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.

Estadificación ganglionar tras terapia sistémica primaria en mujeres con cáncer de mama y afectación ganglionar al diagnóstico / Lymph node staging after primary systemic therapy in women with breast cancer and lymph node involvement at diagnosis

Objetivo: El objetivo principal de este estudio es analizar la eficacia del marcaje ganglionar combinado (clip y biopsia de ganglio centinela (BGC)) para la estadificación axilar en pacientes con tratamiento sistémico primario (TSP) y cáncer de mama con ganglios positivos confirmados patológicamente en el momento del diagnóstico. El objetivo secundario es determinar el impacto del marcaje ganglionar en la supresión de la linfadenectomía axilar (LA) en el grupo a estudio. Métodos: Estudio prospectivo en el que se realizó la estadificación ganglionar mediante la localización con alambre metálico (arpón) de los ganglios afectados y una BGC con doble trazador. Todas las pacientes sin afectación metastásica del ganglio centinela (GC) o del ganglio marcado con clip/alambre no realizaron una LA. El comité multidisciplinar acordó el tratamiento axilar de las pacientes con afectación ganglionar. Resultados: Ochenta y un pacientes cumplieron los criterios de inclusión. Identificamos y extirpamos el ganglio marcado con clip/alambre en 80 de 81 pacientes (98,8%), y la BGC se realizó con éxito en el 88,9% de los pacientes. El GC y el nódulo marcado con arpón coincidieron en el 78,9% de las pacientes. El 76,2% de las pacientes no se sometieron a LA. Conclusiones: El marcaje axilar combinado (clip y BGC) en pacientes con ganglios metastásicos al diagnóstico y TSP ofrece una alta tasa de identificación (98,8%) y una alta correlación entre el ganglio marcado con arpón y el GC (78,8%). Este procedimiento ha permitido la supresión de la LA en el 76,2% de las pacientes incluidas en el estudio. (AU)

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. (AU)

Reconstrucción mamaria inmediata mediante implante prepectoral de poliuretano. Resultados preliminares del estudio prospectivo PreQ-20 / Immediate breast reconstruction by prepectoral polyurethane implant: Preliminary results of the prospective study PreQ-20

Introducción: Durante los últimos años las técnicas de mastectomía y reconstrucción han evolucionado hacia procedimientos menos agresivos, mejorando la satisfacción y calidad de vida de la mujer. Por ello, la mastectomía se ha convertido en una opción válida tanto para mujeres con cáncer de mama como en mujeres de alto riesgo. El objetivo de este estudio es analizar la seguridad de la mastectomía y reconstrucción inmediata prepectoral con implante de poliuretano en mujeres con cáncer de mama y reducción de riesgo. Métodos: Estudio prospectivo observacional para evaluar la factibilidad y seguridad de la reconstrucción inmediata mediante implante prepectoral de poliuretano. Se incluyeron todas las mujeres (con cáncer de mama o alto riesgo para cáncer de mama) intervenidas mediante una mastectomía preservadora de piel o piel y pezón con reconstrucción inmediata con implante de poliuretano prepectoral. Se excluyeron las mujeres con sarcomas de mama, progresión de la enfermedad durante el tratamiento sistémico primario, reconstrucción diferida, autóloga o retropectoral y aquellas pacientes que no desearon participar en el estudio. Los procedimientos quirúrgicos fueron realizados tanto por cirujanos senior como junior. Todas las pacientes recibieron los tratamientos complementarios correspondientes. Se analizaron todos los eventos adversos acontecidos durante el seguimiento y los factores de riesgo para desarrollarlos. Resultados: Se realizaron 159 reconstrucciones en 102 mujeres, el 80,4% por un carcinoma mamario. Catorce pacientes desarrollaron complicaciones, siendo el seroma y la dehiscencia de la herida las más frecuentes. Ocho mujeres precisaron una reintervención (5%), 7 de ellas por exposición del implante. Cuatro reconstrucciones (2,5%) culminaron con pérdida del implante. Tres pacientes presentaron progresión de su proceso oncológico: una recaída local en el colgajo de la mastectomía, una progresión axilar y una progresión sistémica. (AU)

Introduction: In recent years, mastectomy and reconstruction techniques have evolved towards less aggressive procedures, improving the satisfaction and quality of life of women. For this reason, mastectomy has become a valid option for both women with breast cancer and high-risk women. The objective of this study is to analyze the safety of mastectomy and immediate prepectoral reconstruction with polyurethane implant in women with breast cancer and risk reduction. Method: Observational prospective study to evaluate the feasibility and safety of immediate reconstruction using prepectoral polyurethane implant. All women (with breast cancer or high risk for breast cancer) who underwent skin-sparing or skin-and-nipple-sparing mastectomy with immediate reconstruction with a prepectoral polyurethane implant were included. Women with breast sarcomas, disease progression during primary systemic therapy, delayed, autologous or retropectoral reconstruction, and those who did not wish to participate in the study were excluded. Surgical procedures were performed by both senior and junior surgeons. All patients received the corresponding complementary treatments. All adverse events that occurred during follow-up and the risk factors for developing them were analyzed. Results: 159 reconstructions were performed in 102 women, 80.4% due to breast carcinoma. Fourteen patients developed complications, the most frequent being seroma and wound dehiscence. Eight women required a reoperation (5.0%), seven of them due to implant exposure. Four reconstructions (2.5%) resulted in loss of the implant. Three patients progressed from their oncological process: a local relapse in the mastectomy flap, an axillary progression and a systemic progression. (AU)

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.

Recaídas locorregionales tras mastectomías preservadoras y reconstrucción inmediata en mujeres con cáncer de mama / Locoregional relapse after sparing mastectomies and immediate reconstruction in women with breast cancer

Introducción: Durante los últimos años, los cambios culturales de la sociedad actual y la mejora en la valoración del riesgo han incrementado la indicación de las mastectomías en mujeres con cáncer de mama. Diversos estudios han confirmado la seguridad oncológica de la mastectomías preservadoras y reconstrucción inmediata. El objetivo de este estudio es analizar la incidencia de recaídas locorregionales de este procedimiento y su impacto en la reconstrucción y la supervivencia global. Pacientes y métodos: Estudio prospectivo de pacientes con un carcinoma de mama que realizaron una mastectomía preservadora y reconstrucción inmediata. Se analizaron las recaídas locorregionales, el tratamiento de las mismas y la capacidad de preservar la reconstrucción, así como su impacto en la supervivencia. Resultados: El grupo a estudio lo constituyen 271 mujeres con carcinoma mamario tratadas mediante una mastectomía ahorradora de piel y reconstrucción inmediata. El seguimiento medio fue de 7,98 años y durante el mismo se diagnosticaron 18 recaídas locorregionales (6,6%): 72,2% en el colgajo de la mastectomía y 27,8% ganglionares. No se evidenciaron diferencias significativas en las características patológicas del tumor primario entre las pacientes con y sin una recaída locorregional, aunque el porcentaje de mujeres con tumores hormonosensibles fue superior en el grupo sin recaída. Las pacientes con recaída ganglionar presentaban tumores de mayor tamaño (el 80% T2-T3) y el 60% tenían metástasis axilares al diagnóstico vs. 7,7% de las mujeres con recaída en piel (p = 0,047). Todas las pacientes intervenidas de una recaída locorregional preservaron su reconstrucción. La incidencia de metástasis y muertes fue significativamente mayor en las pacientes con una recaída, causando una disminución no significativa de la supervivencia global. (AU)

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. (AU)

Immediate breast reconstruction by prepectoral polyurethane implant: Preliminary results of the prospective study PreQ-20.

INTRODUCTION: In recent years, mastectomy and reconstruction techniques have evolved towards less aggressive procedures, improving the satisfaction and quality of life of women. For this reason, mastectomy has become a valid option for both women with breast cancer and high-risk women. The objective of this study is to analyze the safety of mastectomy and immediate prepectoral reconstruction with polyurethane implant in women with breast cancer and risk reduction. METHOD: Observational prospective study to evaluate the feasibility and safety of immediate reconstruction using prepectoral polyurethane implant. All women (with breast cancer or high risk for breast cancer) who underwent skin-sparing or skin-and-nipple-sparing mastectomy with immediate reconstruction with a prepectoral polyurethane implant were included. Women with breast sarcomas, disease progression during primary systemic therapy (PST), delayed, autologous or retropectoral reconstruction, and those who did not wish to participate in the study were excluded. Surgical procedures were performed by both senior and junior surgeons. All patients received the corresponding complementary treatments. All adverse events that occurred during follow-up and the risk factors for developing them were analyzed. RESULTS: 159 reconstructions were performed in 102 women, 80.4% due to breast carcinoma. Fourteen patients developed complications, the most frequent being seroma and wound dehiscence. Eight women required a reoperation (5.0%), seven of them due to implant exposure. Four reconstructions (2.5%) resulted in loss of the implant. Three patients progressed from their oncological process: a local relapse in the mastectomy flap, an axillary progression and a systemic progression. CONCLUSIONS: Prepectoral reconstruction with a polyurethane implant is a procedure with a low incidence of postoperative complications (8.8%) and implant loss (2.5%). Its use is safe with perioperative cancer treatments (neoadjuvant chemotherapy and radiotherapy).

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.

Underestimation of invasive breast carcinoma in patients with initial diagnosis of ductal carcinoma in situ: Size matters.

BACKGROUND: The aim of our study was to identify those patients with preoperative diagnosis of ductal carcinoma in situ (DCIS) and high risk of upstaging to invasive breast carcinoma (IBC), in whom sentinel lymph node biopsy (SLNB) should be considered. MATERIALS AND METHODS: One-hundred and five DCIS patients treated with breast-conserving surgery (BCS) or mastectomy were studied. Preoperative features of the tumours were analyzed to investigate its association with underestimation of IBC on final pathology. RESULTS: Overall, the underestimation rate of IBC was 16.2%. The underestimation rate was highest in lesions with initial size >2 cm compared with those with size ≤2 cm (26.8% vs. 4.1%, respectively; p < 0.003). Eighty-eight patients (83.8%) underwent concurrent SLNB and only one case had lymph node involvement (1.1%). CONCLUSIONS: SLNB should be considered in DCIS patients receiving BCS with lesions greater than 2 cm since approximately one in four will harbour an IBC.

Infraestimación de carcinoma infiltrante de mama en pacientes con diagnóstico inicial de carcinoma ductal in situ: el tamaño importa / Underestimation of invasive breast carcinoma in patients with initial diagnosis of ductal carcinoma in situ: Size matters

Introducción: El objetivo de nuestro estudio consistió en identificar aquellas pacientes con diagnóstico preoperatorio de carcinoma ductal in situ (CDIS) y alto riesgo de presentar un carcinoma infiltrante en la lesión, en las que se debería considerar realizar una biopsia selectiva de ganglio centinela (BSGC). Métodos: Se estudiaron 105 pacientes con CDIS tratadas mediante cirugía conservadora o mastectomía. Se analizaron las características preoperatorias de los tumores para investigar su asociación con la infraestimación de carcinoma infiltrante. Resultados: El porcentaje global de infraestimación de carcinoma infiltrante fue del 16,2%. El porcentaje de infraestimación fue mayor en las lesiones con un tamaño inicial superior a 2 cm en comparación con las lesiones con un tamaño igual o menor a 2 cm (26,8% vs. 4,1%, respectivamente; p < 0,003). Se realizó la BSGC en 88 pacientes (83,8%), encontrándose afectación ganglionar en un solo caso (1,1%). Conclusiones: En pacientes con diagnóstico inicial de CDIS tratadas mediante cirugía conservadora, se debería considerar realizar una BSGC cuando el tamaño de la lesión es superior a 2 cm, ya que uno de cada cuatro casos albergará la presencia de un carcinoma infiltrante. (AU)

Introduction: The aim of our study was to identify those patients with preoperative diagnosis of ductal carcinoma in situ (DCIS) and high risk of upstaging to invasive breast carcinoma (IBC), in whom sentinel lymph node biopsy (SLNB) should be considered. Methods: One-hundred and five DCIS patients treated with breast-conserving surgery (BCS) or mastectomy were studied. Preoperative features of the tumors were analyzed to investigate its association with underestimation of IBC on final pathology. Results: Overall, the underestimation rate of IBC was 16.2%. The underestimation rate was highest in lesions with initial size >2 cm compared with those with size ≤2 cm (26.8% vs. 4.1%, respectively; p < 0.003). Eighty-eight patients (83.8%) underwent concurrent SLNB and only one case had lymph node involvement (1.1%). Conclusions: SLNB should be considered in DCIS patients receiving BCS with lesions greater than 2 cm since approximately one in four will harbor an IBC. (AU)

Underestimation of invasive breast carcinoma in patients with initial diagnosis of ductal carcinoma in situ: Size matters. / Infraestimación de carcinoma infiltrante de mama en pacientes con diagnóstico inicial de carcinoma ductal in situ: el tamaño importa.

INTRODUCTION: The aim of our study was to identify those patients with preoperative diagnosis of ductal carcinoma in situ (DCIS) and high risk of upstaging to invasive breast carcinoma (IBC), in whom sentinel lymph node biopsy (SLNB) should be considered. METHODS: One-hundred and five DCIS patients treated with breast-conserving surgery (BCS) or mastectomy were studied. Preoperative features of the tumors were analyzed to investigate its association with underestimation of IBC on final pathology. RESULTS: Overall, the underestimation rate of IBC was 16.2%. The underestimation rate was highest in lesions with initial size >2 cm compared with those with size ≤2 cm (26.8% vs. 4.1%, respectively; p < 0.003). Eighty-eight patients (83.8%) underwent concurrent SLNB and only one case had lymph node involvement (1.1%). CONCLUSIONS: SLNB should be considered in DCIS patients receiving BCS with lesions greater than 2 cm since approximately one in four will harbor an IBC.

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%).

Lesiones del plexo braquial en la cirugía mamaria. Recomendaciones para su prevención / Brachial plexus lesions in breast surgery. Recommendations for prevention

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