Sankaran Narayanan

Early multicentre experience of pre-pectoral implant based immediate breast reconstruction using Braxon ®

Background The last two decades have seen significant changes in surgical management of breast cancer. The offer of immediate breast reconstruction (IBR) following mastectomy is currently standard practice. Skin sparing and nipple sparing mastectomy with implant-based IBR have emerged as oncologically safe treatment options. Prepectoral implant placement and complete coverage of implant with acellular dermal matrix (ADM) eliminates the need to detach the muscle from underlying chest wall in contrast to the subpectoral technique. We report short-term outcomes of a multicentre study from the United Kingdom (UK) using Braxon® in women having an IBR. Methods A prospective study was conducted from December 2015 to October 2016 and included all patients from three breast units in the UK who underwent a mastectomy and an implant-based IBR using Braxon®. The demographic details, co-morbidities, operative details, immediate and delayed complications were recorded. Specific complications recorded were infection, seroma, unplanned readmission and loss of implant. A comparison was made with complications reported in the National Mastectomy and Reconstruction Audit. Results Seventy-eight IBRs were included in the analysis with a median follow-up of 9.98 months. Mean age of the cohort was 50 years with a mean body mass index of 25.7 kg/m2. Mean implant volume was 365 cc. The inpatient hospital stay was 1.48 days. About 23% of patients had a seroma, 30% had erythema requiring antibiotics and the explant rate was 10.2 percent. Bilateral reconstructions were significantly associated with implant loss and peri-operative complications on univariate analysis. Conclusions Our early experience with this novel prepectoral technique using Braxon® has shown it to be an effective technique with complication rates comparable to subpectoral IBR. The advantages of prepectoral implant-based IBR are quicker postoperative recovery and short post-operative hospital stay. Long-term studies are required to assess rippling, post-operative animation, capsular contracture and impact of radiotherapy.

Acellular dermal matrix in implant-based immediate breast reconstructions: a comparison of prepectoral and subpectoral approach

Background Implant-based immediate breast reconstruction (IBR) is the most common technique for post-mastectomy reconstructions in the United Kingdom (UK). Subpectoral implant placement is the conventional method of reconstruction. Placement of implant in the subcutaneous pocket covered by an acellular dermal matrix (ADM) is a relatively recent approach. We report a comparative analysis of prepectoral versus subpectoral approach for implant-based IBR from a single institution in the UK. Methods Retrospective analysis from a prospectively maintained data was conducted from January 2015 to May 2017 including all patients who underwent a mastectomy with immediate implant-based IBR in a single breast unit. The demographic details, operative details, immediate and delayed complications were recorded. Specific complications recorded were infection, seroma, unplanned readmission and loss of implant. Factors affecting complication rates and implant loss were analyzed. Results One hundred and fifty-four reconstructions were included in the analysis with a median follow-up of 11.8 months. Mean age of the cohort was 50 years with a mean BMI of 26.09 kg/m2. Major implant-related complication rate was 12.3% with an implant loss rate of 7.8%. Age more than 50 years (P=0.037) and bilateral reconstructions (P=0.0001) had significant impact on complication rate, on multivariate analysis. Patients with bilateral implants had a significantly higher implant loss rate (P=0.0001). Implant loss rates in the prepectoral group (4.2%) and subpectoral group (10.8%) were not statistically significant (P=0.29). Conclusions Prepectoral and subpectoral techniques of IBR have comparable outcomes. Studies reporting on long-term outcomes are planned.

Association of One-Step Nucleic Acid Amplification Detected Micrometastases with Tumour Biology and Adjuvant Chemotherapy

One-step nucleic acid amplification (OSNA) is an intraoperative technique with a high sensitivity and specificity for sentinel node assessment. The aim of this study was to assess the impact of OSNA on micrometastases detection rates and use of adjuvant chemotherapy. A retrospective review of patients with sentinel node micrometastases over a five-year period was carried out and a comparison of micrometastases detection using OSNA and H&E techniques was made. Out of 1285 patients who underwent sentinel node (SLN) biopsy, 76 patients had micrometastases. Using H&E staining, 36 patients were detected with SLN micrometastases (9/year) in contrast to 40 patients in the OSNA year (40/year) (p < 0.0001), demonstrating a fourfold increase with the use of OSNA. In the OSNA group, there was also a proportional increase in Grade III, triple-negative, ER-negative, and HER-2-positive tumours being diagnosed with micrometastases. Also on interactive PREDICT tool, the number of patients with a predicted 10-year survival benefit of more than 3% with adjuvant chemotherapy increased from 52 to 70 percent. OSNA has resulted in an increased detection rate of micrometastases especially in patients with aggressive tumour biology. This increased the number of patients who had a predicted survival benefit from adjuvant chemotherapy.