported in 75% of patients, although sensation was low (mean of 2.8 of 10). As nipple-sparing mastectomy is becoming an increasing patient preference, preoperative discussion needs to address expectations, aesthetic satisfaction, and long-term cancer control.

Conservative surgery without radiotherapy in the treatment of patients with early-stage invasive breast cancer. A review.

ObjectiveThe authors determined whether some patients with clinical stage I or II invasive breast cancer can be adequately treated by conservative surgery without radiotherapy. Summary Background DataCurrently, there are many patients who are being treated in this manner in both academic and community hospitals. This approach is not as effective as either mastectomy or conservative surgery followed by radiotherapy in preventing local recurrence. However, there may be subsets of patients who might be adequately treated by surgery atone with acceptably low recurrence rates MethodsThe authors reviewed retrospective studies of conservative surgery alone and of randomized trials comparing the results of treatment with and without postoperative radiotherapy. ResultsThe local recurrence rate is unacceptably high when random patients are treated with conservative surgery without radiotherapy. More favorable results may be possible when relatively wide excisions are performed on selected postmenopausal patients with small lesions without an extensive intraductal component, lymphatic or blood-vessel invasion, and histologically negative axillary nodes. The role of tamoxifen in reducing the risk of breast recurrence is uncertain. Despite salvage therapy, some individuals may develop disseminated disease as a result of local recurrence. ConclusionsThe authors believe that conducting carefully designed prospective studies of conservative surgery alone is reasonable for patients who are adequately informed of the potential risks of omitting radiation therapy. However, currently, patients should not be treated with conservative surgery alone (without radiotherapy) without such stringent guidelines.

Evaluation of the SCA instrument for measuring patient satisfaction with cancer care administered via paper or via the Internet

Background: Patients’ perspectives provide valuable information on quality of care. This study evaluates the feasibility and validity of Internet administration of Service Satisfaction Scale for Cancer Care (SCA) to assess patient satisfaction with outcome, practitioner manner/skill, information, and waiting/access. Patients and methods: Primary data collected from November 2007 to April 2008. Patients receiving cancer care within 1 year were recruited from oncology, surgery, and radiation clinics at a tertiary care hospital. An Internet-based version of the 16-item SCA was developed. Participants were randomised to Internet SCA followed by paper SCA 2 weeks later or vice versa. Seven-point Likert scale responses were converted to a 0–100 scale (minimum–maximum satisfaction). Response distribution, Cronbach’s alpha, and test–retest correlations were calculated. Results: Among 122 consenting participants, 78 responded to initial SCA. Mean satisfaction scores for paper/Internet were 91/90 (outcome), 95/94 (practitioner manner/skill), 89/90 (information), and 86/86 (waiting/access). Response rate and item missingness were similar for Internet and paper. Except for practitioner manner/skill, test–retest correlations were robust r = 0.77 (outcome), 0.74 (information), and 0.75 (waiting/access) (all P < 0.001). Conclusions: Internet SCA administration is a feasible and a valid measurement of cancer care satisfaction for a wide range of cancer diagnoses, treatment modalities, and clinic settings.

Breast reconstruction in a changing breast cancer treatment paradigm.

Current trends in the treatment of breast cancer reveal a progressively higher value being placed on the conservation of breast tissue. In the shift from the radical mastectomies of Halsted to breast-conserving therapies, there has been a greater realization of the possibility and the benefits of providing less invasive procedures with decreased tissue volume resections as procedures are increasingly tailored to specific tumor characteristics. This move toward smaller procedures and more individualized therapies achieves multiple advances in improving care and outcomes for women undergoing breast cancer treatment. The goal of recent developments in breast conservation therapy, including sentinel lymph node biopsy and partial breast irradiation techniques, is to decrease morbidity and complications for women. In addition to improving functional results for women, these new advances allow breast surgeons and plastic surgeons to truly maximize aesthetic and reconstructive outcomes. The use of bilateral reduction mammaplasty as a strategy for avoiding breast contour defects after large-volume partial mastectomy has shown excellent results in optimizing breast symmetry and appearance. When mastectomy is indicated, breast surgeons are preserving an increasing amount of skin envelope through skin-sparing and nipple-sparing mastectomy techniques, providing plastic surgeons with an improved aesthetic pocket in which to place implants or autologous tissue flaps and a virtually intact nipple-areola complex that requires little, if any, further reconstruction. Refinement of the deep inferior epigastric perforator (DIEP) flap and other perforator flaps has continued to improve outcomes after autologous tissue reconstructions. In this article, the authors review the recent development of new tools, techniques, and strategies for the management of breast cancer. The paradigm shift shaping the surgical treatment of breast cancer makes the current options and environment in the field of breast reconstruction ever evolving and increasingly rewarding.

Primary sphincter repair in anorectal trauma.

Two patients who sustained severe anorectal trauma from “fist fornication” were treated by irrigation, colostomy, drainage, antibiotics, and primary repair of the rectum and anal sphincters without complications. Both had complete return of continence. Primary sphincter repair is advocated for these and similar anorectal injuries.

Surgical upgrade rate of breast atypia to malignancy: An academic center's experience and validation of a predictive model

Atypical ductal hyperplasia (ADH), atypical lobular hyperplasia (ALH), and lobular carcinoma in situ (LCIS) are commonly seen on breast core needle biopsy (CNB). Many institutions recommend excision of these lesions to exclude malignancy. A retrospective chart review was performed on patients who had ADH, ALH, or LCIS on breast CNB from 1/1/08 to 12/31/10 who subsequently had surgical excision of the biopsy site. Study objectives included determining upgrade to malignancy at surgical excision, identification of predictors of upgrade, and validation of a recently published predictive model. Clinical and demographic factors, pathology, characteristics of the biopsy procedure and visible residual lesion were recorded. T test and chi‐squared test were used to identify predictors. Classification tree was used to predict upgrade. 151 patients had mean age of 53 years. The mean maximum lesion size on imaging was 11 mm. The primary atypia was ADH in 63.6%, ALH in 27.8%, and LCIS in 8.6%. 16.6% of patients had upgrade to malignancy, with 72% DCIS and 28% invasive carcinoma. Risk factors for upgrade included maximum lesion size (P = .002) and radiographic presence of residual lesion (P = .001). A predictive model based on these factors had sensitivity 78%, specificity 80% and AUC = 0.88. Validating a published nomogram with our data produced accuracy figures (AUC = 0.65) within published CI of 0.63‐0.82. In CNB specimens containing ADH, ALH, or LCIS, initial lesion size and presence of residual lesion are predictors of upgrade to malignancy. A validated model may be helpful in developing patient management strategies.

Role of Prophylactic Mastectomy

Deciding which patient should have a prophylactic mastectomy and when it should be performed are not easy decisions. Both the patient and the surgeon face the dilemma of either doing too much, or else of not doing enough only to realize later that mastectomy should have been done earlier. While treatment must be tailored to the physical and emotional needs of the patient, the personal experience of the surgeon (and also perhaps of the oncologist) tend to sway the patient’s decision.