Bilateral Risk-Reducing Mastectomies with Implant-Based Reconstructions Followed Long Term: A Consecutive Series of 185 Patients.

BACKGROUND: Bilateral risk-reducing mastectomy (BRRM) is the most effective method to prevent breast cancer in genetically predisposed women and is often performed concomitantly with breast reconstruction. The reconstruction time varies and corrective surgeries are common. METHODS: This study evaluated 185 consecutive cases of BRRM and immediate breast reconstruction with implants with regard to surgical outcome and resource consumption. With an 18-year observation period, it was possible to compare permanent expander implants (PEIs) with permanent fixed volume implants (PIs). RESULTS: A minimum follow-up of 2 years for all participants but one was achieved. Seventy-five percent (n = 138) of the women received PEI and 25% (n = 47) PI. In a multivariate analysis including age, BMI (<25, ≥25), smoking (yes, no), implant type (PEI, PI), incision technique, operation time and specimen weight <350 g, ≥350 g), only BMI ≥25 was associated with an increased risk of an early complication (OR 7.1, 95% CI 2.44-20.4). As expected, there was a significant difference in median reconstruction time between PEI and PI (12.4 vs. 1.0 months, p < 0.001). The cumulative reoperation-free 2-year survival was significantly higher in the PI than in the PEI group (81% vs. 26%, p < 0.001). CONCLUSION: Implant-based reconstruction remains a valid option after BRRM in high-risk women. Whenever possible (low BMI and small breast volume without severe ptosis), permanent fixed volume implants can be safely recommended and are resource saving in comparison with permanent expander implants.

Validation of data quality in the Swedish National Register for Breast Cancer.

BACKGROUND: The National Breast Cancer Register (NBCR) of Sweden was launched in 2008 and is used for quality assurance, benchmarking, and research. Its three reporting forms encompass Notification, Adjuvant therapy and Follow-up. Target levels are set by national and international guidelines. This national validation assessed data quality of the register. METHODS: Data recorded through the Notification form were evaluated for completeness, timeliness, comparability and validity. Completeness was assessed by cross-linkage to the Swedish Cancer Register (SCR). Comparability was analyzed by comparing registration routines in NBCR with national and international guidelines. Timeliness was defined as the difference between the earliest date of diagnosis and the reporting date to NBCR. Validity was assessed by re-abstraction of medical chart data for 800 randomly selected patients diagnosed in 2013. RESULTS: The completeness of the NBCR was high with a coverage across regions and years (2010-2014) of 99.9%. Of all incident cases reported to the NBCR in 2013 (N = 8654), 98.5% were included within 12 months and differences between health regions were essentially negligible. Coding procedures followed guidelines and were uniformly adhered to. The proportion of missing values was < 5% for most variables and reported information generally had high exact agreement (> 90%). CONCLUSIONS: Completeness of data, comparability and agreement in the NBCR was high. For clinical quality purposes and benchmarking, improved timeliness is warranted. Assessment of validity has resulted in a thorough review of all variables included in the Notification form with clarifications and revision of selected variables.

Sense of coherence is a predictor of survival: A prospective study in women treated for breast cancer.

OBJECTIVE: Sense of coherence (SOC) reflects a person's overall orientation to life. Sense of coherence guides the person in finding and utilizing resources to maintain health and manage stress. Previously, we demonstrated SOC's stability over time among breast cancer (BC) patients, and in the present article, SOC's predictive value for survival is tested. METHODS: A cohort of 487 women underwent surgery for invasive BC and completed preoperatively the SOC-13 within a multicenter trial. Hazard ratios (HRs) were performed to identify significant independent predictors and their association with increase in SOC. RESULTS: Over a median follow-up time of 10 years, patients with a higher SOC had 63% lower risk of BC progression (HR 0.63; 95% CI, 0.11 to 0.85, P .03), 80% lower risk of BC mortality (HR 0.80; 95% CI, 0.38 to 0.96, P .00), and 80% lower risk of all-cause mortality (HR 0.80; 95% CI, 0.47 to 0.93, P .00) than patients with a lower SOC. The mortality risk declined by 2.3% for every 1-unit increase in SOC, both for BC mortality (HR 0.98; 95% CI, 0.96 to 0.99, P .01) and for all-cause mortality (HR 0.98; 95% CI, 0.96 to 0.99, P .00). The risk of progression declined by 1.4% for every 1-unit increase in SOC (HR 0.99; 95% CI, 0.97 to 1.00, P .03). CONCLUSIONS: This study provides evidence of SOC's predictive value for disease progression and BC-caused and all-cause mortality. Sense of coherence provides a complement when designing individual plans that aims to support patients during their treatment.

Waiting times for cancer patients in Sweden: A nationwide population-based study.

AIMS: The reported long waiting times for cancer patients have mostly been related to prognostic outcome and less to patient-related experience to outcome. We assessed waiting times for patients with cancer of the breast, prostate, colon or rectum in Sweden. METHODS: The median time from referral to start of treatment was assessed using data from clinical cancer registers for patients who received curative treatment during 2011, 2012 and 2013. RESULTS: The median overall waiting time in different counties ranged from 7 to 28 days for breast cancer, from 117 to 280 days for prostate cancer, from 27 to 64 days for colon cancer and from 48 to 80 days for rectal cancer. For the entire nation, the median time from referral to start of treatment remained unchanged from 2011 to 2013 for each cancer diagnosis. CONCLUSIONS: Large variations were found in waiting times between different counties in Sweden and between different types of cancer. The long waiting times identified in this study emphasize the need to improve national programmes for more rapid diagnosis and treatment.

Stability of the 13-item sense of coherence (SOC) scale: a longitudinal prospective study in women treated for breast cancer.

PURPOSES: To test the stability of the SOC scale over time and to test the stability of the latent construct in 417 breast cancer patients at the time of diagnosis, after 1 year and in a subsample (n = 80) also 2 and 3 years later. METHODS: The 13-item SOC scale was firstly tested with mean values and ICC over time and secondly explored with cross-sectional factor analysis, separately for two time points (baseline and after 1 year), followed by a longitudinal factor analyses. RESULTS: Our results provide support for the stability over time (ICC 0.68, effect size 0.06). The cross-sectional factor analysis revealed a modified three-factor and a second-order factor model meeting criteria for goodness of fit. The longitudinal modified second-order factor model confirmed the construct stability character of the SOC scale with an acceptable goodness-of-fit criteria; X (2)/df = 2.91; GFI = 0.87; RMSEA = 0.07; CFI = 0.84; AIC = 962.3. The proportion of variance (R (2)) was 0.42. CONCLUSIONS: The SOC scale is stable over time when applied to women with breast cancer. The longitudinal factor analysis gives support of a stable latent construct in the second-order factor model, allowing for merging all items to one scale reflecting the theoretical construct of SOC. Measurement errors between some items challenge future studies on alternative factor structures.

Preoperative MRI of the breast (POMB) influences primary treatment in breast cancer: a prospective, randomized, multicenter study.

BACKGROUND: Breast magnetic resonance imaging (MRI) has shown high sensitivity in determining tumor extent, multifocality, and occult contralateral breast cancer. Low specificity, unnecessary mastectomies, and costs are arguments against MRI. The purpose of this study was to determine whether preoperative breast MRI would affect primary surgical management, reduce reexcision/reoperation procedures, and influence the choice of neoadjuvant treatment in patients with newly diagnosed breast cancer. METHODS: This prospective, randomized, multicenter study included 440 breast cancer patients younger than aged 56 years from three, Swedish, large-volume breast units. Patients were randomly allocated on a 1:1 basis to either preoperative staging with breast MRI (n = 220) or no breast MRI (n = 220) (control group). Treatment planning of all patients was discussed at multidisciplinary team conferences. RESULTS: In patients randomized to the MRI group, who had an observed higher percentage of planned breast-conserving surgery (BCS) compared with the control group, a change from suggested breast conservation to mastectomy occurred in 23 of 153 (15 %) patients. Breast MRI provided additional information in 83 of 220 (38 %) patients, which caused a change in treatment plan in 40 (18 %). The breast reoperation rate was significantly lower in the MRI group: 11 of 220 (5 %) versus 33 of 220 (15 %) in the control group (p < 0.001). The number of mastectomies, axillary reoperations, and the number of patients receiving neoadjuvant chemotherapy after definitive treatment did not differ significantly between the groups. CONCLUSIONS: Preoperative staging with breast MRI in women younger than age 56 years altered the treatment plan in 18 % of the patients. Although a higher MRI-related conversion rate from breast conservation to mastectomy was found, the final numbers of mastectomies did not differ between the two groups. The breast reoperation rate in the MRI group was significantly reduced.

Debate article: Management of breast cancer in patients with pre-existing bilateral breast augmentation-a snapshot of global practice and call for international guidelines.

Breast cancer (BC) is the most common female cancer, and as bilateral breast augmentation (BBA) increases, more women are presenting with BC within an augmented breast. No international guidelines exist on how to manage such a situation, so this group undertook a global survey to provide a snapshot of current surgical practice. The key finding was the variable oncoplastic management of BC after BBA: most surgeons responded that when oncologically safe, breast conservation with implant preservation was appropriate as radiotherapy was not a contra-indication to preserving implants. Immediate symmetrisation could be considered but was not always available. We propose a large multicenter observational study to support the development of international guidelines. This will help patients, healthcare funders, providers, and surgeons to optimize care and reduce inequity of access to appropriate oncoplastic surgery options for the increasing number of women with BBA and BC.

Clinical assessment of breast symmetry and aesthetic outcome: can 3D imaging be the gold standard?

There is a lack of an accurate standardised objective method to assess aesthetic outcome after breast surgery. In this methodological study, we investigated the intra- and inter-observer reproducibility of breast symmetry and volume assessed using three-dimensional surface imaging (3D-SI), evaluated the reproducibility depending on imaging posture, and proposed a new combined volume-shape-symmetry (VSS) parameter. Images were acquired using the VECTRA XT 3D imaging system, and analysed by two observers using VECTRA Analysis Module. Breast symmetry was measured through the root mean square distance. All women had undergone bilateral risk-reducing mastectomy and immediate breast reconstruction. The reproducibility and correlations of breast symmetry and volume measurements were compared using Bland-Altman's plots and tested with Spearman's rank correlation coefficient. 3D surface images of 58 women were analysed (348 symmetry measurements, 696 volume measurements). The intra-observer reproducibility of breast symmetry measurements was substantial-excellent, the inter-observer reproducibility was substantial, and the inter-posture reproducibility was substantial. For measurements of breast volumes, the intra-observer reproducibility was excellent, the inter-observer reproducibility was moderate-substantial, and the inter-posture reproducibility was substantial-excellent. The intra-observer reproducibility of VSS was excellent while the inter-observer reproducibility was substantial for both observers, independent of posture. There were no statistically strong correlations between breast symmetry and volume differences. The intra-observer reproducibility was found to be substantial-excellent for several 3D-SI measurements independent of imaging posture. However, the inter-observer reproducibility was lower than the intra-observer reproducibility, indicating that 3D-SI in its present form is not a great assessment for symmetry.

Breast reconstruction in patients with personal and family history of breast cancer undergoing contralateral prophylactic mastectomy, a 10-year experience.

BACKGROUND: The purpose of this study was to evaluate the clinical course of breast reconstruction in patients with personal and family history of breast cancer undergoing contralateral prophylactic mastectomy (CPM) and elucidate the association between reoperation risk and adjuvant treatment. METHODS: A descriptive retrospective study of a consecutive series of breast cancer patients who underwent CPM with breast reconstruction at Karolinska University Hospital between 1998 and 2008 was performed. Reoperation was chosen as an outcome variable assessing morbidity and thus documented for each patient and for each reconstructed breast. Regression analyses were performed to evaluate the risk of reoperation after bilateral breast reconstruction. RESULTS: Ninety-one patients underwent CPM during the study period. Their mean age at CPM was 45.3 years (SD =9.4). No contralateral breast cancer was diagnosed after CPM during the median follow-up period of 3.9 years. All women, but two, received an implant based breast reconstruction. The majority (n =75, 82%) underwent CPM with concurrent bilateral breast reconstruction. Overall, after bilateral breast reconstruction 45/75 (60%) required at least one reoperation on the CPM side (n =2, 3%), therapeutic mastectomy (TM) side (n =17, 23%) or both sides (n =26, 33%). In the paired analyses, the probability of reoperation was significantly higher after TM reconstruction as compared to CPM (0.57 vs. 0.37, p =0.001). The mean number of reoperations required for completion of TM and CPM reconstruction was 0.84 and 0.49, respectively (p =0.003). Among all potential risk factors, only radiotherapy was associated with reoperation after bilateral breast reconstruction (odds ratio [OR]: 4.2, 95% CI, 1.3 to 13.6, p =0.015). CONCLUSIONS: Breast reconstruction in patients with personal and family history of breast cancer is a complex operation. This study found that the clinical course after bilateral breast reconstruction was predominantly affected by reoperations on the TM side and given radiotherapy was associated with reoperation. Further studies are necessary to examine the possible predictors of unanticipated reoperations in candidates for CPM with breast reconstruction.

Case-based learning in surgery: lessons learned.

BACKGROUND: The aim of the study was to obtain a deepened understanding of the implementation process of case-based learning (CBL) during a surgical semester at the Undergraduate Medical Program at Karolinska Institutet. The objectives are to identify the level of success of the implementation and to identify practical and theoretical implications of importance in connection to the process. METHODS: Based on a qualitative study design, the study explores students' and teachers' perceptions of the educational intervention CBL in context. Five faculty members involved in the entire reform and five students from the second cohort were interviewed 1 year into the implementation phase. Narrative data from the semistructured interviews were coded using a blend of an inductive and deductive approach to derive the coding categories. RESULTS: The results of the study reflect two overarching themes: the importance of a well-functioning implementation process and the misalignment between the student/faculty Teaching Learning Regime and the attributes of CBL. The findings have resulted in a checklist for implementation of CBL in a surgical curriculum. CONCLUSIONS: The implementation of CBL was not satisfactory. Still, exposure of the weaknesses of the implementation process, the misalignment between CBL and the reigning teaching and learning regime, and promotion of the future use of the checklist are key to future successful implementation of CBL in any surgical undergraduate curriculum.

Polyacrylamide gel injections for breast augmentation: management of complications in 106 patients, a multicenter study.

BACKGROUND: Polyacrylamide gel (PAAG) was first manufactured in Ukraine in the late 1980s and introduced as a biomaterial for "breast augmentation without surgery." Since it is prohibited in most countries, PAAG injections are rare nowadays, but their consequences and long-term complications can be crucial. METHODS: We identified 106 patients consecutively operated on for PAAG complications at three teaching Ukrainian hospitals between 1998 and 2009. All relevant sociodemographic, clinical, and treatment characteristics were collected. Forty-five (42%) patients were available for clinical follow-up. RESULTS: The majority (88%) had had bilateral PAAG injections. The mean volume of injected PAAG was 230 ml/breast (range = 50-400). Mean age at injection was 29 years (range = 17-49) and the mean time from the injection to complications was 6.1 years (SD = 4.1). Symptoms preceding debridement were pain in 85 patients (80%), breast hardening in 79 (74%), breast deformity in 77 (73%), lumps in 57 (54%), gel migration in 39 (37%), fistulas in 17 (16%), and gel leakage in 12 (11%). The surgical interventions in 199 breasts included gel evacuation alone in 107 (54%) or in combination with partial mastectomy in 65 (33%), partial mastectomy and partial pectoralis muscle resection in 12 (6%), or subcutaneous mastectomy in 15 (7%). Of the 199 operated breasts, 86 (43%) immediate and 58 (29%) delayed implant-based breast reconstructions were performed. CONCLUSION: Injections of PAAG can cause irreversible damage to the breast necessitating complex debridement procedures, even mastectomy and breast reconstruction. Despite numerous surgical interventions, gel remnants are still found on subsequent breast imaging. Although PAAG is prohibited in many countries, different types of injections with unknown long-term effects are currently being used. Making the public aware of the problems of injectables for breast augmentation is warranted.

Effectiveness of Single vs Multiple Doses of Prophylactic Intravenous Antibiotics in Implant-Based Breast Reconstruction: A Randomized Clinical Trial.

Importance: Multiple-dose antibiotic prophylaxis is widely used to prevent infection after implant-based breast reconstruction despite the lack of high-level evidence regarding its clinical benefit. Objective: To determine whether multiple-dose antibiotic prophylaxis is superior to single-dose antibiotic prophylaxis in preventing surgical site infection (SSI) after implant-based breast reconstruction. Design, Setting, and Participants: This prospective, multicenter, randomized clinical superiority trial was conducted at 7 hospitals (8 departments) in Sweden from April 25, 2013, to October 31, 2018. Eligible participants were women aged 18 years or older who were planned to undergo immediate or delayed implant-based breast reconstruction. Follow-up time was 12 months. Data analysis was performed from May to October 2021. Interventions: Multiple-dose intravenous antibiotic prophylaxis extending over 24 hours following surgery, compared with single-dose intravenous antibiotic. The first-choice drug was cloxacillin (2 g per dose). Clindamycin was used (600 mg per dose) for patients with penicillin allergy. Main Outcomes and Measures: The primary outcome was SSI leading to surgical removal of the implant within 6 months after surgery. Secondary outcomes were the rate of SSIs necessitating readmission and administration of intravenous antibiotics, and clinically suspected SSIs not necessitating readmission but oral antibiotics. Results: A total of 711 women were assessed for eligibility, and 698 were randomized (345 to single-dose and 353 to multiple-dose antibiotics). The median (range) age was 47 (19-78) years for those in the multiple-dose group and 46 (25-76) years for those in the single-dose group. The median (range) body mass index was 23 (18-38) for the single-dose group and 23 (17-37) for the multiple-dose group. Within 6 months of follow-up, 30 patients (4.3%) had their implant removed because of SSI. Readmission for intravenous antibiotics because of SSI occurred in 47 patients (7.0%), and 190 women (27.7%) received oral antibiotics because of clinically suspected SSI. There was no significant difference between the randomization groups for the primary outcome implant removal (odds ratio [OR], 1.26; 95% CI, 0.69-2.65; P = .53), or for the secondary outcomes readmission for intravenous antibiotics (OR, 1.18; 95% CI, 0.65-2.15; P = .58) and prescription of oral antibiotics (OR, 0.72; 95% CI, 0.51-1.02; P = .07). Adverse events associated with antibiotic treatment were more common in the multiple-dose group than in the single-dose group (16.4% [58 patients] vs 10.7% [37 patients]; OR, 1.64; 95% CI, 1.05-2.55; P = .03). Conclusions and Relevance: The findings of this randomized clinical trial suggest that multiple-dose antibiotic prophylaxis is not superior to a single-dose regimen in preventing SSI and implant removal after implant-based breast reconstruction but comes with a higher risk of adverse events associated with antibiotic treatment. Trial Registration: EudraCT 2012-004878-26.

Bilateral prophylactic mastectomy in Swedish women at high risk of breast cancer: a national survey.

BACKGROUND/OBJECTIVE: This study attempted a national inventory of all bilateral prophylactic mastectomies performed in Sweden between 1995 and 2005 in high-risk women without a previous breast malignancy. The primary aim was to investigate the breast cancer incidence after surgery. Secondary aims were to describe the preoperative risk assessment, operation techniques, complications, histopathological findings, and regional differences. METHODS: Geneticists, oncologists and surgeons performing prophylactic breast surgery were asked to identify all women eligible for inclusion in their region. The medical records were reviewed in each region and the data were analyzed centrally. The BOADICEA risk assessment model was used to calculate the number of expected/prevented breast cancers during the follow-up period. RESULTS: A total of 223 women operated on in 8 hospitals were identified. During a mean follow-up of 6.6 years, no primary breast cancer was observed compared with 12 expected cases. However, 1 woman succumbed 9 years post mastectomy to widespread adenocarcinoma of uncertain origin. Median age at operation was 40 years. A total of 58% were BRCA1/2 mutation carriers. All but 3 women underwent breast reconstruction, 208 with implants and 12 with autologous tissue. Four small, unifocal, invasive cancers and 4 ductal carcinoma in situ were found in the mastectomy specimens. The incidence of nonbreast related complications was low (3%). Implant loss due to infection/necrosis occurred in 21 women (10%) but a majority received a new implant later. In total, 64% of the women underwent at least 1unanticipated secondary operation. CONCLUSIONS: Bilateral prophylactic mastectomy is safe and efficacious in reducing future breast cancer in asymptomatic women at high risk. Unanticipated reoperations are common. Given the small number of patients centralization seems justified.

Patient-reported Outcomes and 3-dimensional Surface Imaging after Risk-reducing Mastectomy and Immediate Breast Reconstruction.

The cosmetic results after risk-reducing mastectomy (RRM) and immediate breast reconstruction (IBR) are intended to be long-lasting. Long-term follow-up of the cosmetic outcome can be evaluated subjectively by the women themselves through patient-reported outcome measures such as questionnaires, or by using data from three-dimensional surface imaging (3D-SI) to calculate the volume, shape, and symmetry of the reconstructed breasts as a more objective cosmetic evaluation. The study aim was to evaluate the correspondence between patient-reported measures and 3D-SI measurements. METHODS: Questionnaires (EORTC QLQ-BRECON23 and BIS) were sent to women on average 13 [7-20] years after RRM and IBR. Items were preselected for comparison with 3D measurements of women imaged using the VECTRA XT 3D-imaging system at the long-term follow-up. RESULTS: Questionnaire responses and 3D images of 58 women, 36 without and 22 with previous breast cancer (where 15 also received radiotherapy) before RRM and IBR, were analyzed. Median age at follow-up was 57 [41-73] years. Patient-reported satisfaction with the cosmetic outcome was positive for both groups. 3D measurements indicated more symmetrical cosmetic results for women without previous breast cancer. No statistically significant associations between patient-reported satisfaction and 3D measurements were found. CONCLUSIONS: Satisfaction with the long-term cosmetic outcome after RRM and IBR was, in general, positive when evaluated by the women. 3D-SI could be used as a more objective approach to assess the cosmetic outcome in terms of volume and shape-symmetry; however, it does not directly translate to the patient-reported satisfaction.

Prognostic Risk Assessment and Prediction of Radiotherapy Benefit for Women with Ductal Carcinoma In Situ (DCIS) of the Breast, in a Randomized Clinical Trial (SweDCIS).

Prediction of radiotherapy (RT) benefit after breast-conserving surgery (BCS) for DCIS is crucial. The aim was to validate a biosignature, DCISionRT®, in the SweDCIS randomized trial. Women were randomly assigned to RT or not after BCS, between 1987 and 2000. Tumor blocks were collected, and slides were sent to PreludeDxTM for testing. In 504 women with complete data and negative margins, DCISionRT divided 52% women into Elevated (DS > 3) and 48% in Low (DS ≤ 3) Risk groups. In the Elevated Risk group, RT significantly decreased relative 10-year ipsilateral total recurrence (TotBE) and 10-year ipsilateral invasive recurrence (InvBE) rates, HR 0.32 and HR 0.24, with absolute decreases of 15.5% and 9.3%. In the Low Risk group, there were no significant risk differences observed with radiotherapy. Using a cutoff of DS > 3.0, the test was not predictive for RT benefit (p = 0.093); however, above DS > 2.8 RT benefit was greater for InvBE (interaction p = 0.038). Recurrences at 10 years without radiotherapy increased significantly per 5 DS units (TotBE HR:1.5 and InvBE HR:1.5). Continuous DS was prognostic for TotBE risk although categorical DS did not reach significance. Absolute 10-year TotBE and InvBE risks appear sufficiently different to indicate that DCISionRT can aid physicians in selecting individualized adjuvant DCIS treatment strategies. Further analyses are planned in combined cohorts to increase statistical power.

Eleven-year follow-up of a randomized study of pectoral fascia preservation after mastectomy for early breast cancer.

BACKGROUND: The present study reports results of a randomized trial in which breast cancer patients operated with preserved pectoral fascia compared to removal of the pectoral fascia showed a trend toward an increased risk for chest wall recurrence The aim of the study was to assess whether the different procedural modes had any impact on survival or local control in breast cancer patients followed in the long term. METHOD: The trial included 247 patients with breast cancer who underwent modified radical mastectomy in five Swedish hospitals between 1993 and 1997. The median follow-up time was 11 years. The patients were randomized between removal (n = 122) versus preservation (n = 125) of the pectoral fascia. RESULTS: The breast-cancer-specific survival at 10 years was 73%. Removal or preservation of the pectoral fascia had no significant impact on chest-wall recurrence rate or breast-cancer-specific survival. A total of 18 patients with chest-wall recurrence were seen in the group allocated to pectoral fascia preservation versus a total of 10 in patients allocated to pectoral fascia removal (hazard ratio = 1.8, 95% confidence interval = 0.8-4.0). The majority of the chest-wall recurrences were detected 0-5 years postoperatively. The cumulative chest-wall recurrence rates at 5 and at 10 years were 13 and 15%, respectively, in patients allocated to pectoral fascia preservation and 8 and 9% in patients allocated to pectoral fascia removal. CONCLUSIONS: With long-term follow-up neither the chest wall recurrence rate nor the breast-cancer-specific survival was significantly influenced by the preservation of the pectoral fascia. A trend toward an increased risk for chest wall recurrence was observed in patients with preserved pectoral fascia. A hazard ratio of 1.8 for a chest-wall recurrence in patients with preserved fascia indicates that fascia-sparing mastectomy may negatively affect prognosis.

Is breast cancer the same disease in Asian and Western countries?

UNLABELLED: A mini-symposium was held in Montreal, Canada, at the International Surgical Week for the Breast Surgical International in 2007 addressing the question whether breast cancer is the same disease in Asian and Western countries. Numerous investigators from Asian and Western countries presented the epidemiologic and clinical outcome data of women with breast cancer. Although there are significant similarities, the striking difference is that the peak age for breast cancer is between 40 and 50 years in the Asian countries, whereas the peak age in the Western countries is between 60 and 70 years. Also, the incidence of breast cancer in Asia is rising and is associated with increased mortality. In the West, although the incidence is increasing, the mortality rate is definitely decreasing. Future prospective data collection from Asian and Western countries may provide further interesting epidemiologic and outcome data regarding the outcome of women with breast cancer from Asian and Western countries. BACKGROUND: Whether breast cancer is the same disease in Asian and Western countries was the topic of a 2007 Breast Surgery International symposium at International Surgical Week. METHODS: Participating investigators from China, Taiwan, India, Japan, South Korea, Sweden, Canada, and the United States were asked beforehand to provide data on the epidemiology and treatment outcome of women in their countries. RESULTS: Comparisons of the epidemiologic and clinical outcome data of women with breast cancer showed significant similarities, but the striking difference is that the peak age is between 40 and 50 years in Asian countries, but is between 60 and 70 years in Western countries. The incidence of breast cancer in Asia is rising and is associated with increased mortality. In the West, although the incidence is also increasing, the mortality rate is definitely decreasing. DISCUSSION: Future prospective data collection from Asian and Western countries may provide further interesting epidemiologic and outcome data regarding the outcome of women with breast cancer from Asian and Western countries.

Loss of expression for the Wnt pathway components adenomatous polyposis coli and glycogen synthase kinase 3-beta in parathyroid carcinomas.

The development of parathyroid carcinoma has been associated with inactivating mutations of the Hyperparathyroidism type 2 (HRPT2) gene encoding parafibromin, a member of the human RNA Polymerase II-Associated Factor Complex (hPAF) and functionally linked to the Wingless type (Wnt) pathway. In this study, we characterized the expression of Wnt pathway molecules in parathyroid benign and malignant tumors. Tumors were investigated by immunohistochemistry supplemented with Western blot analyses using monoclonal antibodies. The study comprised 13 tumors from 12 cases of unequivocal parathyroid carcinoma, 18 cases of parathyroid adenoma, as well as non-tumorous parathyroid tissue. Adenomatous polyposis coli (APC) was uniformly expressed in non-tumorous parathyroid tissue and adenomas, but absent in carcinomas from 9 of 12 patients (75%). Expression of glycogen synthase kinase 3-beta (GSK3-beta) was lost in 4/12 carcinomas and in 1/18 adenomas. The loss of APC and GSK3-beta did not lead to augmentation of the Wnt target protein cyclin D1 or the Wnt oncoprotein beta-catenin. Active beta-catenin showed cytoplasmic and nuclear expression in all non-tumorous tissues and tumors. Loss of APC immunoreactivity was significantly associated with parathyroid carcinoma as compared to adenomas (p<0.001), giving a high specificity (100%) and sensitivity (75%) for the detection of parathyroid malignancy. The results suggest the involvement of Wnt-pathway members APC and GSK3-beta in parathyroid carcinoma development. In addition, APC immunohistochemistry could become a useful tool for improved recognition of parathyroid carcinoma together with immunohistochemistry for parafibromin and proliferation index. Furthermore, the involvement of APC related pathways in the disease development opens possibilities to explore therapeutic routes complementary to surgery.

Body image problems in women with and without breast cancer 6-20 years after bilateral risk-reducing surgery - A prospective follow-up study.

PURPOSE: To prospectively follow-up and investigate women's perceptions of the cosmetic outcome of their implant-based breast reconstruction, body image, sexuality, anxiety/depressive symptoms, and health-related quality of life (HRQoL) 6-20 years after bilateral risk-reducing mastectomy (RRM), or complementary RRM after breast cancer diagnosis, due to increased risk of hereditary breast cancer. PATIENTS AND METHODS: Women with and without previous breast cancer diagnosis that underwent RRM between March 1997 and September 2010 were invited (n = 200). We compared 146 (73%) sets of long-term questionnaire responses (e.g., EORTC QLQ-BRR26, Body Image Scale, Sexuality Activity Questionnaire, Hospital Anxiety and Depression Scale, and SF-36) with responses one year after surgery. Women with and without previous breast cancer were compared at the long-term assessment point. RESULTS: The HRQoL and anxiety/depressive symptoms remained unchanged compared with one year after surgery, and there were no between-group differences. The negative impact on body image persisted in both groups for most of the items. 'Sexual discomfort' increased significantly for women with previous breast cancer (p = 0.016). Women with previous breast cancer also reported more problems with 'Disease treatment/surgery related symptoms' (p = 0.006) and 'Sexuality' (p = 0.031) in the EORTC QLQ-BRR26 questionnaire. CONCLUSION: Problems with body image appeared to persist long time post-RRM. No differences in HRQoL were found at the long-term follow-up between women with and without previous breast cancer. The results of this investigation might be of use in improving future counselling before risk-reducing surgery for women in the decision-making process.

Post-mastectomy radiation therapy with or without implant-based reconstruction is safe in terms of clinical target volume coverage and survival - A matched cohort study.

BACKGROUND AND PURPOSE: Patients with breast cancer receiving mastectomy in our institution are offered immediate breast reconstruction (IBR). IBR may have an impact on the optimisation of radiation therapy (RT). Therefore, we aimed to evaluate the clinical target volume (CTV) dose coverage when disregarding the dose received by the breast implant in women treated for breast cancer. Furthermore, to investigate the safety of immediate breast reconstruction (IBR) with an implant (IBR+) in terms of recurrence and survival compared to patients without an implant (IBR-). PATIENTS AND METHODS: This matched-cohort included 128 patients with IBR+ and 252 IBR- patients (controls). The potential confounding effects of tumour stage and treatment were controlled for. For IBR+ patients, the implant volume was excluded from the CTV in the RT planning images, and the RT target coverage (V95%: CTV covered by ≥the 95% isodose) was compared between the IBR+ and IBR- groups. RESULTS: A limited under dosage was observed in patients without lymph-node irradiation; the V95% mean values for the CTV subtracting the implant were 84% and 92%, for IBR+ and IBR- groups, respectively. Median follow-up duration was 5.8 years (0.1-7.5 years). In comparing IBR+ and IBR- groups, no statistically significant differences were found in the incidence of recurrence rate ratios or recurrence free survival (log-rank p = 0.142), overall survival (log-rank p = 0.096), or breast cancer specific survival (log-rank p = 0.147). CONCLUSIONS: Post-mastectomy radiation therapy and implant-based reconstruction lead to minor under dosage of the target, due to the projection of the subcutaneous tissue in the presence of the implant. However, recurrence and survival rates were equally distributed among IBR+ and IBR- patients indicating that the overall treatment protocol used in our institution is safe.