Combining Wire Localization of Clipped Nodes with Sentinel Lymph Node Biopsy After Neoadjuvant Chemotherapy in Node-Positive Breast Cancer: Preliminary Results from a Prospective Study.

BACKGROUND: The ideal technique for lymph node staging for patients with pathologically confirmed node-positive breast cancer at diagnosis and neoadjuvant chemotherapy (NAC) is unclear. OBJECTIVE: The aim of this study was to analyze the feasibility of wire/clip localization and sentinel lymph node biopsy (SLNB) for the axillary staging of these patients. METHODS: We conducted a prospective study in which lymph node staging was performed using wire localization of positive lymph nodes and an SLNB with dual tracer. All patients who presented no metastatic involvement of the sentinel lymph node (SLN) or clip/wire-marked lymph node were spared an axillary lymph node dissection (ALND). The multidisciplinary committee agreed on axillary treatment for patients with lymph node involvement. RESULTS: Forty-two patients met the inclusion criteria. We identified and extirpated the clip/wire-marked node in all patients (100%), with SLNB performed successfully in 95.3% of patients. The SLN and wire-marked node matched in 80% of patients; 73.8% of patients did not undergo ALND. DISCUSSION AND CONCLUSIONS: Several studies have evaluated the efficacy of various procedures for lymph node marking for women with prechemotherapy lymph node involvement. Most of the studies reported high identification rates (> 94.8%), with false negative rates of < 7%. Similarly, our study allows us to conclude that combined axillary marking (clip and SLNB) in patients with metastatic lymph node at diagnosis and NAC offers a high identification rate (100%) and a high correlation between the wire-marked lymph node and the SLN (80%). This procedure has enabled the suppression of ALND for a significant number of patients (73%).

Cosmetic sequelae after oncoplastic breast surgery: long-term results of a prospective study.

BACKGROUND: To analyze risk factors for the cosmetic sequelae of patients treated with oncoplastic procedures and their impact on patient-reported satisfaction. METHODS: Prospective nonrandomized study between 2003 and 2020. Complications and cosmetic sequelae were reported by the surgeon. We employed the Clough classification for oncoplastic procedures (Level 1 and Level 2) and to define the cosmetic sequelae (Type I, Type II and Type III). The assessment of satisfaction and quality of life was performed with the BreastQ™ questionnaire. RESULTS: 429 level 1 and 326 level 2 oncoplastic operations were included. We recorded 89 cosmetic sequelae: 55 deformities (type II), 29 asymmetries (type I), and 5 type III defects. The incidence of cosmetic sequelae at 10 years for levels 1 and 2 oncoplastic procedures was 11.5% and 20.0%, respectively. The level 2 techniques and the postoperative complications increased the risk of cosmetic sequelae. Patients with cosmetic sequelae did not achieve significant improvements in breast satisfaction. CONCLUSIONS: Cosmetic sequelae affect up to 17% of oncoplastic procedures. Most of them appear during the first 5 years. Cosmetic sequelae and their predisposing factors should be part of the shared decision-making process with patients, as well as part of the training programs for breast surgeons.

Single-Incision Approach for Breast-Conserving Surgery: Effectiveness, Complications and Quality of Life.

OBJECTIVE: The aim of this study was to assess the success of tumor resection and its postoperative complications, satisfaction, and quality of life using a single-incision approach for breast-conserving surgery. MATERIALS AND METHODS: This was an observational, prospective study conducted between 2015 and 2018. The study group consisted of patients in whom tumor extirpation and lymph node (LN) staging was performed using a single incision, while the control group consisted of patients who underwent a breast-conserving procedure with independent incisions. All patients were given the preoperative and postoperative module of the Breast-Q™ questionnaire. RESULTS: Overall, 226 patients met the study's inclusion criteria, 152 of whom successfully underwent breast and LN removal using a single-incision approach (98.7% overall success). There were no significant differences in postoperative complications, although there was a greater tendency towards breast seroma in the study group and axillary neuralgia in the control group. Both groups presented a similar rate of breast and axillary salvage surgery. The postoperative Breast-Q™ questionnaire showed that the study group had greater satisfaction with both the breast and the information provided by the surgeon. CONCLUSION: The single-incision approach is as effective as standard surgery, with custom incisions in terms of breast resection, LN staging, and complications. There was greater satisfaction with both the breast and the information provided.

Predictive factors of satisfaction and quality of life after immediate breast reconstruction using the BREAST-Q©.

AIMS AND OBJECTIVES: To analyse quality of life and satisfaction after immediate breast reconstruction due to cancer and its determining factors. BACKGROUND: Studying breast reconstruction is important because of its frequency and variability. In addition to the surgical results, it is necessary to analyse the quality of life and patient satisfaction using a specific tool. DESIGN METHODS: An ambispective design was used (n = 101; α = 0.05; precision = 10%), studying anthropometric, sociocultural data, Fagerström test and the BREAST-Q© questionnaire. A logistic regression analysis was performed to identify variables associated with quality of life and satisfaction. RESULTS: Mean age of the patients on diagnosis was 44.87 ± 8.5 years. Forty-one of the patients were carried out a skin-sparing mastectomy (42.7%). Immediate reconstruction was performed with implant in 73 (74.5%). The domains on the BREAST-Q© for quality of life with the lowest scores were physical well-being chest (74) and sexual well-being (61.5). The satisfaction domain with the lowest score was with the breast (59). The variables associated with the worst quality of life in the physical well-being chest domain were the skin-sparing mastectomy (OR, 4.2; 95% confidence interval (CI), 1.2-14.1) and lymphedema (OR, 12.9; 95% CI, 1.0-159.9). Antibody treatment was associated with a worse score on the psychosocial well-being domain (OR, 4.25; 95% CI, 1.0-18.0) and sexual well-being domain (OR, 7.34; 95% CI, 0.9-54.6). Satisfaction was associated with nicotine dependence on the breast and outcome scale. The higher the dependence on nicotine, the greater the dissatisfaction with the breasts (OR, 2.41; 95% CI, 1.1-5.3) and with the result (OR, 2.45; 95% CI, 1.0-5.9). CONCLUSIONS: The type of treatment and lymphedema modify the patients' quality of life. Nicotine dependence is associated with lower satisfaction with the breast and with the outcome. RELEVANCE TO CLINICAL PRACTICE: This study suggests the need for multidisciplinary attention during the first year of adjuvant treatment despite the benefits of immediate reconstruction. It shows the need for preoperative assessment of the level of nicotine dependence, anxiety and depression of smoking patients before preoperative counselling.

The role of oncoplastic breast reduction in the conservative management of breast cancer: Complications, survival, and quality of life.

BACKGROUND AND OBJECTIVES: Reduction Mammaplasty (RM) in breast cancer allows mammary remodeling after wide excisions. We aimed to analyze the complications, survival, and quality of life after RM. METHODS: Retrospective study of women who underwent a surgical intervention for breast cancer between 2000 and 2016. Patients were divided into two groups: RM and tumorectomy. Postoperative complications, survival and quality of life were assessed using the Breast-Q questionnaire. RESULTS: A total of 801 patients were evaluated, with a mean follow up of 84 months. RM patients experienced a longer operating time and hospital stay, and a higher proportion of tissue necrosis compared to tumorectomy patients (P < 0.001). No significant differences were observed regarding rate of re-excision or rate of mastectomy, but the recurrence rate at 10 years was higher for RM patients (P < 0.03). Patients who underwent RM reported optimal satisfaction with the breast and a good quality of life. CONCLUSIONS: RM is a useful approach in breast cancer surgery, with a low rate of re-excision and mastectomy. Overall survival at 10 years is similar to that associated with tumorectomy, though with a higher rate of local recurrence. Patient satisfaction and quality of life appears to be good one year after radiotherapy.

Treatment of the axila in breast cancer surgery: Systematic review of its impact on survival. / Estado actual del tratamiento de la axila en la cirugía primaria del cáncer de mama: Revisión sistemática de su impacto en la supervivencia.

Sentinel lymph node biopsy and ACOSOG-Z0011 criteria have modified axillary treatment in breast cancer surgery. We performed a systematic review of studies assessing the impact of axillary treatment on survival. The search showed 6891 potentially eligible items. Of them, 23 clinical trials and 12 meta-analyses published between 1980 and 2017 met the study criteria. The review revealed that axillary lymph node dissection (ALND) can be omitted in patients pN0 and pN1mic, without compromising survival. In patients pN1 it is proposed not to treat the axilla or replace ALND for axillary radiotherapy. The main limitations of this study are the inclusion of old tests that do not use therapeutic targets and lack of risk categorization of relapse. In conclusion, axillary treatment can be avoided in patients without metastatic involvement or micrometastases in the sentinel lymph node. However, there is no evidence to make a recommendation of axillary treatment in N1 patients, so individualized analysis of patient risk factors is needed.

Rotational flaps in oncologic breast surgery. Anatomical and technical considerations. / Colgajos por rotación en la cirugía oncológica de la mama. Fundamentos anatómicos y técnicos para su planificación quirúrgica.

Local flaps are a group of surgical procedures that can solve the thoracic closure of large defects after breast cancer surgery with low morbidity. Its use in skin necrosis complications after conservative surgery or skin sparing mastectomies facilitates the initiation of adjuvant treatments and reduces delays in this patient group. This article describes the anatomical basis for the planning of thoracic and abdominal local flaps. Also, the application of these local flaps for closing large defects in the chest and selective flaps for skin coverage by necrosis in breast conserving surgery.

Axillary radiotherapy in conservative surgery for early-stage breast cancer (stage I and II). / Radioterapia axilar en la cirugía conservadora del cáncer de mama en estadio temprano (estadio I y II).

INTRODUCTION: Several clinical studies analyze axillary treatment in women with early-stage breast cancer because of changes in the indication for axillary lymph node dissection. The aim of the study is to analyze the impact of axillary radiotherapy in disease-free and overall survival in women with early breast cancer treated with lumpectomy. METHODS: Retrospective study in women with initial stages of breast carcinoma treated by lumpectomy. A comparative analysis of high-risk women with axillary lymph node involvement who received axillary radiotherapy with the group of women with low risk without radiotherapy was performed. Logistic regression was used to determine factors influencing survival and lymphedema onset. RESULTS: A total of 541 women were included in the study: 384 patients (71%) without axillary lymph node involvement and 157 women (29%) with 1-3 axillary lymph node involvement. Patients with axillary radiotherapy had a higher number of metastatic lymph node compared to non-irradiated (1.6±0.7 vs. 1.4±0.6, P=.02). The group of women with axillary lymph node involvement and radiotherapy showed an overall and disease-free survival at 10 years similar to that obtained in patients without irradiation (89.7% and 77.2%, respectively). 3 lymph nodes involved multiplied by more than 7 times the risk of death (HR=7.20; 95% CI: 1.36 to 38.12). The multivariate analysis showed axillary lymph node dissection as the only variable associated with the development of lymphedema. CONCLUSION: The incidence of axillary relapse on stage I and II breast cancer is rare. In these patients axillary radiotherapy does not improve overall survival, but contributes to regional control in those patients with risk factors.

Cosmetic sequelae after oncoplastic surgery of the breast. Classification and factors for prevention.

Oncoplastic surgery is an essential tool in the surgical approach to women with breast cancer. These techniques are not absolute guarantee for a good cosmetic result and therefore some patients will have cosmetic sequelae secondary to poor surgical planning, the effects of adjuvant treatments or the need for resection greater than originally planned. The high frequency of these cosmetic sequelae in oncology practice makes it necessary to classify them for optimal surgical planning. The aim of this paper is to present a classification of cosmetic sequelae after oncoplastic procedures to identify those factors that are crucial to its prevention. This classification contains 4 groups: breast contour deformities, asymmetries, alterations in nipple-aréola complex (NAC) and defects in the three dimensional structure of the breast. A significant group of these sequelae (asymmetries and deformities) are associated with breast irradiation and need an accurate information process with patients to set realistic expectations about cosmetic results. Finally, there is another group of sequelae (NAC disorders and three-dimensional structure) that are related to poor planning and deficiencies in surgical approach, therfore specific training is essential for learning these surgical techniques.

Evaluation of the efficacy and concordance of indocianine color green angiography in oncoplastic and reconstructive breast surgery. Preliminary results of the gBREAST-22 prospective study.

INTRODUCTION: During oncoplastic procedures, the vascularization and perfusion of the skin flaps is modified, thus increasing the possibility of skin necrosis. The objective of this study is to evaluate the effectiveness of indocyanine color green angiography (ICG-A) to determine intraoperative skin necrosis after oncoplastic surgery or skin-sparing or nipple-skin sparing mastectomy (NSSM). PATIENTS AND METHOD: Prospective observational study to evaluate the sensitivity, specificity and positive and negative predictive values ​​of the ICG-A in women with high-risk breast cancer. RESULTS: 98 women and 156 breasts were included in the study. A total of 20 women (20.4%) presented an image of ischemia in the ICG-A. 21 women (21.4%) presented ischemic events in the postoperative period, 71.4% of these events had been detected in the third ICG-A. Three of these patients (3.1%) presented a serious complication that required reintervention. The sensitivity and specificity of the ICG-A was 71.4% and 93.5%, respectively. CONCLUSIONS: ICG-A has high specificity and negative predictive value for detecting areas of low perfusion. In breast units with highly complex surgery, it can be useful to plan extreme surgeries and identify skin areas of low perfusion.

Local Flaps to Cover Skin Necrosis after Skin-sparing Mastectomy and Prepectoral Reconstruction from PreQ-20 Trial.

Background: In recent years, mastectomy has increasingly been indicated for women at high risk and those with breast cancer. Prepectoral reconstruction with polyurethane implant is an option for these patients. Nevertheless, this procedure can become complicated with exposure of the implant. The aim of this article is to describe the feasibility of local flaps to treat skin necrosis and dehiscence after prepectoral reconstruction and its impact on implant loss. Methods: This study includes the women who met the inclusion/exclusion criteria of the PreQ-20 protocol (12), which assessed patients with exposed implant who required a local flap for its coverage. Three types of flaps were used: thoracoepigastric, lateral thoracic, and batwing. Results: The study included 226 skin-sparing mastectomies and immediate reconstruction using prepectoral implants (52.7% bilateral mastectomies). Some 20.9% of the patients showed complications, with wound dehiscence the most frequent. Thirteen local flaps to cover the implant were performed. All flaps presented appropriate perfusion; however, the implant cover failed in six patients (46.2%). Conclusions: The use of local flaps can be a low-morbidity option for preventing implant loss when skin dehiscence or necrosis occurs and delays in oncology treatments.

Our house believes that: The clipped lymph node is the true sentinel node after neoadjuvant chemotherapy in N+ patients.

Axillary staging is an important prognostic factor in breast cancer, being sentinel lymph node biopsy (SLNB) the gold standard staging method in early stages. However, in clinically node positive (cN+) patients who converted to clinically node-negative (cN0) after primary systemic therapy (PST) the axillary staging method during surgery remains controversial. There are at least three validated methods: SLNB, targeted axillary dissection (TAD) and marking axillary nodes with radioactive iodine seeds (MARI) procedure. Our house believe that the biopsied and clipped lymph node could predict response to systemic treatment.

Lymph node staging after primary systemic therapy in women with breast cancer and lymph node involvement at diagnosis.

OBJECTIVE: The main objective of this study is to analyze the efficacy of combined axillary marking (lymph node clipping and sentinel lymph node biopsy (SLNB)) for axillary staging in patients with primary systemic treatment (PST) and pathologically confirmed node-positive breast cancer at diagnosis. The secondary objective is to determine the impact of lymph node marking in the suppression of axillary lymph node dissection (ALND) in the study group. METHODS: We conducted a prospective study in which lymph node staging was performed using wire localization of positive lymph nodes and a SLNB with dual tracer. All patients who presented no metastatic involvement of the sentinel lymph node (SLN) or clip/wire-marked lymph node were spared an ALND. The multidisciplinary committee agreed on axillary treatment for patients with lymph node involvement. RESULTS: Eighty one patients met the inclusion criteria. We identified and extirpated the clip/ wire-marked node in 80 of 81 patients (98.8%), with SLNB performed successfully in 88,9% of patients. The SLN and wire-marked node matched in 78.9% of patients; 76.2% of patients did not undergo ALND. CONCLUSIONS: The combined axillary marking (clip and SLNB) in patients with metastatic lymph node at diagnosis and PST offers a high identification rate (98.8%) and a high correlation between the wire-marked lymph node and the SLN (78.9%). This procedure has enabled the suppression of ALND in 76.2% of patients.

Safety and Quality of Life in Women with Immediate Reconstruction with Polyurethane Implants after Neoadjuvant Chemotherapy: Outcomes from The Preq-20 Trial.

INTRODUCTION: Various studies have evaluated the impact of neoadjuvant chemotherapy (NAC) on the complications of breast cancer surgery, most of which were retrospective and did not assess the variables related to postoperative risk factors. The aim of this study is to analyse the safety and satisfaction of women included in the PreQ-20 trial who underwent NAC and who underwent mastectomy and immediate reconstruction with prepectoral polyurethane implants. MATERIAL AND METHODS: The patients included in the study belong to the prospective study PreQ-20. The study group consisted of patients who underwent immediate reconstruction after primary systemic therapy. The control groups consisted of patients with immediate reconstruction and adjuvant chemotherapy (control group 1) and patients with an infiltrating carcinoma or in situ ductal carcinoma who did not require chemotherapy (control group 2). RESULTS: The study included 157 women, 58 (36.9%) of whom underwent primary systemic therapy. The indication for genetic study was significantly greater for the study group (87.9%) than for control groups 1 (49.1%) or 2 (30.4%). Seventy-two (45.9%) of the patients underwent bilateral mastectomy (BM), a procedure that was performed significantly more frequently in the study group (69%) than in control groups 1 (30.2%) or 2 (34.8%). The incidence rate for BM after complete pathologic response was 78%. There were no statistically significant differences in the number of complications between the groups. Implant loss was significantly more frequent in control group 1 (13.2%) than in the study group (3.4%) and control group 2 (2.2%). CONCLUSIONS: Mastectomy with prepectoral polyurethane implant reconstruction in patients with neoadjuvant chemotherapy presented a similar incidence of complications compared with patients who underwent primary surgery. There is a high rate of BM in women with NAC.

Locoregional relapse after sparing mastectomies and immediate reconstruction in women with breast cancer.

INTRODUCTION: In recent years, cultural changes in today's society and improved risk assessment have increased the indication for mastectomies in women with breast cancer. Various studies have confirmed the oncological safety of sparing mastectomies and immediate reconstruction. The objective of this study is to analyze the incidence of locoregional relapses of this procedure and its impact on reconstruction and overall survival. PATIENTS AND METHODS: Prospective study of patients with breast carcinoma who underwent a sparing mastectomy and immediate reconstruction. Locoregional relapses and their treatment and their impact on survival were analyzed. RESULTS: The study group is made up of 271 women with breast carcinoma treated with a skin-sparing mastectomy and immediate reconstruction. The mean follow-up was 7.98 years and during the same 18 locoregional relapses (6.6%) were diagnosed: 72.2% in the mastectomy flap and 27.8% lymph node. There were no significant differences in the pathological characteristics of the primary tumor between patients with and without locoregional relapse, although the percentage of women with hormone-sensitive tumors was higher in the group without relapse. Patients with lymph node relapse had larger tumors (80% T2-T3) and 60% had axillary metastases at diagnosis, compared to 7.7% of women with skin relapse (p = 0.047). All patients operated on for locoregional relapse preserved their reconstruction. The incidence of metastases and deaths was significantly higher in patients with a relapse, causing a non-significant decrease in overall survival. CONCLUSION: Locoregional relapses are a rare event in women with a sparing mastectomy and immediate reconstruction. Most patients with locoregional relapse can preserve their initial reconstruction through local resection of the tumor and adjuvant and / or neoadjuvant therapies.