Comparing morbidity rates between wise pattern and standard horizontal elliptical mastectomy incisions in patients undergoing immediate breast reconstruction.

BACKGROUND: Breast cancer patients with ptotic breasts pursuing mastectomy with immediate reconstruction can present challenges. A wise pattern (inverted-T) mastectomy incision (WPM) has been suggested as an alternative to the standard horizontal elliptical mastectomy (EM) to reduce redundant skin and correct ptosis. Herein, we sought to examine the differences in morbidity between the two techniques. METHODS: We performed a retrospective review of women undergoing mastectomy with immediate reconstruction at our institution from June 2007 to January 2016. We compared those undergoing WPM to a control population undergoing EM. Statistical analysis was performed evaluating clinical, pathological, and surgical outcome variables according to patient and per breast. All tests were two-sided with alpha level set at 0.05 for statistical significance. RESULTS: A total of 241 women underwent mastectomy and reconstruction in 421 breasts; 78/241 (32%) had WPM (149 breasts), 163/241 (68%) had EM (272 breasts). Both groups were similar in age, smoking status, diabetes, race, tumor type, and pathologic stage (all P > 0.07). Skin flap necrosis was the most frequently encountered complication, occurring in 58/149 (38.9%) of WPM breasts and in 24/272 (8.9%) of EM breasts (P < 0.0001). There was no difference in the need for revisional procedures between the groups (WPM: 24.1% vs EM: 17.6%, P = 0.207). CONCLUSION: Patients should be counseled WPM is associated with higher rates of skin flap necrosis. However, this does not translate into higher rates of revisional procedures or return to OR.

The Influence of Breast Density on Preoperative MRI Findings and Outcome in Patients with a Known Diagnosis of Breast Cancer.

BACKGROUND: The role of breast density as an indication for preoperative breast magnetic resonance imaging (MRI) for surgical planning in women with breast cancer is unknown. METHODS: We retrospectively reviewed breast cancer patients diagnosed from 2007 to 2011 who underwent preoperative MRI. We obtained clinical and pathological data and grouped patients by mammographic breast density, with Breast Imaging Reporting and Data System (BI-RADS) density A and B considered low density, and C and D considered high density. We analyzed local recurrence rates by breast density. RESULTS: Among 683 patients, 66.6% had high breast density. We noted MRI abnormalities in the ipsilateral breast in 41.8% high-density and 30.7% low-density breasts, while contralateral abnormalities were noted in 24.9% high-density and 13.8% low-density breasts. Biopsy was recommended for MRI findings in a similar number of patients regardless of density cohort. While more abnormalities were found in high-density breasts, the rate of additional cancer found was not significantly different (ipsilateral: 32 vs. 23%; contralateral: 6.2 vs. 3.2%) for high-and low-density patients, respectively (both p > 0.15). With a median follow-up of 89 months, and similar rates of adjuvant systemic and radiation therapy, no difference in local recurrence rates existed when stratified according to density classification (p > 0.53). CONCLUSION: While more abnormalities were identified on MRI in dense breasts, there was no statistically significant difference in the number of cancers identified or in recurrence rates. These findings question the routine use of preoperative breast MRI in women with newly diagnosed breast cancer based solely on breast density.

Trends in Sexual Function After Breast Cancer Surgery.

PURPOSE: Sexual dysfunction is assumed to be common, but understudied, in breast cancer patients. Herein, we use the validated female sexual functioning index (FSFI) to evaluate changes in female sexual function after breast cancer surgery. METHODS: The FSFI assesses sexual function in six domains (desire, arousal, lubrication, orgasm, satisfaction, pain) on a 36-point scale, with scores >26.6 indicating better sexual function. We identified 226 women with unilateral breast cancer undergoing surgery at our institution from June 2010-January 2015. All completed the FSFI preoperatively and at a median of 13 months postoperatively. We quantified declines in FSFI scores and considered p-values <0.05 statistically significant. RESULTS: Overall, 119 women had breast-conserving surgery (BCS), 40 had unilateral mastectomy (UM), and 67 had UM plus contralateral prophylactic mastectomy (CPM). All women had similar baseline FSFI scores (medians: BCS, 26.3; UM, 25.2; UM+CPM, 23.7; p = 0.23). At follow-up, sexual function had declined significantly in BCS (23.5; p < 0.001) and UM (17.4; p = 0.010), but was unchanged in UM+CPM (22.8; p = 0.74) women. Interestingly, all women maintained their desire for sex (p = 0.17). BCS and UM women demonstrated significant declines in all other subscale domains (all p < 0.045). UM+CPM women demonstrated no decline in any subscale domain, yet did not exhibit superior sexual function to those having UM or BCS (medians: BCS, 23.5; UM, 17.4; UM+CPM, 22.8; p = 0.21). CONCLUSIONS: Baseline sexual dysfunction exists in women diagnosed with breast cancer. Surgery negatively impacts sexual function. Patients who choose mastectomy do not exhibit superior sexual function over those having BCS at 13 months following surgery.

Symptomatic Axillary Seroma after Sentinel Lymph Node Biopsy: Incidence and Treatment.

BACKGROUND: Postoperative seroma is a nuisance for patients and surgeons. Few studies investigate predisposing factors for axillary seroma after sentinel lymph node biopsy (SLNB). We sought to quantitate the risk of symptomatic seroma and characterize interventions. METHODS: We performed a retrospective review of 667 women undergoing breast-conserving surgery and SLNB at our institution between July 2007 and January 2015. Surgeons dissected sharply or with standard electrocautery. We correlated patient and tumor characteristics with symptomatic seroma using logistic regression models for univariate and multivariate predictors. All statistical tests were two sided, with p < 0.05 considered significant. RESULTS: Overall, 127 (19 %) of 667 women had axillary seromas and 98 (77 %) of 127 required further intervention for symptom relief. Seroma patients were similar in age, BMI, race, tumor type, T and N stage, and number of nodes removed as those without (all p > 0.07). Seroma rates did not vary according to surgeon, nodal mapping technique, or axillary closure technique (p = 0.8789). Multivariate analysis identified diabetes, smoking, and SSI as predictors of symptomatic axillary seroma with odds ratio of 1.97, 1.98, and 37.19 (all p < 0.017), respectively. Among the 98 of 127 patients with seroma, most (81 of 98, 83 %) resolved with a mean of 1.3 aspirations. The remainder resolved after axillary drain (13 of 98, 13 %) or additional surgery (4 of 98, 4 %). CONCLUSIONS: Symptomatic axillary seroma occurs in 14 % patients undergoing breast-conserving surgery with SLNB and is not influenced by tumor, nodal mapping, or surgeon characteristics. Management infrequently requires more than simple aspiration. Drain placement at initial surgery may be considered in smokers or patients with diabetes.

Is postexcision, preradiation mammogram necessary in patients after breast-conserving surgery with negative margins.

BACKGROUND: In women with breast cancer and calcifications, controversy exists over the need for postexcision/lumpectomy, preradiation mammogram (PEM) after breast-conserving surgery (BCS). Further, the need for excision of remaining or suspicious calcifications after PEM when surgical margins are negative is unclear. We sought to characterize the utility of PEM hypothesizing that its value in directing the need for additional surgery is minimized after achieving negative surgical margins. METHODS: We identified 524 women with breast cancer and calcifications treated with BCS with negative margins between 1996 and 2011. RESULTS: PEM was performed in 112 of 524 (21 %) women, with residual calcifications identified in 10 of 112 (9 %); of these, 2 of 112 (1.8 %) had residual disease. Local recurrence occurred in 4 of 112 (4 %) patients, none of whom had residual calcifications identified on PEM. The remaining 412 of 524 (79 %) women did not have PEM but had a postradiation mammogram 6 to 12 months after treatment identifying calcifications in 19 (5 %) women. Tissue diagnosis was benign in 14 women and was not pursued in the remaining 5. Local recurrence occurred in 13 (3 %) patients, none of whom had calcifications on the new post radiation baseline mammogram. CONCLUSIONS: Mammographically apparent calcifications representing residual disease occur infrequently after BCS with negative margins. The value of PEM may be to document the new radiographic baseline but should not be required to ensure adequate surgery. Radiation plays an integral role in sterilization of the remaining breast tissue after BCS.

Which eligible breast conservation patients choose mastectomy in the setting of newly diagnosed breast cancer?

PURPOSE: Breast conserving therapy (BCT) and mastectomy offer equivalent survival for women with newly diagnosed breast cancer (BrCa). Despite this, many women eligible for BCT elect mastectomy. Herein, we identify factors associated with choosing ipsilateral mastectomy instead of BCT when mastectomy is not required. METHODS: Between July 2007 and June 2010, 520 women with BrCa were treated by a single surgeon who prospectively documented patient eligibility for BCT. For patients who did not require mastectomy (n=392), we evaluated associations between treatment choice and potential predictors using odds ratios (ORs) obtained from multivariable logistic regression models. P values≤0.0029 were significant after correction for multiple testing. RESULTS: Of 392 women eligible for BCT, 106 (27%) chose mastectomy and 286 (73%) chose BCT. Multivariate analysis found an increased likelihood of electing mastectomy over BCT for patients with no comorbidities (OR 5.4; P<0.001) and those with previous mastectomy (OR 23.2; P<0.001). MRI and biopsy findings were associated with treatment choice because patients who had a second-site biopsy positive for cancer in the same quadrant as the index tumor were more likely to elect mastectomy compared with patients with no additional MRI abnormalities (OR 4.3; P=0.0027). No association existed on multivariate analysis between choice of mastectomy and patient age, family history, or tumor stage. CONCLUSIONS: One in four eligible BCT patients chooses mastectomy. Factors independently associated with choosing mastectomy over BCT include findings of second-site biopsy, previous mastectomy, and absence of comorbidities but not primary tumor characteristics. Further study into a patient's choice for mastectomy is warranted.

Breast surgery outcomes as quality measures according to the NSQIP database.

BACKGROUND: The National Surgical Quality Improvement Program (NSQIP) is a risk-adjusted database designed to benchmark quality initiatives. NSQIP captures uniform morbidity variables for all operations and calculates expected morbidity probabilities. Given the frequent need for reoperation following breast-conserving surgery (BCS) and mastectomy, we hypothesized that NSQIP may inaccurately reflect surgical morbidity after breast cancer operations. METHODS: Using the 2008 NSQIP database, we identified 24,447 breast surgery patients. We calculated the observed versus expected (O/E) morbidity ratios, compared them to other general surgery procedures, and analyzed the O/E morbidity ratios among benign and malignant breast diagnoses. RESULTS: The NSQIP database shows that breast surgery has an O/E morbidity ratio of 3.11, which is higher than other general surgery procedures. Additionally, breast operations for malignancy have higher O/E morbidity ratios (3.22) than those performed for benign disease (2.59). Analysis of malignant patients by CPT code revealed that BCS patients had an O/E morbidity ratio of 7.75 and attributed 89 % of morbidity to reoperation, whereas mastectomy patients had an O/E morbidity ratio of only 1.7. Elimination of the reoperation variable from morbidity calculations in breast surgery reduces the O/E morbidity ratio to less than expected in all breast procedures. DISCUSSION: Breast surgery has a higher O/E morbidity ratio than other general surgery procedures. Reoperations are expected in BCS for positive margins and in mastectomy for completion ALND. Breast surgeons should advocate for benchmarking by surgical site-specific metrics, because current NSQIP criteria may negatively affect the quality assessment of high-volume breast centers.

Value of Axillary Ultrasound after Negative Axillary MRI for Evaluating Nodal Status in High-Risk Breast Cancer.

BACKGROUND: It is assumed that axillary ultrasound (AxUS) is the best method for axillary nodal evaluation in newly diagnosed breast cancer patients. However, few have evaluated the efficacy of preoperative axillary MRI. We compared the statistical accuracy of AxUS and MRI in detecting nodal metastases among breast cancer patients who were selected for neoadjuvant chemotherapy. STUDY DESIGN: We retrospectively analyzed 219 breast cancer patients undergoing neoadjuvant chemotherapy from 2007 to 2015, all of whom had AxUS and breast MRI before chemotherapy. Two breast radiologists, blinded to clinical, pathologic, and AxUS findings, re-reviewed all breast MRIs, specifically focusing on axillary nodal characteristics. We correlated clinico-pathologic characteristics, AxUS, and MRI findings, and quantified predictive values of both imaging modalities. RESULTS: Overall, 101 of 219 (47%) patients had T2 tumors. The most common abnormal nodal finding was size >10 mm. Axillary ultrasound and MRI agreed on nodal status in 192 of 219 patients (87.6%). When correlated with pre-chemotherapy needle biopsy in 129 patients, AxUS and axillary MRI performed similarly (sensitivity of 99.1% vs 97.4% and specificity 15.4% vs 15.4%, respectively). Only 4 of 129 (3.1%) patients had a negative MRI and positive AxUS; 3 of 4 of these patients (75%) had a positive biopsy and 2 of 3 had positive lymph nodes on final pathology, therefore suggesting MRI missed clinically significant disease in only 2 of 129 (1.5%) patients. CONCLUSIONS: In a high-risk patient population, AxUS and MRI have similar statistical profiles in evaluating axillary nodal status. Routine use of AxUS after a normal axillary MRI is not warranted.

Trends in risk reduction practices for the prevention of lymphedema in the first 12 months after breast cancer surgery.

BACKGROUND: Lymphedema is a feared complication of breast cancer surgery. We evaluated the trends in lymphedema development, patient worry, and risk reduction behaviors. STUDY DESIGN: We prospectively enrolled 120 women undergoing sentinel node biopsy (SLNB) or axillary node dissection (ALND) for breast cancer and assessed lymphedema by upper extremity volume preoperatively and at 6 and 12 months postoperatively. We defined lymphedema as a >10% volume change from baseline relative to the contralateral upper extremity. Patients completed a validated instrument evaluating lymphedema worry and risk reducing behaviors. Associations were determined by Fisher's exact and signed rank tests. RESULTS: At 6 months, lymphedema was similar between ALND and SLNB patients (p = 0.22), but was higher in ALND women at 12 months (19% vs 3%, p = 0.005). A clear relationship exists between relative change in upper extremity volume at 6 and 12 months (Kendall tau coefficient 0.504, p < 0.001). Among the women with 0 to 9% volume change at 6 months, 22% had progressive swelling, and 18% resolved their volume changes at 12 months. Overall, 75% of ALND and 50% of SLNB patients had persistent worry about lymphedema at follow-up, and no difference existed in the number of risk reducing behaviors practiced among the 2 groups (p > 0.34). CONCLUSIONS: Upper extremity volumes fluctuate, and there is a period of latency before development of lymphedema. Despite the low risk of lymphedema after SLNB, most women worry about lymphedema and practice risk reducing behaviors. Additional study into early upper extremity volume changes is warranted to allay the fears of most women and better predict which women will progress to lymphedema.