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)

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.

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).

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.

The PreQ-20 TRIAL: A prospective cohort study of the oncologic safety, quality of life and cosmetic outcomes of patients undergoing prepectoral breast reconstruction.

BACKGROUND: Mastectomy currently constitutes a necessary surgical procedure in the oncologic setting and in the context of high risk. Prepectoral breast reconstruction (PBR) has been proposed as a surgical alternative to retropectoral techniques by providing less postoperative morbidity and a better cosmetic result. However, there is a lack of prospective studies that have evaluated its safety and patient-reported satisfaction. METHODS: We conducted a prospective cohort study to assess the safety, quality of life and cosmetic sequelae of PBR in women with breast cancer and high risk. The study's main objective is to assess the safety of PBR in terms of postsurgical complications and the feasibility of reconstruction (loss of implants). The secondary objectives are to evaluate oncologic safety (local relapses, residual glandular tissue) and to identify factors related to quality of life and cosmetic sequelae. The evaluation of residual tissue will be conducted by MRI 12 to 18 months after the surgery, and the quality-of-life assessment will be performed using the Breast-Q questionnaire. An initial patient evaluation will be conducted 12-18 months after the surgery, and a second evaluation will be performed at 5 years. The estimated sample size is 81 patients. DISCUSSION: The PreQ-20 study will analyze the impact of PBR on 3 separate measures: safety, quality of life and cosmetic sequelae. Unlike other studies that analyzed these three measures jointly for women with breast cancer and high risk, this study will individualize the results for these 2 patient groups. This differentiation is necessary from the methodological point of view, given that the 2 patient groups have separate clinical and emotional implications. The assessment of these groups will focus on the following aspects: postoperative complications, local relapses, evaluation of residual glandular tissue and incidence rate of primary tumors in the same, the cosmetic sequelae and the satisfaction and the quality-of-life assessment by the patients. TRIAL REGISTRATION: ClinicalTrials.gov: NCT04642508.

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.

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%).

Dispositivos venosos implantables: principales complicaciones y factores de riesgo asociados / Implantable venous devices: main complications and associated risk factors

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Crisis Sanitaria COVID-19: el papel de un cirujano / The COVID-19 health crisis: the surgeon role

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