A long-term follow up of the laparoscopically harvested free omental flap for breast reconstruction.

BACKGROUND: There are different types of reconstruction after mastectomy and breast-conserving surgery. Autologous reconstructions are nowadays more often preferred over implant-based reconstructions for many reasons. A more natural looking breast with a durable long-term result is one of the advantages. The greater omentum is frequently used in the general field of reconstructive surgery but has not been widely adopted in breast surgery. This report is the first larger series of patients who underwent a breast reconstruction using the laparoscopically harvested omental free flap (LHOFF). The aim of this report is to provide information about indication, surgical technique, short- and long-term complications, and patient satisfaction with aesthetic outcomes and health-related quality of life (HR-QoL). METHODS: Patients underwent a breast reconstruction with the LHOFF from 2014 to 2021 in Máxima Medical Center, Veldhoven, the Netherlands. All patients underwent a diagnostic laparoscopy prior to the reconstruction to examine whether the volume of omentum was deemed sufficient. Outcome measures included the Breast-Q for HR-QoL, patient satisfaction, short- and long-term complications, and abdominal complaints related to the transplanted omentum. Surgical data were retrieved retrospectively. RESULTS: Twenty-six patients were included in this article. Patients were 40 to 71 years old with a mean BMI of 21.5 (range 17.0-25.0). Mean weight of the omental free flap was 228 g (range 112-395). Four out of 26 cases underwent surgery due to venous congestion. There was one case of flap failure due to venous thrombosis. Mean time of follow-up was 54 months (range 8-179). Secondary corrections include a nipple reconstruction (n = 11), lipofilling (n = 11), a contralateral breast reduction (n = 3) or a breast implant (n = 2). Patients reported improvement in HR-QoL and good satisfaction with aesthetic outcomes. No abdominal complications were reported during the follow-up period. CONCLUSION: The LHOFF is an autologous breast reconstruction technique that results in a soft, small breast with natural ptosis and minimal donor site morbidities. Patients report satisfactory aesthetic outcomes and good quality of life. The main limitation of this technique is the limited amount of volume of the omentum and the possible need for secondary corrections. No abdominal complications were reported. In the future, larger prospective studies are required to support implementation of the LHOFF reconstruction on a broader scale.

[A bleeding tumor on the scalp]. / Een bloedende tumor op het hoofd.

A 83-year-old man presented with a large tumour on his head. He had been postponing his visit due to COVID. Physical examination revealed an ulcerating, bleeding tumour of 5.5x5x3 cm. Histologic analyses showed a poorly differentiated squamous cell carcinoma. Additional imaging displayed damage of the tabula externa without pathological lymph nodes.

Use of Patient-Reported Outcome Measures in the Surgical Treatment of Hidradenitis Suppurativa: A Systematic Review.

BACKGROUND: Surgery is considered to be the best treatment for recurrent hidradenitis suppurativa (HS). Although it is necessary to assess the effect on health-related quality of life (HR-QoL), patient-reported outcome measures (PROMs) are scarce and heterogeneously used in the literature about the surgical treatment of HS. OBJECTIVE: The aim of this study was to provide a review of the complete literature for different PROMs used in the surgical treatment of HS and to assess their methodological qualities. METHODS: A systematic literature search of PubMed, Medline, Cochrane, CINAHL, and Embase with an assessment following the COnsensus-based standards for the Selection of health status Measurement INstrument criteria. RESULTS: The search identified 218 articles, with the inclusion of 6 studies for analysis. Identified PROMs were as follows: the Dermatology Life Quality Index (DLQI), the Derriford Appearance Scale-24 (DAS-24), and the Work Productivity and Activity Impairment (WPAI). These non-disease-specific PROMs seem to have poor results concerning development and content validation. CONCLUSION: The DLQI, WPAI, and DAS-24 are generic PROMs with poor methodological qualities for PROM development and content validation. Hidradenitis suppurativa-specific instruments are not used in available studies because they have been developed recently and, therefore, partially validated. More research is needed to further investigate methodological qualities of HS-specific instruments.

Quality of life in a real-world cohort of advanced breast cancer patients: a study of the SONABRE Registry.

PURPOSE: We aimed to evaluate quality of life (QoL) using the European Quality of Life Five-Dimensions questionnaire (EQ-5D-3L) in a real-world cohort of Dutch advanced breast cancer (ABC) patients. Secondary, we reported differences in QoL between subgroups of patients based on age, comorbidity, tumor-, and treatment characteristics, and assessed the association of duration of metastatic disease and time to death with QoL. METHODS: ABC patients who attended the outpatient clinic between October 2010 and May 2011 were asked to fill out the EQ-5D-3L questionnaire. Patient-, disease-, and treatment characteristics were obtained from the medical files. Health-utility scores were calculated. Subgroups were described and compared for utility scores by parametric and non-parametric methods. RESULTS: A total of 92 patients were included with a median utility score of 0.691 (Interquartile range [IQR] 0.244). Patients ≥ 65 years had significantly worse median utility scores than younger patients; 0.638 versus 0.743, respectively (p = 0.017). Moreover, scores were significantly worse for patients with versus those without comorbidity (medians 0.620 versus 0.725, p = 0.005). Utility scores did not significantly differ between subgroups of tumor type, type of systemic treatment, number of previous palliative treatment(s), or number or location of metastatic site(s). The remaining survival was correlated with utility scores (correlation coefficient (r) = 0.260, p = 0.0252), especially in the subgroup < 65 years (r = 0.340, p = 0.0169), whereas there was no significant correlation with time since metastatic diagnosis (r = - 0.106, p = 0.3136). CONCLUSION: Within this real-world cross-sectional study, QoL was significantly associated with age, comorbidity, and remaining survival duration. The observation of a lower QoL in ABC patients, possibly indicating the last period of life, may assist clinical decision-making on timing of cessation of systemic antitumor therapy.

The role of chemotherapy in treatment of advanced breast cancer: an overview for clinical practice.

This review aims to evaluate the role of chemotherapy-containing regimens in the treatment of advanced breast cancer (ABC), with the purpose to optimize selection, sequencing and duration of treatment with the currently available agents for clinical practice. Data from observational as well as randomized phase II and III studies were included. Chemotherapy yielded a median overall survival (OS) of 2 years in registration studies, with comparable efficacy of different agents. Combining chemotherapy agents did not yield OS improvement and caused greater toxicity compared with single-agent chemotherapy. Continuing chemotherapy till progression or unacceptable toxicity generated greater efficacy without detrimental impact on quality of life compared with a limited amount of cycles. In real-world studies, benefits after third-line chemotherapy were modest compared with first- and second-line. Furthermore, effects of previous chemotherapy predicted effects of next-line therapy in real-world. Physicians increasingly prescribed capecitabine or taxanes as first- or second-line chemotherapy over time.

Secondary analyses of the randomized phase III Stop&Go study: efficacy of second-line intermittent versus continuous chemotherapy in HER2-negative advanced breast cancer.

Background: Previously, we showed that reintroduction of the same (first-line) chemotherapy at progression could only partially make up for the loss in efficacy as compared to continuously delivered first-line chemotherapy. Here, we report the probability of starting second-line study chemotherapy in the Stop&Go trial, and the progression-free survival (PFS) and overall survival (OS) of patients who received both the first- and second-line treatment in an intermittent versus continuous schedule.Methods: First-line chemotherapy comprised paclitaxel plus bevacizumab, second-line capecitabine or non-pegylated liposomal doxorubicin, given per treatment line as two times four cycles (intermittent) or as eight consecutive cycles (continuous).Results: Of the 420 patients who started first-line treatment within the Stop&Go trial (210:210), a total of 270 patients continued on second-line study treatment (64% of all), which consisted of capecitabine in 201 patients and of non-pegylated liposomal doxorubicin in 69 patients, evenly distributed between the treatment arms. Median PFS was 3.7 versus 5.0 months (HR 1.07; 95% CI: 0.82-1.38) and median OS 10.9 versus 12.4 months (HR 1.27; 95% CI: 0.98-1.66) for intermittent versus continuous second-line chemotherapy. Second-line PFS was positively influenced by prior hormonal therapy for metastatic disease and longer first-line PFS duration, while triple-negative tumor status had a negative influence. Patients with a shorter time to progression (TTP) in first-line (≤10 months) had a higher probability of starting second-line treatment if they received intermittent compared to continuous chemotherapy (OR 1.97; 95% CI: 1.02-3.80).Conclusion: We recommend continuous scheduling of both the first- and second-line chemotherapy for advanced breast cancer.

The influence on quality of life of intermittent scheduling in first- and second-line chemotherapy of patients with HER2-negative advanced breast cancer.

BACKGROUND: The Stop&Go study randomized patients with advanced breast cancer to intermittent (two times four) or continuous (eight subsequent cycles) first- and second-line chemotherapy. METHODS: QoL was measured with RAND-36 questionnaires every 12 weeks. The primary objective was to estimate differences in changes from baseline between intermittent and continuous treatment. An effect size of 0.5 SD (5 points) was considered clinically meaningful. RESULTS: A total of 398 patients were included with a median follow-up of 11.4 months (IQR 5.6-22.2). Mean physical QoL baseline scores were 38.0 resp. 38.2, and mental scores 45.0 resp. 42.4 for intermittent and continuous treatment. Physical QoL declined linearly in the intermittent arm causing a clinically meaningful difference of 5.40 points at 24 months (p < 0.001), while scores in the continuous arm stabilized after a small decline of ± 3.4 points at 12 months. Conversely, mental QoL was fairly stable and even improved with 1.58 (p = 0.005) and 2.48 points (p < 0.001) at 12 months for intermittent and continuous treatment, respectively. When comparing arms for both components in changes from baseline, the maximum differences were 2.46 (p = 0.101) and 1.95 points (p = 0.182) for physical and mental scores, both measured at 30 months and in favor of continuous treatment. CONCLUSION: Intermittent first- and second-line chemotherapy in patients with HER2-negative advanced breast cancer showed a trend for worse impact on QoL compared to continuous chemotherapy, with neither significant nor meaningful differences in course. We recommend prescribing chemotherapy continuously until progressive disease or unacceptable toxicity. Trial registration EudraCT 2010-021519-18; BOOG 2010-02.

Conduction disorders and impact on survival after sutureless aortic valve replacement compared to conventional stented bioprostheses.

OBJECTIVES: Sutureless and rapid-deployment aortic valve prostheses are frequently used for the treatment of aortic stenosis. However, postoperative left bundle branch block (LBBB) and permanent pacemaker (PPM) implantation have emerged as frequent complications. The aim of this study was to compare the incidence of new-onset LBBB and PPM implantation after sutureless aortic valve replacement (sAVR) with stented bioprostheses, and the impact on postoperative survival. METHODS: Patients undergoing isolated surgical aortic valve replacement (AVR) or concomitant AVR with coronary artery bypass surgery between January 2010 and July 2017 were included in the study. Two groups were defined: sAVR and conventional AVR (cAVR). The findings of preoperative electrocardiograms were compared with postoperative electrocardiogram findings for both groups. The incidence of new-onset LBBB and the requirement for PPM implantation were recorded. The effect of these conduction disorders on late survival was analysed. RESULTS: A total of 987 patients were analysed, consisting of 132 sAVR and 855 cAVR patients. The sAVR group had an increased incidence of new-onset LBBB compared to the cAVR group (16.7% vs 2.3%, P < 0.001). A significantly higher rate of postoperative PPM implantation was found for sAVR patients compared to cAVR (6.8% vs 1.6%, P = 0.001). The multivariate Cox analysis revealed that neither postoperative new-onset LBBB nor PPM implantation was associated with increased mortality (hazard ratio 1.73, 95% confidence interval 0.74-4.03, P = 0.204). CONCLUSIONS: sAVR is associated with an increased risk of new-onset LBBB and PPM requirement compared to cAVR. In this population, postoperative conduction disorders did not affect the mid-term survival.

Intermittent versus continuous first-line treatment for HER2-negative metastatic breast cancer: the Stop & Go study of the Dutch Breast Cancer Research Group (BOOG).

PURPOSE: We determined if intermittent first-line treatment with paclitaxel plus bevacizumab was not inferior to continuous treatment in patients with HER2-negative, advanced breast cancer. METHODS: Patients were randomized to 2 × 4 cycles or continuous 8 cycles of paclitaxel plus bevacizumab, followed by bevacizumab maintenance treatment until disease progression or unacceptable toxicity. The primary endpoint was overall progression-free survival (PFS). A proportional-hazards regression model was used to estimate the HR. The upper limit of the two-sided 95% CI for the HR was compared with the non-inferiority margin of 1.34. RESULTS: A total of 420 patients were included with well-balanced characteristics. In the intention-to-treat analysis, median overall PFS was 7.4 months (95% CI 6.4-10.0) for intermittent and 9.7 months (95% CI 8.9-10.3) for continuous treatment, with a stratified HR of 1.17 (95% CI 0.88-1.57). Median OS was 17.5 months (95% CI 15.4-21.7) versus 20.9 months (95% CI 17.8-24.0) for intermittent versus continuous treatment, with a HR of 1.38 (95% CI 1.00-1.91). Safety results and actually delivered treatments revealed longer durations of treatment in the continuous arm, without significant unexpected findings. CONCLUSION: Intermittent first-line treatment cannot be recommended in patients with HER2-negative advanced breast cancer. CLINICAL TRIAL REGISTRATION: EudraCT 2010-021519-18; BOOG 2010-02.