Reverse-sequence endoscopic nipple-sparing mastectomy with immediate implant-based breast reconstruction: an improvement of conventional minimal access breast surgery.

Background: Our center proposes a new technique that effectively provides space to broaden the surgical field of view and overcomes the limitations of endoscopy-assisted nipple-sparing mastectomy (E-NSM) by changing the dissection sequence and combining it with air inflation. The purpose of this study was to compare the clinical outcomes of the new technique designated "reverse-sequence endoscopic nipple-sparing mastectomy (R-E-NSM) with subpectoral breast reconstruction (SBR)" and the conventional E-NSM (C-E-NSM) with SBR. Method: All patients undergoing E-NSM with SBR at our breast center between April 2017 and December 2022 were included in this study. The cohort was divided into the C-E-NSM group and the R-E-NSM group. The operation time, anesthesia time, medical cost, complications, cosmetic outcomes, and oncological safety were compared. Results: Twenty-six and seventy-nine consecutive patients were included in the C-E-NSM and R-E-NSM groups, with average ages of 36.9 ± 7.0 years and 39.7 ± 8.4 years (P=0.128). Patients in the R-E-NSM group had significantly shorter operation time (204.6 ± 59.2 vs. 318.9 ± 75.5 minutes, p<0.001) and anesthesia time (279.4 ± 83.9 vs. 408.9 ± 87.4 minutes, p<0.001) and decreased medical costs [5063.4 (4439.6-6532.3) vs. 6404.2 (5152.5-7981.5), USD, p=0.001] and increase SCAR-Q scores (77.2 ± 17.1 vs. 68.8 ± 8.7, P=0.002) compared to the C-E-NSM group. Although trends increased in both the excellent rate of Ueda scores (53.8% vs. 42.3%, P = 0.144), excellent rate of Harris scores (44.0% vs. 63.1%, P=0.102), and decreased surgical complications (7.6% vs. 19.2%, P = 0.135) were observed in the R-E-NSM group, the differences were not significant. There were no significant differences in oncological outcomes between the two groups. Conclusion: R-E-NSM improves cosmetic outcomes and efficiency of C-E-NSM, reduces medical costs, and has a trend of lower surgical complications while maintaining the safety of oncology. It is a safe and feasible option for oncological procedures that deserves to be promoted and widely adopted in practice.

A novel technique of reverse-sequence endoscopic nipple-sparing mastectomy with direct-to-implant breast reconstruction: medium-term oncological safety outcomes and feasibility of 24-h discharge for breast cancer patients.

BACKGROUND: Due to the short operation time and no need for special instruments, reverse-sequence endoscopic nipple-sparing mastectomy (R-E-NSM) with direct-to-implant breast reconstruction (DIBR) has been rapidly becoming popular in the last three years. However, there has yet to be an evaluation of its oncologic safety or the feasibility of discharging patients within 24 h. MATERIALS AND METHODS: In this single-centre retrospective cohort study, individuals diagnosed with stage 0-III breast cancer between May 2020 and April 2022 who underwent traditional open mastectomy or R-E-NSM with DIBR were included. Follow-up started on the date of surgery and ended in December 2023. Data, including demographics, tumour characteristics, medium-term oncological outcomes, and postoperative complications, were collected and analyzed. Propensity score matching (PSM) was performed to minimize selection bias. RESULTS: This study included 1679 patients [median (IQR) age, 50 [44-57) years]. Of these, 344 patients underwent R-E-NSM with DIBR (RE-R group), and 1335 patients underwent traditional open mastectomy (TOM group). The median [IQR] follow-up time was 30 [24-36] months [29 (23-33) months in the RE-R group and 30([24-36) months in the TOM group]. Regarding before or after PSM, the P value of local recurrence-free survival (LRFS, 0.910 and 0.450), regional recurrence-free survival (RRFS, 0.780 and 0.620), distant metastasis-free survival (DMFS, 0.061 and 0.130), overall survival (OS, 0.260 and 0.620), disease-free survival (DFS, 0.120 and 0.330) were not significantly different between the RE-R group and the TOM group. The 3y-LRFS and 3y-DFS rates were 99.0% and 97.1% for the RE-R group and 99.5% and 95.3% for the TOM group, respectively. The rates of any complications and major complications were not significantly different between the RE-R patients who were discharged within 24 h and the RE-R patients who were not discharged within 24 h ( P =0.290, P =0.665, respectively) or the TOM patients who were discharged within 24 h ( P =0.133, P =0.136, respectively). CONCLUSIONS: R-E-NSM with DIBR is an innovative oncologic surgical procedure that not only improves cosmetic outcomes but also ensures reliable oncologic safety and fewer complications, enabling patients to be safely discharged within 24 h. A long-term prospective multicenter assessment will be supporting.

Clinical Outcomes of Transaxillary Reverse-Sequence Endoscopic Nipple-Sparing Mastectomy and Direct-to-Implant Prepectoral Breast Reconstruction: A Prospective Study of Initial 68 Procedures.

BACKGROUND: Minimal access breast surgery improves cosmetic outcomes over conventional breast surgery but still faces barriers in becoming standard procedure for breast reconstruction. This report introduces a novel technique of transaxillary reverse-sequence endoscopic nipple-sparing mastectomy (R-E-NSM) followed by direct-to-implant prepectoral breast reconstruction (DTI-PBR) and describes its clinical outcomes. METHODS: This prospective study enrolled patients who underwent R-E-NSM and DTI-PBR from March 2021 to December 2021 at a single institution. Perioperative data, surgical complications, oncologic outcomes, and patient- and surgeon-reported cosmetic results were noted. RESULTS: The 60 patients in this study who underwent 68 R-E-NSM and DTI-PBR had a mean age was 40.4 ± 10.3 years. The average durations of uni- and bilateral operations were 156.5 ± 48.3 min and 191.3 ± 36.1 min, respectively. The overall surgical complication rate was 13.3%, including 10.0% of patients with minor complications and 3.3% of patients with major complications. The study had one case (1.7%) of implant loss and one case (1.7%) of skin flap necrosis treated by reoperation. During the median follow-up period of 24 months, one patient (1.7%) who discontinued chemotherapy for myelosuppression experienced liver metastases 5 months postoperatively, and one patient experienced new-onset contralateral ductal carcinoma in situ 24 months postoperatively. The preoperative and 18-month postoperative Breast-Q scores for satisfaction with breasts, psychosocial well-being, sexual well-being, and chest well-being did not differ significantly, and the Scar-Q was 81.2 ± 14.5 points. The good-to-excellent rate in surgeon-reported cosmetic results reached 90%. CONCLUSIONS: Transaxillary R-E-NSM followed by DTI-PBR is a safe and efficient technique with high cosmetic outcomes and reliable medium-term oncologic results.

Minimally Invasive and Innovative Management of Prosthesis Infections in Endoscopic-Assisted Breast Reconstruction.

BACKGROUND: Implant infection continues to be the most common complication of breast reconstruction, and it can lead to serious consequences of implant loss. Recently, endoscopic-assisted nipple-sparing mastectomy with direct-to-implant breast reconstruction is being performed more frequently, with similar prosthetic infection incidence compared to conventional techniques. But there is little information published in the literature on the management of periprosthetic infection in endoscopic-assisted breast reconstruction. METHODS: A retrospective review was performed of patients who underwent endoscope-assisted breast reconstruction and developed periprosthetic infection between January 2020 and December 2022. Prosthesis infection was defined as any case where antibiotics were given, beyond the surgeon's standard perioperative period, in response to clinical signs such as swelling, pain, erythema, increased temperature, fever, etc. We summarized our clinical approach and treatment protocol for periprosthetic infection patients. Collected data include preoperative basic information, surgical details, postoperative data, and outcomes. RESULTS: A total of 580 patients (713 reconstructions) underwent endoscopic-assisted immediate breast reconstruction. There were 58 patients developed periprosthetic infection, 14 of whom had bilateral prosthesis reconstruction with unilateral prosthesis infection. The incidence of infection was 10.0%. Average follow-up was 17.3 ± 8.9 months (range = 2-37 months). Of the 58 patients, 53 (91.4%) patients successful salvaged implant and 5(8.6%) patients removed prosthesis. During follow-up, Baker III capsular contracture occurred in 2 patients (3.8%) who had radiotherapy. CONCLUSION: Our management of prosthesis infections in endoscopic-assisted breast reconstruction is easy, minimally invasive, and inexpensive. This method can be repeated if the implant infection does not improve after the first drainage. What's more, our data suggest that our prosthesis salvage of periprosthetic infection is effective. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

An Innovative and Highly Efficient Single-Port Endoscopic Nipple-/Skin-Sparing Mastectomy and Dual-Plane Direct-to-Implant Breast Reconstruction: A Prospective Study from a Single Institution.

BACKGROUND: The difficulty in creating and maintaining a stable workspace of the breast makes endoscopic nipple-/skin-spring mastectomy (E-N/SSM) develop slowly. This study aims to report the preliminary results of a novel endoscopic technique for N/SSM followed by dual-plane direct-to-implant (DP-DTI) breast reconstruction. METHODS: A prospectively maintained database was reviewed that included patients who underwent single-axillary-incision E-N/SSM and DP-DTI breast reconstruction from September 2020 to April 2021 at a single institution by three surgeons. The data were collected prospectively and analyzed to determine the efficacy, feasibility, safety, and esthetic results of the operation, as well as quality of life (QoL). RESULTS: During the study period, a total of 68 E-N/SSM and DP-DTI reconstruction procedures through a single axillary incision were performed in 63 female patients. Among all the procedures, the majority were performed for grade 1-3 ptotic breasts (n =46, 73.0%). During the median follow-up of 26.5 months, the major and minor surgical complication rates were 1.6% (1/63) and 9.5% (6/63), respectively. The cosmetic complication rate was 14.3%. One patient suffered local recurrence 4 months postoperation. The average scores in patient-reported outcomes at 2 years postoperation of satisfaction with breast (66.57), psychosocial well-being (75.93) and sexual well-being (56.29) were not significantly different compared with the baseline, except for physical well-being: chest (69.85). CONCLUSIONS: The proposed procedure for E-N/SSM and DP-DTI breast reconstruction is feasible, time-saving and safe with good outcomes in terms of cosmetic results and QoL and expands the indications of DTI reconstruction to ptotic breasts, making it easier to popularize. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Single Axillary Incision Reverse Sequence Endoscopic Nipple-Sparing Mastectomy in the Management of Gynecomastia: Short-Term Cosmetic Outcomes, Surgical Safety, and Learning Curve of the Preliminary 156 Consecutive Procedures from a Prospective Cohort Study.

BACKGROUND: Currently, a standard, optimal surgical procedure is still lacking for gynecomastia. Despite the development of a variety of surgical interventions, these techniques were often limited to patients with Simon I and II. The present study aimed to introduce a novel technique for all types and grades of gynecomastia, and reported the preliminary results. METHODS: Patients who received single axillary incision reverse sequence endoscopic nipple-sparing mastectomy (R-E-NSM) from March 2021 to March 2023 were enrolled at a single institution. The data from 3-month follow-up cut-off were collected prospectively and analyzed to determine the short-term esthetic and safety results of this technique, as well as the learning curve. RESULTS: A total of 159 single axillary incision reverse sequence endoscopic nipple-sparing mastectomy procedures were performed in 81 gynecomastia patients. Among these 81 patients, 7 patients (8.6%) were classified as Simon grade I, 29 patients (35.8%) as grade IIa, 24 patients (29.6%) as grade IIb, and 21 patients (25.9%) as grade III. In the patient-reported cosmetic results, the overall satisfaction score was 8.4 ± 1.4. A total of 74.1% of patients were highly satisfied, and 25.9% were satisfied. The overall complication rate was 10.1%, and only 1 patient had a major complication. According to the cumulative sum plot analysis, approximately 12 cases were needed for surgeon B and 11 cases for surgeon C to decrease their operation time significantly. CONCLUSIONS: R-E-NSM is safe and effective for all Simon grade gynecomastia patients, with excellent cosmetic results and a short learning curve. However, a long-term follow-up assessment is still needed. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Short-term safety and cosmetic outcomes of endoscopic direct-to-implant breast reconstruction and simultaneous contralateral breast augmentation for breast cancer: a prospective analysis of 33 patients.

BACKGROUND: For patients with small breasts, breast-conserving surgery (BCS) and unilateral nipple-/skin-sparing mastectomy (N/SSM) with breast reconstruction may result in visible breast deformities or asymmetry, and contralateral breast augmentation often require a two-staged operation. We propose a novel endoscopic technique, direct-to-implant breast reconstruction and simultaneous contralateral breast augmentation (DTI-BR-SCBA), and report its short-term safety and cosmetic outcomes. METHODS: In this prospective study, patients with early breast cancer who underwent endoscopic DTI-BR-SCBA between November 2020 and August 2022 were followed for more than 3 months to analysed short-term postoperative safety (complications and oncological safety) and cosmetic outcomes (doctor-assessed results by Ueda scale and patient-reported results by Breast-Q scale). RESULTS: A total of 33 patients, including 30 treated with endoscopic prepectoral DTI-BR-SCBA, 1 with endoscopic dual-plane DTI-BR-SCBA and 2 with endoscopic subpectoral DTI-BR-SCBA, were analysed. The mean age was 39.7 ± 6.7 years. The mean operation time was 165.1 ± 36.1 min. The overall surgical complication rate was 18.2%. All complications were minor, including haemorrhage (3.0%), cured by compression haemostasis, surgical site infection (9.1%), cured by oral antibiotics, and self-healing nipple-areolar complex ischaemia (6.1%). Furthermore, rippling and implant edge visibility occurred in 6.2% of them. The outcome was graded as "Excellent" and "Good" in 87.9% and 12.1% of patients in the doctor cosmetic assessment, respectively, and patient satisfaction with breasts was significantly improved (55.0 ± 9.5 vs. 58.8 ± 7.9, P = 0.046). CONCLUSIONS: The novel endoscopic DTI-BR-SCBA method may be an ideal alternative for patients with small breasts because it can improve cosmetic results with a relatively low complications rate, which makes it worthy of clinical promotion.

Single axillary incision reverse-order endoscopic nipple/skin-sparing mastectomy followed by subpectoral implant-based breast reconstruction: Technique, clinical outcomes, and aesthetic results from 88 preliminary procedures.

BACKGROUND: Single axillary incision reverse-order endoscopic nipple-sparing mastectomy overcomes the limitations of conventional endoscopic nipple-sparing mastectomy application. We introduce this technique and report the preliminary results of this study. METHODS: Patients who received single axillary incision reverse-order endoscopic nipple-/skin-sparing mastectomy from May 2020 to May 2022 were enrolled from a single institution. Data were analyzed to evaluate the safety and effectiveness of this technique. Patient-reported and surgeon-reported cosmetic outcomes were collected. RESULTS: In total, 68 patients who underwent 88 single axillary incision reverse-order endoscopic nipple-/skin-sparing mastectomy combined with subpectoral implant-based breast reconstruction were enrolled in the current study. The overall complication rate was 10.3%. In total, 2.9% of patients suffered from major complications, and 5 (7.4%) experienced minor complications. Only 1 patient experienced partial nipple-areola complex necrosis. During a median follow-up time of 24 months, the locoregional recurrence and distant metastasis rate was both 1.6%. In the surgeon-reported cosmetic results, 92.1% of patients achieved good or excellent results. The mean SCAR-Q scores were 82.07 ± 8.86, and 85.3% evaluated their breasts as good or excellent. The mean overall cost was 5,670.4 ± 1,351.3 USD. The total mean operation time and maturity-stage mean operation time were 234.3 ± 80.4 and 172.55 ± 41.29 min, respectively. According to cumulative sum plot analysis, approximately 18 cases were needed for surgeons to decrease their operation time significantly and complication rate. CONCLUSION: Single axillary incision reverse-order endoscopic nipple-sparing mastectomy is a safe, less expensive, and efficient surgical technique with reliable intermediate-term oncologic safety. For suitable candidates, the technique with subpectoral implant-based breast reconstruction can provide a good cosmetic outcome.

Three-Pedicle Reduction Mammaplasty Technique in the Treatment of Greater Breast Hypertrophy Patients With or Without Breast Cancer: Surgical and Patient-reported outcomes.

BACKGROUND: Reduction mammoplasty (RM) is an important procedure in the management of symptomatic greater breast hypertrophy with or without early-stage breast cancer. We aim to introduce a new procedure: the three-pedicle reduction mammaplasty technique. METHODS: A prospectively maintained database was reviewed, and two prospectively registered clinical studies were included of all breast hypertrophy patients with or without breast cancer who underwent three-pedicle RM with inverted T incision at West China Hospital or the Fourth People's Hospital of Sichuan Province from 2018 to 2022. Patient demographics, patient-reported cosmetic results, quality of life (QoL), surgical outcomes and complications were assessed. RESULTS: During a median period of 22.5 months, 101 reduction mammaplasties were performed (Mage= 35.80; MBMI= 27.05). Mean reduction weight was 880.9 g ranging from 423-1630 g per breast. The nipple-to-sternal notch distance (N-SN) at post-operation was significantly shorter than preoperatively (left, 34.51 cm; right, 34.69 cm). Major complications and minor complications were 1.9% (1/52 patients) and 13.5% (7/52 patients), respectively. Multivariate logistic regression analyses showed that BMI > 30 was independent risk factors for a complication. Except for sexual and physical well-being at 1-month post-operation, patients gave a higher score on the BREAST-Q (breast satisfaction, physical well-being, psychosocial well-being) after the operation than before the operation (P<0.001). CONCLUSIONS: The three-pedicle RM technique was demonstrated to be an effective and safe RM procedure for moderate to severe breast hypertrophy patients with or without breast cancer, with the advantages of removing the lesions, reducing hypertrophic breasts and accomplishing mammoplasty. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors   http://www.springer.com/00266.

Endoscopic Nipple- or Skin-Sparing Mastectomy and Immediate Breast Reconstruction with Endoscopic Harvesting of the Latissimus Dorsi Flap: A Preliminary Experience of an Innovative Technique.

Background: Endoscopic nipple- or skin-sparing mastectomy (E-N/SSM) and endoscopic latissimus dorsi muscle flap (E-LDMF) harvest have been operational difficulties over decades. The aim of this study was to describe the preliminary outcomes of our novel surgical technique, which allows the performance of E-N/SSM and E-LDMF harvest for immediate breast reconstruction (IBR) through a single cosmetic axillary incision for breast cancer patients. Methods: This prospective study included 20 breast cancer patients who underwent E-N/SSM and E-LDMF harvesting through a single axillary incision in our hospital from September 2020 to June 2022. The outcomes were statistically calculated, including patient characteristics, operative data, complication rate, hospital length of stay and costs, and patient-reported outcomes. Results: A total of 20 breast cancer patients underwent our sufficiently mature novel endoscopy technique. The mean LD flap harvest time was 96.5 ± 25.3 min, the mean operation time was 262.6 ± 54.4 min, and the average length of LDMF was 26.9 ± 3.1. During the median follow-up time of 7.5 months, 4 patients developed donor-site seroma. One of them was also complicated by hypopigmentation of the nipple areola, and one of them suffered from breast cellulitis. No bleeding or flap necrosis happened. No tumor recurrence or metastasis was found until the last follow-up. In the BREAST-Q evaluation, although they gave a lower score beginning at 1-month post-operation than preoperatively (P > 0.05, except for physical well-being: chest and physical well-being: back and shoulder, P < 0.01), there was an uptrend at 3 months postoperatively. Because of the hidden and short incision, the mean score of the appearance scale of the SCAR-Q at 3 months post-operation was 74.2 ± 8.8. Conclusions: The novel endoscopy technique, which was first reported to perform lymph node surgery, N/SSM, and LDMF harvesting in an operation for breast cancer patients through a single axillary incision, is associated with a shorter surgery time, lower complication rates, and better patient-reported outcomes.

Geriatric Early-Stage Triple-Negative Breast Cancer Patients in Low-risk Population: Omitting Chemotherapy Based on Nomogram.

BACKGROUND: Considering old age and comorbidities, the actual benefit of chemotherapy in older patients with early triple-negative breast cancer (TNBC) remains uncertain. We aimed to select appropriate patients who could avoid chemotherapy in this population. METHODS: A total of 6482 patients more than 65 years old with T1-2N0-1M0 TNBC in 2010-2015 were extracted from SEER program. Multivariate logistic regression was performed to identify independent factors associated with chemotherapy usage. Survival analysis was performed using Kaplan-Meier plots and log-rank tests. Independent prognostic factors were identified by multivariate Cox analysis. A nomogram predicting breast cancer-specific survival (BCSS) and a risk stratification model were constructed. RESULTS: A total of 3379 (52.13%) patients received chemotherapy while 3103 (47.87%) did not. Age, married status, grade, T-stage, N-stage, radiation and breast-conserving surgery (BCS) were significantly associated with chemotherapy usage (all P < .05). Chemotherapy significantly improved OS (HR = 0.606, P < .001) and BCSS (HR = 0.763, P = .006) in the entire population. A nomogram was built by incorporating independent risk factors (age, T-stage, N-stage, grade and radiation). Based on the score of the nomogram, the risk stratification model demonstrated that chemotherapy improved OS (P < .001) and BCSS (P < .001) of patients in the high-risk group (score >180), but not in the low-risk group (score ≤75). CONCLUSION: Chemotherapy is beneficial for geriatric patients with T1-2N0-1M0 TNBC in this study, and the risk stratification model indicates the feasibility of sparing chemotherapy in low-risk subgroup without sacrificing survival, providing clinicians tools to weigh the risk-benefit of chemotherapy and customize the individualized treatment accordingly.

Novel technique for endoscopic-assisted nipple-sparing mastectomy and immediate breast reconstruction with endoscopic-assisted latissimus dorsi muscle flap harvest through a single axillary incision: a retrospective cohort study of comparing endoscopic and open surgery.

Background: A novel endoscopic-assisted technique (NET) was created by our team for nipple-sparing mastectomy (NSM) and latissimus dorsi muscle flap (LDMF) reconstruction that enables the procedure to be conducted through a single axillary incision. The authors hypothesized that the NET has the advantages of the traditional ET (TET) and a reduced operation time. The purpose of this study is to compare the advantages and disadvantages of NET, TET and open surgery. Methods: A retrospective cohort study was performed on patients who underwent LDMF reconstruction after NSM using open surgery, the TET, or the NET between January 2013 and June 2021. The following outcomes were compared: the operation time, size of the LDMF, the complication rate, hospital length of stay, hospital costs, aesthetic results (the BREAST-Q questionnaire), and quality of life (QoL). The BREAST-Q questionnaire and QoL were underwent preoperatively and 1, 3, and 12 months postoperatively. Results: A total of 17 ETs (comprising 10 NETs and 7 TETs) and 28 open surgery procedures were identified and analyzed, the baseline characteristics were comparable in terms of age, body mass index (BMI), tumor location, cup size, and disease stage of the three groups. The mean operation time of the NET group (395.8±176.0 min) in the exploration stage was shorter than that of the TET group (531.6±69.6 min) and equivalent to that of the open surgery group (400.9±67.3 min). The overall postoperative complication rates of the ET and open surgery groups were 35.3% and 60.7%, respectively (P=0.09). The aesthetic results in relation to patients' satisfaction with their breasts (P=0.001) and backs (P=0.001) were better in the ET group than the open surgery group beginning at 1 month postoperatively. The ET group had better psychosocial well-being beginning at 1 month postoperatively (P=0.002) and sexual well-being beginning at 3 months postoperatively (P<0.001) than the open surgery group. Conclusions: LDMF reconstruction after NSM using the ET is associated with lower complication rates, good aesthetic results, and a better QoL than open surgery procedures. The NET is a promising approach, a more convenient procedure, and has a shorter surgery time than TET, however, this conclusion needs to be further validated by randomized clinical trial (RCT) research with a larger sample size.

The prognostic role of surgery and a nomogram to predict the survival of stage IV breast cancer patients.

Background: Since numerous retrospective studies and prospective trials have shown divergent results, whether the surgical excision of the primary tumor results in survival benefits for de novo stage IV breast cancer patients is inconclusive. Consequently, we need a prediction model of prognosis, judge the efficiency of breast surgery, and identify the advanced breast cancer patients who would benefit from surgery. Methods: We analyzed the data of 2,747 metastatic breast cancer patients (the surgery group) and 4,508 patients (the non-surgery group) from the Surveillance, Epidemiology, and End Results (SEER) database during 2010-2015. Propensity score matching (PSM) was used to attain a balance between the covariates of both groups. We then assessed the potential risk factors for the breast cancer-specific survival (BCSS) of patients in the non-surgery group by Cox regression and constructed a nomogram to predict BCSS. All the patients were classified into different risk groups based on the median risk score obtained from the nomogram. The hazard ratios of BCSS and overall survival (OS) of patients in the two groups were calculated. Results: After PSM, 2,288 patients severally in the two groups (the surgery group and the non-surgery group) were enrolled in the study. A nomogram incorporating 13 potential risk factors (i.e., age, race, cohabitation status, income, tumor grade, histotype, tumor size, lymph node status, molecular subtype, metastasis to brain, liver, lung, and chemotherapy) was constructed using the data of patients in the non-surgery group. The C statistics for the internal (patients in the non-surgery group) and external (patients in the surgery group) validation of the nomogram were 0.70 [95% confidence interval (CI), 0.69-0.71] and 0.73 (95% CI, 0.72-0.74), respectively. In the low-risk group, patients in the surgery group had lower risks of breast cancer-specific mortality (BCSM) (hazard ratio =0.53; 95% CI, 0.47-0.59; P for interaction =0.014) and overall mortality (OM) (hazard ratio =0.52; 95% CI, 0.46-0.58; P for interaction =0.002) than those in the non-surgery group. Conclusions: Breast surgery might improve the survival of metastatic breast cancer patients in the low-risk group. The established nomogram could provide a reference for clinicians in enabling personalized treatment among advanced breast cancer patients.

CCL5 mediates breast cancer metastasis and prognosis through CCR5/Treg cells.

Background and aims: CCL5 is considered to contribute to the biological function of a variety of cancer types, but its specific mechanism is still unclear. This study aimed to reveal the mechanism of CCL5 in the invasion, metastasis, and prognosis of breast cancer. Methods: The expression of CCL5 in tumor tissue and serum was measured with a Luminex protein detection kit, and the correlation between CCL5 and clinical parameters was evaluated. Kaplan-Meier analysis was used to analyze the effect of CCL5 on the prognosis of breast cancer patients. Protein interaction network analysis and gene coexpression were used to determine the receptor that has the strongest interaction with CCL5. Enrichment analysis was used to study the possible pathway by which CCL5 affects breast cancer progression. We used immunofluorescence staining and flow cytometry to estimate the fraction of immunity-related components in the tumor microenvironment. Results: The expression level of CCL5 in breast cancer patients was positively correlated with the degree of axillary lymph node metastasis; CCL5 in tumor tissue was correlated with estrogen receptor status (P = 0.034), progesterone receptor (P = 0.009), nuclear grade (P = 0.013), clinical stage (P < 0.001) and molecular subtype (P = 0.024) in breast cancer patients. Breast cancer patients with high CCL5 expression had worse disease-free survival (P = 0.031) and breast cancer-specific survival (P = 0.043); however, CCL5 had no effect on overall survival (P = 0.077). CCL5 affected tumor progression through CCR5, and the T-cell-related immune pathway may be the main pathway; the CD4+/CD8+, CCR5+/CD4+ and Treg/CCR5+ cell ratios were significantly increased in the lymph node metastasis group. Conclusion: CCL5 affects the Treg/CD4+CCR5+ cell ratio in breast cancer patients through CCR5, thus affecting breast cancer metastasis and prognosis.

Can Radiotherapy After Breast-Conserving Surgery be Omitted in Elderly Patients with Early-Stage, Hormone-Receptor Negative Breast Cancer? A Population-Based Study and Proposed Nomogram.

INTRODUCTION: We aimed to evaluate whether radiotherapy (RT) after breast-conserving surgery (BCS) can be omitted in elderly patients with early-stage, hormone receptor-negative breast cancer. METHODS: Patients aged 65 years and older with T1-2N0-1, hormone receptor-negative breast cancer in 2010-2015 were extracted from the Surveillance, Epidemiology, and End Results program. Propensity score matching was used to balance the baseline of different groups. Survival analysis was performed using Kaplan-Meier plot and log-rank test. Independent risk factors were identified by multivariate Cox analysis. A nomogram predicting breast cancer-specific survival (BCSS) and a risk stratification model were constructed and validated. RESULTS: A total of 4465 patients were included and 27.7% (1237/4465) patients did not receive postoperative RT. RT was significantly associated with improved overall survival (OS) (HR = 0.552 P < 0.001) and BCSS (HR = 0.559, P < 0.001) in the matched cohort. The same results were found after adjusting independent risk factors by multivariate analysis. On the basis of the nomogram predicting BCSS of patients without RT by incorporating independent risk factors (age, race, HER2 status, T stage, and N stage), we built a risk stratification model which indicated that RT improved OS (HR = 0.511, P < 0.001) and BCSS (HR = 0.517, P < 0.001) in the high-risk group (total score > 150), but not in the low-risk group (total score ≤ 120). The C-index and all calibration curves demonstrated sufficient accuracies and good predictive capabilities. CONCLUSIONS: RT is indeed beneficial for the whole cohort in this study. However, it may be omitted in the low-risk subgroup without significantly sacrificing survival. For patients in the high-risk group, RT following BCS remained beneficial. This study highlights the need for prospective randomized trials to study RT de-escalation strategies.

What Is the Optimal Strategy for Drain Removal After Mastectomy and Axillary Surgery in Breast Cancer Patients? A Multicenter, Three-Arm Randomized Clinical Trial.

INTRODUCTION: The best strategy for drain removal after mastectomy and axillary surgery in breast cancer patients has remained controversial. We conducted a multicenter, three-arm randomized clinical trial to determine the optimal strategy. METHODS: A total of 187 eligible breast cancer patients who underwent mastectomy and axillary surgery were randomized into 10 mL (n = 62), 20 mL (n = 63), and 30 mL (n = 63) groups for drain removal on the first day when the output decreased to a corresponding volume in 24 h. The drain duration, total drain duration, incidence of seroma, quality of life, outpatient visit times, healthcare costs, and postoperative complications were evaluated. RESULTS: The median axillary drain durations and total drain durations were all significantly different between three groups (both P < 0.001). The incidences of seroma were 31.1%, 38.3%, and 52.1%, and the difference between the 30 mL and 10 mL groups was significant (RR = 2.41). The 20 mL group reported significantly better quality of life (QoL) in terms of physical functioning (PF) at the 2-week (30 mL versus 20 mL, HR:-14.18) and 3-week (20 mL versus 10 mL, HR: 11.65) follow-up and role functioning (RF) at the 2-week follow-up (20 mL versus 10 mL, HR: 18.15). No between-group differences were found in G-QoL, outpatient visits, costs, or complications. CONCLUSIONS: The 20 mL group had a moderate drain duration, total drain duration, and incidence of seroma but a significant advantage over the other two groups in terms of PF and RF, with relatively low outpatient costs and comparable postoperative complication rates. These findings could aid in clinical decision-making regarding drain removal timing (http://www.chictr.org.cn/: ChiCTR2000028729).

Video-assisted Transaxillary Nipple-sparing Mastectomy and Immediate Implant-based Breast Reconstruction: A Novel and Promising Method.

BACKGROUND: Although video-assisted breast surgery is gaining popularity, endoscopic reconstruction after mastectomy is still facing lots of problems, bring about that endoscopic method has not yet become a standard procedure for breast cancer reconstruction. Here, we introduce a novel surgical technique of video-assisted transaxillary nipple-sparing mastectomy and immediate implant-based breast reconstruction and describe the detailed surgical procedure using this technique. METHODS: Detailed steps of surgical procedure, the patient characteristics and the mean operative time of this new technique were described in this article. All patients were asked to score their satisfaction with their reconstructed breasts preoperatively, 1 month, 3 months, 6 months and 12 months postoperatively using the BREAST-Q. RESULTS: At first, we used our "conventional method" and performed on 10 patients from April 2017 to June 2020; the operative time was 324.80 ± 66.39 minutes. After improving several procedures of the technique, the "optimized method" was performed on 14 cases from July 2020 to November 2020; the operative time decreased to 193.71 ± 28.75 minutes with shortest was 133 minutes; the optimized method was novel and easy to learn and be generalized. Most of the patients were satisfied with the reconstruction results. There was no significant difference between preoperative scores and scores at 3 months, 6 months and 12 months (p = 0.364). Since there is no wound on the breast dome, no obvious postoperative complications were observed except for one patient presented with infection. CONCLUSIONS: This new technique has allowed surgeons to achieve excellent and reproducible outcomes in a single-stage procedure and represents an excellent technique for patients who wish to have a scarless and aesthetically pleasing appearance after mastectomy for breast cancer. This article also highlights the mean operative time (193.71 ± 28.75 minutes) that has been made possible with this new technique. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors http://www.springer.com/00266 .