Incidence and characteristics of chronic postsurgical pain at 6 months after total mastectomy under pectoserratus and interpectoral plane block combined with general anesthesia: a prospective cohort study.

INTRODUCTION: Chronic postsurgical pain (CPSP) occurs in 20%-30% of patients who undergo total mastectomy (TM) performed under general anesthesia alone and significantly affects the quality of life. Pectoserratus and interpectoral plane block have been reportedly combined with general anesthesia to control immediate postoperative pain after TM. Our prospective cohort study aimed to evaluate the incidence of CPSP after TM when pectoserratus and interpectoral plane block were combined with general anesthesia. METHODS: We recruited adult women scheduled to undergo TM for breast cancer. Patients planned for TM with flap surgery, those who underwent breast surgery in the past 5 years, or those presenting with residual chronic pain after prior breast surgery were excluded. After general anesthesia induction, an anesthesiologist performed pectoserratus and interpectoral plane block with a ropivacaine (3.75 mg/mL) and clonidine (3.75 µg/mL) in 40 mL of 0.9% sodium chloride. The primary endpoint was the occurrence of CPSP-defined as pain with a Numeric Rating Scale Score of ≥3, either at the breast surgical site and/or at axilla, without other identifiable causes-evaluated during a pain medicine consultation at 6 months post TM. RESULTS: Overall, 43/164 study participants had CPSP (26.2%; 95% CI: 19.7 to 33.6); of these, 23 had neuropathic type of pain (53.5%), 19 had nociceptive (44.2%), and 1 had mixed (2.3%) type of pain. CONCLUSION: Although postoperative analgesia has significantly improved in the last decade, there is still need for improvement to reduce CPSP after oncologic breast surgery. TRIAL REGISTRATION NUMBER: NCT03023007.

Seroma after Simple Mastectomy in Breast Cancer-The Role of CD4+ T Helper Cells and the Evidence as a Possible Specific Immune Process.

Seroma development after breast cancer surgery is the most common postoperative complication seen after mastectomy but neither its origin nor its cellular composition is known. To investigate the assumption of immunological significance, one of the first aims of this pilot study is to describe the cellular content of collected seroma fluids and its corresponding serum in patients with simple mastectomy after needle aspiration, as well as the serum of healthy controls. The content of red blood cells (RBC) was measured by haemato-counter analyses, and the lymphocyte identification/quantification was conducted by flow cytometry analyses in seroma fluid (SFl) and the sera of patients (PBp) as well as controls (PBc). Significantly lower numbers of RBCs were measured in SFl. Cytotoxic T cells are significantly reduced in SFl, whereas T helper (Th) cells are significantly enriched compared to PBp. Significantly higher numbers of Th2 cells were found in SFl and PBp compared to PBc. The exact same pattern is seen when analyzing the Th17 subgroup. In conclusion, in contrast to healthy controls, significantly higher Th2 and Th17 cell subgroup-mediated immune responses were measured in seroma formations and were further confirmed in the peripheral blood of breast cancer (including DCIS) patients after simple mastectomy. This could lead to the assumption of a possible immunological cause for the origin of a seroma.

Health-related quality of life following breast reconstruction compared to total mastectomy and breast-conserving surgery among breast cancer survivors: a systematic review and meta-analysis.

The present review evaluated health-related quality of life (HR-QoL) outcomes in surgical breast cancer survivors who received breast reconstruction (BR), breast-conservation surgery (BCS) or mastectomy (M), and whether HR-QoL domains across generic and disease/surgery-specific questionnaires are compatible. Six electronic databases were searched for appropriate observational studies. Standardized scores for different HR-QoL domains in the BR, BCS, and M treatment groups were extracted from each study for the purpose of a meta-analysis. Using Stata version 14.0, a random-effects meta-analysis model was adopted for each outcome variable to estimate the effect size, 95% CI-confidence intervals, and statistical significance. Sixteen of the 18 eligible studies with BR (n = 1474) and BCS (n = 2612) or M (n = 1458) groups were included in the meta-analysis. The BR group exhibited a better physical health (k = 12; 0.1, 95% CI 0.04, 0.24) and body image (k = 12; 0.50, 95% CI 0.10, 0.89) than the M group. However, the two groups exhibited comparable social health (k = 13; 0.1, 95% CI -0.07, 0.37), emotional health (k = 13; -0.08, 95% CI - 0.41, 0.25), global health (k = 7; 0.1, 95% CI - 0.01, 0.27), and sexual health (k =11; 0.2, 95% CI - 0.02,0.57). There was no clear evidence of the superiority of BR to BCS for all the six domains. These results suggest that HR-QoL outcomes in BR and BCS groups are better than the M group. Therefore, women opting for BR or BCS are likely to report fairly better HR-QoL outcomes than M. However, due to the significant heterogeneity observed in most BR versus BCS outcomes, developing a unified questionnaire incorporating both breast/surgery-specific and generic HR-QoL domains is warranted.

Reconstrução mamária com implantes e tela sintética / Breast reconstruction with implants and synthetic mesh

Introdução: As mastectomias com reconstruções mamárias imediatas podem proteger a paciente de um período de estresse psicossocial, imagem corporal negativa e insatisfação sexual. O advento e utilização de novos materiais como os implantes, expansores e matrizes dérmicas acelulares também contribuíram para o sucesso das reconstruções mamárias. Porém, o uso das matrizes dérmicas acelulares é restrito no Brasil pela legislação e seu alto custo. O objetivo do estudo foi relatar a experiência do autor na reconstrução mamária com implantes e tela sintética como uma alternativa às matrizes dérmicas acelulares. Método: Foi realizada uma análise retrospectiva de 12 pacientes consecutivas (20 mamas reconstruídas) que foram submetidas à reconstrução mamária imediata ou tardia pela técnica descrita com implantes e tela sintética, entre novembro de 2015 e dezembro de 2016. Resultados: Doze pacientes (20 mamas) foram operadas pela técnica apresentada no estudo. O tempo médio de follow-up foi de 14 meses. Nesta série, 15% apresentaram complicações menores como hematoma, deiscência de sutura e rippling. O número de complicações, apesar do número restrito de casos, é compatível com a literatura. O grau de satisfação global com a cirurgia foi, em média, de 75,2 pontos em uma escala de 0-100, sendo a nota mais alta atribuída à aparência das mamas (85 pontos). Conclusão: A reconstrução mamária com implantes e tela sintética se mostrou uma técnica com baixo índice de complicações, alto grau de satisfação das pacientes com o resultado estético e com menores custos em relação ao uso de matrizes dérmicas acelulares.

Introduction: Mastectomy with immediate breast reconstruction may prevent patients from experiencing a period of psychosocial stress, negative body image, and sexual dissatisfaction. The advent and implementation of novel materials such as implants, expanders, and acellular dermal matrices have also contributed to the success of breast reconstruction procedures. However, the use of acellular dermal matrices in Brazil is restricted by law and by their high cost. The objective of the present study was to report the author's experience in breast reconstruction with implants and synthetic mesh as an alternative to acellular dermal matrices. Method: This was a retrospective analysis of 12 consecutive patients (20 reconstructed breasts) who underwent immediate or delayed breast reconstruction using the described technique with implants and synthetic mesh between November 2015 and December 2016. Results: Twelve patients (20 breasts) were operated on using the technique described in this report. The mean time of follow-up was 14 months. In this series, 15% of patients had minor complications, including hematoma, suture dehiscence, and rippling. The rate of complications was similar to the rates reported in the literature, despite the limited number of cases. The average degree of overall satisfaction with the surgery was 75.2 points on a scale of 0-100, and the highest score was given to breast appearance (85 points). Conclusion: Breast reconstruction with implants and synthetic mesh was shown to be a technique with a low rate of complications, high degree of patient satisfaction with the cosmetic result, and decreased cost relative to acellular dermal matrices.

Operative and Oncologic Outcomes in 9861 Patients with Operable Breast Cancer: Single-Institution Analysis of Breast Conservation with Oncoplastic Reconstruction.

BACKGROUND: Oncoplastic reconstruction is an approach that enables patients with locally advanced or adversely located tumors to undergo breast conserving surgery (BCS). The objectives were to identify the use of BCS with oncoplastic reconstruction (BCS + R) and determine the operative and oncologic outcomes compared with other breast surgical procedures for breast cancer. METHODS: This retrospective cohort study interrogated a single institution's prospectively maintained databases to identify patients who underwent surgery for breast cancer between 2007 and 2014. Surgeries were categorized as BCS, BCS + R, total mastectomy (TM), or TM with immediate reconstruction (TM + R). Demographic and clinicopathologic characteristics and postoperative complications were analyzed. RESULTS: There were 10,607 operations performed for 9861 patients. Median follow-up was 3.4 years (range, 0-9.1 years). The use of BCS + R had a nearly fourfold increase in the percentage of all breast cancer surgeries during the study period; 75 % of patients who underwent BCS + R had a T1 or T2 tumor. There was no difference in the use of BCS + R compared with BCS for any quadrant of the breast except the lower outer quadrant (11.1 vs. 6.8 %; p < .0001). BCS + R had a lower rate of seroma formation (13.4 vs. 18 %; p = .002) and positive or close margins compared with BCS (5.8 vs. 8.3 %; p = .04). There was no difference in overall survival or recurrence-free survival when comparing BCS and BCS + R. CONCLUSIONS: Patients undergoing BCS + R are not disadvantaged in terms of complications and short-term (3-year) outcomes compared with BCS patients or patients who underwent TM.

Prediction of margin involvement and local recurrence after skin-sparing and simple mastectomy.

UNLABELLED: Skin-sparing mastectomy (SSM) facilitates immediate breast reconstruction. We investigated locoregional recurrence rates after SSM compared with simple mastectomy and the factors predicting oncological failure. METHODS: Patients with early breast cancer that underwent mastectomy between 2000 and 2005 at a single institution were studied to ascertain local and systemic recurrence rates between groups. Kaplan-Meier curves and log-rank test were used to evaluate disease-free survival. RESULTS: Patients (n = 577) underwent simple mastectomy (80%) or SSM (20%). Median follow up was 80 months. Patients undergoing SSM were of younger average age, less often had involved lymph nodes (22% vs 44%, p < 0.001), more often had DCIS present (79% vs 53%, p < 0.001) and involved margins (29% vs 15%, p = 0.001). Involved surgical margins were associated with large size (p = 0.001). The 8-year local recurrence (LR) rates were 7.9% for SSM and 5% for simple mastectomy respectively (p = 0.35). Predictors of locoregional recurrence were lymph node involvement (HR 8.0, for >4 nodes, p < 0.001) and involved surgical margins (HR 3.3, p = 0.002). In node negative patients, SSM was a predictor of locoregional recurrence (HR 4.8 [1.1, 19.9], p = 0.033). CONCLUSION(S): Delayed reconstruction is more appropriate for node positive early breast cancer after post-mastectomy radiotherapy. Re-excision of involved margins is essential to prevent local recurrence after mastectomy.

Early postoperative outcomes in lumpectomy versus simple mastectomy.

BACKGROUND: Relatively scarce outcomes research exists that compares early postoperative complications between breast conservation surgery (BCS) and simple mastectomy (SM). Such information would improve a surgeon's ability to provide informed consent when considering treatment options, especially for women with early stage breast cancer who have the option to receive either BCS or SM. MATERIALS AND METHODS: The National Surgical Quality Improvement Program database from years 2009-2012 was analyzed. For each treatment group, we used Current Procedural Terminology codes specific to the treatment modality with sentinel lymph node biopsy as an inclusion criteria. We excluded patients who received axillary lymphadenectomies, bilateral disease or symmetry procedures, and additional breast reconstructive surgery. We compared each group with chi square and two-sample t-tests to look for preoperative comorbidity differences, then used unadjusted odds ratios to compare postoperative complication rates. RESULTS: Inclusion and exclusion criteria provided 6682 patients in the BCS group and 3339 patients in the SM group. Baseline comorbid condition characteristics showed no clinical differences between groups except for diabetes (8.5% in SM versus 6.5% in BCS). Statistical analysis between each treatment modality revealed that the SM group had significantly higher wound complications, bleeding, infections, and overall complications than the BCS group. CONCLUSIONS: Although both BCS and SM options have low early postoperative complication rates when treating early stage breast cancer, BCS has fewer complications with regard to bleeding, wound complications and infections.

Comparison of quality of life based on surgical technique in patients with breast cancer.

OBJECTIVE: More than 80% of women with breast cancer survive for more than 5 years; quality of life is an important issue in these patients. The aim of this study was to assess differences in quality of life among patients who have undergone breast-conserving surgery, total mastectomy and immediate reconstruction after total mastectomy. METHODS: A cross-sectional study was conducted during follow-up visits. Women who underwent surgical treatment at least 2 years prior were eligible if they were aged 20-70 years and had a diagnosis of breast cancer (Stages 0-III). Quality of life was evaluated based on the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 and European Organization for Research and Treatment of Cancer Quality of Life Questionnaire breast cancer-specific module, Rosenberg Self-esteem Scale, Beck Depression Index, Body Image Scale and sexual scale of the Cancer Rehabilitation Evaluation System. RESULTS: A total of 407 patients completed the questionnaires; 254 were treated with breast-conserving surgery, 122 with total mastectomy and 31 with reconstruction after total mastectomy. The mean period between surgery and the survey was 49 months. Women in the breast-conserving surgery group showed better outcomes than women in the total mastectomy and reconstruction after total mastectomy groups with respect to emotional-social function, nausea/vomiting, financial difficulty, body image, arm symptoms and self-esteem. Patients in the reconstruction after total mastectomy group had significantly better outcomes on the sexual scale of the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire breast cancer-specific module and arm symptoms than the total mastectomy group. CONCLUSIONS: Quality of life was better in the breast-conserving surgery group than in the total mastectomy or reconstruction after total mastectomy groups, and the total mastectomy and reconstruction after total mastectomy groups had similar quality of life. Efforts to evaluate and improve the quality of life of patients with breast cancer should be continued.

No increase of local recurrence rate in breast cancer patients treated with skin-sparing mastectomy followed by immediate breast reconstruction.

BACKGROUND: The aim of this study was to evaluate the incidence of local recurrence after SSM with IBR and to determine whether complications lead to postponement of adjuvant therapy. METHOD: Patients that underwent IBR after SSM between 2004 and 2011 were included. RESULTS: A total of 157 reconstruction procedures were performed in 147 patients for invasive breast cancer (n = 117) and ductal carcinoma in situ (n = 40). The median follow-up was 39 months [range 6-97]. Estimated 5-year local recurrence rate was 2.9% (95% CI 0.1-5.7). The median time to start adjuvant therapy was 27.5 days [range 19-92] in 18 patients with complications, and 23.5 days [range 8-54] in 46 patients without complications (p = 0.025). CONCLUSION: In our single-institution cohort, IBR after SSM carried an acceptable local recurrence rate. Complications caused a delay of adjuvant treatment but this was within guidelines and therefore not clinically relevant.

Breast cancer in women under age 40 years: treatment by total mastectomy and reconstruction.

INTRODUCTION: Breast cancer in women under 40 years of age is rare, accounting for approximately 5% of cases. The disease tends to be more aggressive in younger women. Younger age has been shown to be an independent predictive of breast reconstruction after total mastectomy. Treatment by total mastectomy and reconstruction is examined in relation to patient age. METHODS: A retrospective review of all breast cancer patients treated by total mastectomy and reconstruction between 2005 and 2009 was performed by querying a prospective database. RESULTS: A total of 671 patients underwent total mastectomy and reconstruction; of them, 106 (16%) aged <40 and 565 (84%) aged ≥40 years. Compared with older patients, the age <40 group was more likely to present with advanced breast cancer (P < 0.001), receive radiation (P = 0.006), undergo contralateral prophylactic mastectomy (P < 0.001) and bilateral reconstruction (P = 0.005), and undergo delayed reconstruction (P = 0.02). Transverse rectus abdominis musculocutaneous flap reconstruction was more common in the age ≥40 years (P = 0.03). Bilateral reconstruction was most commonly performed with tissue expansion regardless of patient age. CONCLUSIONS: Breast reconstruction in women less than 40 years of age is influenced by advanced tumor stage and the necessity for adjuvant radiation therapy as well as an increased use of contralateral prophylactic mastectomy.

Reliability and limits of agreement of circumferential, water displacement, and optoelectronic volumetry in the measurement of upper limb lymphedema.

We conducted a reliability comparison study to determine the intrarater and inter-rater reliability and the limits of agreement of the volume estimated by circumferential measurements using the frustum sign method and the disk model method, by water displacement volumetry, and by infrared optoelectronic volumetry in the assessment of upper limb lymphedema. Thirty women with lymphedema following axillary lymph node dissection surgery for breast cancer surgery were enrolled. In each patient, the volumes of the upper limbs were estimated by three physical therapists using circumference measurements, water displacement and optoelectronic volumetry. One of the physical therapists performed each measure twice. Intraclass correlation coefficients (ICCs), relative differences, and limits of agreement were determined. Intrarater and interrater reliability ICCs ranged from 0.94 to 1. Intrarater relative differences were 1.9% for the disk model method, 3.2% for the frustum sign model method, 2.9% for water displacement volumetry, and 1.5% for optoelectronic volumetry. Intrarater reliability was always better than interrater, except for the optoelectronic method. Intrarater and interrater limits of agreement were calculated for each technique. The disk model method and optoelectronic volumetry had better reliability than the frustum sign method and water displacement volumetry, which is usually considered to be the gold standard. In terms of low-cost, simplicity, and reliability, we recommend the disk model method as the method of choice in clinical practice. Since intrarater reliability was always better than interrater reliability (except for optoelectronic volumetry), patients should therefore, ideally, always be evaluated by the same therapist. Additionally, the limits of agreement must be taken into account when determining the response of a patient to treatment.

Secondary operations are frequently required to complete the surgical phase of therapy in the era of breast conservation and sentinel lymph node biopsy.

BACKGROUND: Breast conservation therapy (BCT) is an oncologically equivalent and cosmetically preferable alternative to mastectomy for most early-stage breast cancers. The number of operations required to complete the surgical phase of therapy with BCT has not been widely reported. METHODS: From our institutional tumor registry, we reviewed the records of all patients receiving primary surgical therapy for breast cancer from January 1, 1998, to June 30, 2002. There were 204 patients with 210 breast cancers in the cohort. These cancers were initially managed with either BCT (n = 150) or mastectomy (modified radical mastectomy or total mastectomy with sentinel lymph node biopsy) (n = 60). We compared the percentages of patients in each group who required additional surgeries to obtain clear margins, manage axillary disease, or otherwise complete the surgical phase of therapy. Patients with secondary surgery related to long-term local recurrence were excluded. RESULTS: Fifty-one percent of patients initially managed with BCT required additional surgery compared with 12% in the mastectomy group (P <0.05). Factors independently associated with multiple surgeries among all patients included management with BCT (odds ratio [OR] 5.4, P = 0.01) and positive margins at initial excision (OR 4.7, P <0.01). Significant independent predictors of positive margins included BCT (OR 11.9, P <0.01); disease stage (OR 6.7, P <0.01); submission of supplemental margins in addition to the main specimen (OR 2.8, P = 0.03); and positive nodes (OR 1.1, P = 0.04). Breast conservation was ultimately successful in 95% of patients who underwent BCT. CONCLUSIONS: Patients undergoing BCT may require multiple surgeries to reconcile successful breast conservation with sound oncologic resection.

Breast cancer presenting with the syndrome of inappropriate secretion of antidiuretic hormone after simple mastectomy.

A 71-year-old woman showed disorientation 7 days after simple mastectomy for right breast cancer. Computed tomography of the brain was normal. The level of serum sodium was very low (110 mEq/l), while the urine sodium level was normal. The osmolality of urine was higher (342 mosmol/kg) than that of serum (220 mosmol/kg). These data suggested a syndrome of inappropriate secretion of antidiuretic hormone. A fluid restriction, infusion of hypertonic saline and administration of diuretics gradually increased the level of serum sodium. Subsequently, disorientation disappeared. This is a rare case of the syndrome of inappropriate secretion of antidiuretic hormone caused by simple mastectomy, a relatively minor surgical procedure.

Subcutaneous mastectomy for primary breast cancer and ductal carcinoma in situ.

Subcutaneous mastectomy (SCM) has been performed in 323 patients with invasive breast cancer or ductal carcinoma in situ (DCIS) over the last 20 years. This paper assesses the oncological safety of this operation with particular reference to local recurrences (LR) in the skin flaps. LR was assessed in the 134 patients who did not receive post-operative irradiation to the flaps and were followed up for a minimum of 30 months. The rates of LR were similar for SCM (16%) and for women who underwent simple mastectomy without post-operative irradiation (SM) for invasive cancer (14%) over the same time period, both overall and after prognostic stratification. In DCIS LR was only found in women treated with SCM. Four of the five recurrences (from 33 women) were in the nipple and later in the series patients with microscopic tumour involvement in the nipple received prophylactic irradiation to the nipple only; five patients treated in this way have not suffered LR. Subcutaneous mastectomy followed by insertion of a prosthesis is a safe alternative to mastectomy, since it carries no higher risk of LR. It is the simplest form of reconstruction in those proceeding to silicone implant and has the potential of achieving an excellent cosmetic result. Failure does not compromise the chance of more complex reconstruction procedures.

Induction of tumour cell shedding into effluent venous blood breast cancer surgery.

Surgeons have long been concerned that cancer may be disseminated by shedding of tumour cells into the bloodstream during surgery. Early claims that cancer operations induced an increase in the number of tumour cells shed into the circulation were subsequently discredited, and the issue has remained unresolved. We used immunocytochemistry for cytokeratins to detect tumour cells in effluent blood from breast carcinomas in 18 patients undergoing surgery. Tumour cells were detectable in 6/18 patients during surgery, in only one patient before operation and in none post-operatively (P = 0.025). Circulating cells were associated with vascular invasion within the primary tumour (P = 0.032). No cytokeratin-positive cells were found in blood from ten normal volunteers or four patients undergoing surgery for other breast conditions. These results confirm that cancer surgery in humans results in an increase in the shedding of tumour cells into the circulation. The implications for prognosis and practice should be determined by larger prospective studies.

Comparison of postoperative wound complications and early cancer recurrence between patients undergoing mastectomy with or without immediate breast reconstruction.

The incidence of postoperative wound complications and early cancer recurrence was studied in 289 patients who had mastectomy alone and in 113 patients who underwent immediate reconstruction following mastectomy. Patients undergoing immediate reconstruction were younger and had less advanced disease than patients who had mastectomy alone. The postoperative hospital stay was 3.8 days and 4.4 days (p < 0.05) in patients with and without reconstruction, respectively. The overall incidence of postoperative complications was similar in the two groups of patients: 31% and 28% in patients with and without reconstruction, respectively. The incidence of postoperative seroma was higher among patients with mastectomy alone (19% versus 3%, p < 0.05), whereas the incidence of other wound complications was similar in the two groups of patients. Prosthesis-specific complications occurred in 17%. Eight prostheses were removed because of complications. During the relatively short follow-up period (approximately 20 months), local recurrence was noted in 16 patients (6%) who had mastectomy alone and in 1 patient (1%) who had immediate reconstruction after mastectomy (p < 0.05). There was no significant difference in the incidence of distant metastases between the two groups of patients. The results suggest that immediate breast reconstruction can be performed following mastectomy for cancer without increased risk for overall postoperative complications, prolonged hospital stay, or local recurrence. However, patients who choose to have immediate reconstruction need to be informed about risks for specific complications associated with the procedure, especially if an implant is used.

Breast reconstruction in women treated with radiation therapy for breast cancer: cosmesis, complications, and tumor control.

The records of 55 patients who had breast cancer treated by mastectomy, irradiation, and breast reconstruction were reviewed for cosmetic outcome, complications, and tumor control. Median follow-up was 35 months. Local control rates were 95 percent in patients treated for high risk factors or breast conservation and 85 percent in patients treated for recurrent breast cancer. Acceptable cosmetic results were obtained in only 42 percent of patients. The incidence of complications was 55 percent. Transverse rectus abdominis muscle (TRAM) reconstructions gave superior cosmetic results compared with all other types of reconstructions. The timing of reconstruction in relation to mastectomy or radiation therapy did not significantly influence cosmetic outcome, although other factors suggest that delayed reconstruction may give better results. A majority of patients were satisfied with cosmetic outcome.