Oncologic safety of breast reconstruction with autologous fat grafting: A systematic review and meta-analysis.

BACKGROUND: Autologous fat grating has become increasingly popular as a breast reconstructive procedure. Nevertheless, preclinical studies show that fat transfer to a previous breast cancer site could activate latent cancer cells, creating a favourable environment for disease recurrence. A systematic review and meta-analysis was performed to investigate whether fat grafting increases the risk of locoregional recurrence in patients formerly treated for breast cancer. METHODS: Based on PRISMA guidelines, a systematic review searching for randomised clinical trials and matched cohorts on the topic was performed in the electronic databases Pubmed, Embase, Web of Science, and Cochrane. The date of the last search was July 20, 2021. The meta-analysis assessed the comparison of locoregional recurrence between groups. RESULTS: From a total of 558 publications, data from nine matched cohorts (1.6%) reporting on 4247 subjects (1590 and 2657 subjects, respectively, in lipofilling and control groups) were suitable for inclusion in the meta-analysis. Neither of the outcomes had a statistically significant difference for disease recurrence. For the primary outcome, comparing locoregional recurrence rates between groups, the incidence rate ratio was 0.92 (95% CI: 0.68-1.26; P = 0.620). CONCLUSION: The present meta-analysis, which comprises the outcomes of the individual studies with the best current evidence on the topic so far, strengthens the evidence favouring the oncologic safety of lipofilling for breast reconstruction.

Can anesthetic effects and pain treatment influence the long-term prognosis of early-stage lymph node-negative breast cancer after breast-conserving surgery?

BACKGROUND: Breast cancer is currently the leading cause of women's death. It is crucial to further improve the approach to treatment and the long-term survival rate of breast cancer patients, and to reduce the rates of recurrence and metastasis. It has been reported that the possibility of tumor metastasis depends on the metastatic potential of the tumor and the host defense against tumor metastasis, in which cellular immunity and the function of natural killer (NK) cells are critical to maintaining this balance. Surgical stress response and postoperative pain inhibit perioperative immune function in patients and increase the likelihood of dissemination and metastasis of cancer cells after cancer surgery. The study aims to investigate the effect of anesthetic factors and pain treatment on the long-term prognosis of patients with early stage lymph node negative breast preservation surgery. METHODS: A total of 337 patients with early-stage lymph node negative breast cancer (ASA I-II) who had undergone successful breast-conserving surgery in our hospital were included in this retrospective analysis. Cases were divided into general anesthesia with postoperative analgesia group (GA + PCA), general anesthesia without postoperative analgesia group (GA), epidural anesthesia with postoperative analgesia group (EA + PCA), and epidural anesthesia without postoperative analgesia group (EA). The 5-year survival rate and 5-year disease-free survival were recorded in the 4 groups. RESULTS: The general condition and length of hospital stay of the patients were not statistically different between the 4 groups. However, the 5-year survival rate and 5-year disease-free survival rate of the 4 groups were statistically different. The 5-year survival rate and 5-year disease-free survival rate were the lowest in the GA group, while the EA + PCA group had the highest 5-year disease-free survival rate. The 5-year survival rate and 5-year disease-free survival rate in the GA + PCA group were significantly higher than those in the GA group. The 5-year disease-free survival rate in EA group was significantly higher than GA group. CONCLUSIONS: Epidural anesthesia and postoperative pain treatment maybe beneficial to the long-term prognosis of patients with early-stage lymph node-negative breast cancer.

Oncologic Safety of Autologous Fat Grafting after Breast Cancer Surgical Treatment: A Matched Cohort Study.

BACKGROUND: Autologous fat grafting has been an increasingly popular procedure for remodeling the breast of patients undergoing breast cancer surgery. This study's objective was to investigate whether autologous fat grafting is associated with a higher risk of disease recurrence in the context of late breast reconstruction for patients diagnosed with breast cancer who have undergone either breast-conserving surgery or mastectomy. METHODS: A retrospective matched cohort study was performed in a single tertiary health care center. Data were collected from 42 patients formerly treated for breast cancer who underwent the first session of autologous fat grafting between August of 2007 and June of 2016. A total of 126 patients with similar features, who did not undergo autologous fat grafting, were individually matched at a 1:3 ratio with the autologous fat grafting group. The primary endpoint was locoregional recurrence. Secondary outcomes were rates of local and distant recurrences, disease-free survival, and overall survival. RESULTS: At a mean follow-up of 65 months after fat grafting, no significant differences were found between the lipofilling and control groups for locoregional recurrence (7.1 percent versus 6.3 percent; p = 0.856), local recurrence (7.1 percent versus 5.6 percent; p = 0.705), distant recurrence (14.3 percent versus 7.9 percent; p = 0.238), disease-free survival (21.4 percent versus 19.0 percent; p = 0.837), and overall survival (14.3 percent versus 7.1 percent; p = 0.181). CONCLUSIONS: No evidence of increased risk in any of the survival outcomes was identified. Lipofilling seems to be a safe procedure for breast reconstruction after surgical treatment of breast cancer. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Oncoplastic Surgery: Does Patient and Medical Specialty Influences the Evaluation of Cosmetic Results?

BACKGROUND: Oncoplastic surgery (OS) has added plastic surgery concepts and techniques to the breast cancer surgery. However, reports of the impact of OS on cosmesis after breast-conserving surgery (BCS) are limited in the literature. PATIENTS AND METHODS: This cross-sectional prospective study included patients who underwent BCS. The patients self-evaluated the cosmetic outcome of the breasts and had them photographed. The photos were evaluated by BCCT.core software and by 6 breast surgeons (mastologists and plastic surgeons) using the Harvard, Garbay, and Fitoussi scales. Kappa and weighted kappa tests were used to analyze agreement for categorical variables; for continuous variables, the interclass correlation index and the chi-square test to analyze the association between the OS and the symmetrization. RESULTS: A total of 300 patients were evaluated: 228 (76.0%) underwent traditional BCS and 72 (24.0%) underwent OS, and of these, 37 (51.4%) underwent contralateral symmetrization surgery. In the evaluation of the cosmetic result, the correlation between patients and observers (BCCT.core and surgeons) was weak; between the 2 groups of surgeons, the correlation was moderate (Fitoussi scale) and excellent (Garbay scale). Plastic surgeons are more critical for evaluating cosmetic results; they considered it good or excellent in 30.0% whereas patients, mastologists, and BCCT.core results considered it so in 78.8%, 34.0%, and 30.0%, respectively. In terms of cosmesis, OS and symmetrization did not influence the results in this study with long follow-up. CONCLUSION: Patients' self-evaluation reported better cosmesis than surgeons' analyses. Plastic surgeons were the most critical. OS and symmetrization did not influence the results.

Project ECHO: A Telementoring Program for Cervical Cancer Prevention and Treatment in Low-Resource Settings.

Cervical cancer incidence and mortality rates are significantly higher in low- and middle-income countries compared with the United States and other developed countries. This disparity is caused by decreased access to screening, often coupled with low numbers of trained providers offering cancer prevention and treatment services. However, similar disparities are also found in underserved areas of the United States, such as the Texas-Mexico border, where cervical cancer mortality rates are 30% higher than in the rest of Texas. To address these issues, we have adopted the Project ECHO (Extension for Community Healthcare Outcomes) program, a low-cost telementoring model previously proven to be successful in increasing local capacity, improving patient management skills, and ultimately improving patient outcomes in rural and underserved areas. We use the Project ECHO model to educate local providers in the management of cervical dysplasia in a low-resource region of Texas and have adapted it to inform strategies for the management of advanced cervical and breast cancer in Latin America and sub-Saharan Africa. This innovative approach, using ECHO, is part of a larger strategy to enhance clinical skills and develop collaborative projects between academic centers and partners in low-resource regions.

Total Breast Reconstruction With Fat Grafting After Internal Expansion and Expander Removal.

INTRODUCTION: The development of fat grafting techniques both in cosmetic and reconstructive breast surgery has highlighted the need to recreate a breast mound using similar tissues and without visible scarring. Our technique combines skin expansion by conventional expanders and breast volume replacement by serial fat grafting and final expander removal. MATERIALS AND METHODS: Fat grafting had been performed both by Coleman technique and Bodyjet system. We report a series of 12 cases enrolled between 2008 and 2013. Each case has been presented in this article, focusing on received treatment, observed complications, and results. RESULTS: Satisfactory results were observed 6 months after the last session in most of the concluded reconstructions with a low complication rate.

Associations of Body Mass Index and Physical Activity With Sexual Dysfunction in Breast Cancer Survivors.

Sexual dysfunction is a common and distressing consequence of breast cancer (BC) treatment. In the present study, we investigated the sexual functioning of BC patients and its association with women's personal characteristics and cancer treatments. In this cross-sectional study, sexual function was assessed using the Female Sexual Function Index (FSFI). The health-related quality of life (HRQOL) was measured using the European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30 and its breast module BR-23. Of the 235 participants approached, 216 participants were included in the study. Of these, 63 patients reported no sexual activity in the last month and thus were analyzed only in relation to the sexual desire domain of FSFI. A total of 154 (71.3 %) patients were classified with hypoactive sexual desire disorder (HSDD). From those patients reporting sexual activity in the last month, 63.3 % (97 out of 153) were classified with sexual dysfunction. Using hierarchical logistic regression, the variance explained (change in R 2) by the addition of body mass index (BMI) and mild to moderate physical activity in the prediction models of sexual dysfunction and HSDD were 6.8 and 7.2 %, respectively. Age, BMI, and physical activity were independently associated with sexual dysfunction and HSDD. Additionally, BC patients with sexual dysfunction reported lower scores on global HRQOL, role functioning, and fatigue. Based on our findings, BC survivors should be encouraged to practice regular physical activity and to lose weight in order to avoid sexual dysfunction. However, future clinical trials are needed to confirm these findings.

Risk Factors for Arm Lymphedema in a Cohort of Breast Cancer Patients Followed up for 10 Years.

BACKGROUND: The etiology of lymphedema is multifactorial, and definition criteria of lymphedema, its limitation, and follow-up must be considered in studies related to risk factors. The aim of this study is to evaluate risk factors related to arm lymphedema in a cohort study with a long follow-up. PATIENTS AND METHODS: The study was performed in 622 breast cancer patients. The main endpoint reported was the presence of clinical lymphedema reported in medical records. Univariate and multivariate regression analyses were performed to identify factors related to lymphedema. RESULTS: 66.4% of the patients were submitted to mastectomy, 88.4% to level III axillary lymphadenectomy, 34.9% to radiotherapy in the supraclavicular fossa, and 4.3% to axillary radiotherapy. The mean follow-up was 96.7 months. 45 patients (7.2%) developed lymphedema, of which 82.2% had developed lymphedema at 60 months. Univariate regression analysis showed that supraclavicular radiotherapy, adjuvant/palliative chemotherapy, ≥ 15 lymph nodes dissected, and axillary surgery increase the lymphedema rate by 1.87, 2.28, 2.03, and 6.17, respectively. Adjusted multivariate regression analysis showed that the combination of axillary dissection and number of lymph nodes dissected was the main factor related to lymphedema (p = 0.017). CONCLUSION: In the pre-sentinel era, axillary dissection and the number of lymph nodes resected are related to 10-year lymphedema.

Anatomy of the nipple and breast ducts.

Over time, variations of mastectomy came up and started allowing the oncological safety and the possibility of an immediate breast reconstruction. Nipple sparing mastectomy (NSM) procedures have strongly increased in frequency and have become one of the best alternatives to treat breast cancer, also improving overall aesthetic outcomes and the achievement of contralateral breast symmetry. The nipple areola-complex (NAC) must be considered the identity of the breast concerning self-esteem of patients. This paper will remind the main anatomical topics around the nipple and breast ducts.

Evaluation of Aesthetic and Quality-of-Life Results after Immediate Breast Reconstruction with Definitive Form-Stable Anatomical Implants.

BACKGROUND: Although there are many reports on different techniques in breast reconstruction, there are few data regarding immediate breast reconstruction with definitive form-stable anatomical implants in terms of aesthetics and quality-of-life outcomes. METHODS: Ninety-four patients underwent mastectomy with immediate breast reconstruction using anatomical implants and contralateral symmetrization. Aesthetic results were evaluated by three different methods: the patient's self-report, the assessment of four independent specialists (two breast surgeons and two plastic surgeons from different institutions), and the BCCT.core software. Quality of life was evaluated by means of the BREAST-Q instrument. RESULTS: Average age ± SD was 52.1 ± 11.6 years. Most of patients had medium size breasts and T1 tumors. Patients had evaluated their aesthetic results better than did software and specialists. There was no significant difference in the comparison between software and specialist's evaluation. Multifactorial analysis showed that age older than 70 years and radiotherapy were significant risk factors for poor aesthetic outcomes after immediate breast reconstruction with implants. Considering quality of life, most of the patients were satisfied with their outcome and psychosocial and sexual well-being. CONCLUSION: Immediate breast reconstruction with implants and contralateral symmetrization had a positive impact on the quality of life and showed satisfactory outcomes when evaluated by subjective and objective methods.

Cirurgia oncoplástica e reconstrutiva da mama: Reunião de Consenso da Sociedade Brasileira de Mastologia / Oncoplastic and reconstructive surgery of the breast: Consensus Meeting of the Brazilian Society of Mastology

Objetivo: Apesar do grande número de publicações em cirurgia oncoplástica e reconstrutiva da mama, diversas questões permanecem controversas. Assim, o objetivo desta Reunião de Consenso, foi desenvolver um guia prático de recomendações baseadas nas melhores evidências disponíveis na literatura. Método: Os painelistas foram os membros da Comissão de Cirurgia Oncoplástica e Reconstrutiva da Sociedade Brasileira de Mastologia. A reunião foi realizada em agosto de 2015 em Bento Gonçalves (RS). Cada painelista recebeu e respondeu previamente um questionário com 46 itens, com base na melhor evidencia cientifica e em sua experiência. Foi considerado consenso a concordância de 75% entre painelistas. Resultados: Houve consenso em 25 itens, dos quais para oito houve concordância de 100%. O mais importantes foram: comprometimento das margens em cirurgia oncoplástica pode ser resolvido com ampliação de margens na maioria dos casos; tumores multifocais não são contraindicação para cirurgia oncoplástica; idade >70 anos não representa contraindicação para uso de técnicas oncoplásticas; reconstrução imediata pode ser indicada com segurança para a maioria das candidatas à mastectomia; pacientes com indicação de radioterapia pós-mastectomia podem ser submetidas à reconstrução imediata, devendo ter ciência dos riscos maiores para mau resultado estético; mastectomia com preservação do complexo areolopapilar é segura nos casos de câncer; radioterapia após a mastectomia com preservação do complexo areolopapilar não está indicada fora dos critérios clássicos de irradiação do plastrão; tela abdominal reduz chances de hernia no caso de reconstrução com TRAM. Conclusão: através desta reunião foi possível estabelecer importantes pontos consensuais de acordo com a opinião dos especialistas, que poderão auxiliar os mastologistas na tomada de decisões em cirurgias oncoplásticas e reconstrutivas da mama.

Objective: Despite the large number of publications in oncoplastic and breast reconstructive surgery, several issues remain controversial. The aim of this Consensus Meeting was to develop a practical guide of recommendations based on the best evidence in the literature. Method: All panelists were members of the Oncoplastic Commission of the Brazilian Society of Mastology. The Consensus Meeting was held in Bento Gonçalves (RS), in August 2015. Each panelist received and answered a questionnaire with 46 items, based on the best evidence in the literature and in their expertise. It was considered consensus the agreement of 75% between panelists. Results: There was consensus on 25 items, of which eight were for 100% agreement. The most important of these topics were: involvement of the margins in oncoplastic surgery can be solved by resection of margins in most cases; multifocal tumors is not a contraindication for oncoplastic surgery; age >70 years is not a contraindication for use of oncoplastic techniques; immediate reconstruction can be performed safely to most candidates for mastectomy; patients for post-mastectomy radiotherapy may be subject to immediate reconstruction and should be aware of the risks for poor aesthetic result; mastectomy with preservation of the nipple and areola complex is safe in cancer; radiotherapy after mastectomy with preservation of the nipple and areola complex is not indicated outside the classical criteria of irradiation chest wall; abdominal mash reduces chances of hernia in TRAM flaps. Conclusion: In this meeting it was possible to establish important consensus points according to the opinion of experts, which can help breast surgeons in their decision-making in oncoplastic and reconstructive surgery of the breast.

Long-Term Comparison of Aesthetical Outcomes After Oncoplastic Surgery and Lumpectomy in Breast Cancer Patients.

BACKGROUND: Lumpectomy may result in major deformities and asymmetries in approximately one-third of patients. Although oncoplastic surgery (OP) could be a useful alternative to avoid them, lack of strong data is causing some debate. The purpose of this study was to compare aesthetic outcomes in patients undergoing OP versus lumpectomy using three different assessment methods. METHODS: A total of 122 patients were included in this cross-sectional multicentric study; 57 underwent OP (46.7 %), and 65 underwent lumpectomy (53.3 %). Two breast surgeons and two plastic surgeons from different institutions using the Garbay scale independently evaluated aesthetic outcomes. BCCT.core software was applied in both groups, and the patients evaluated their aesthetic outcomes answering a questionnaire about their satisfaction rate. RESULTS: OP group had a higher proportion of excellent aesthetic results according to the BCCT.core software analysis (p = 0.028) and the specialists (p = 0.002). Multifactorial analyses showed that age ≥70 years (RP = 6.02; 95 % confidence interval [CI] 1.73-21.0; p = 0.005), tumors in the medial, inferior, and central quadrants (RP = 4.21; 95 % CI 1.88-9.44; p < 0.001), and large breasts (RP = 7.55; 95 % CI 2.48-23.0; p < 0.001) were significant risk factors for poor aesthetic outcomes after lumpectomy. The patients classified their results as better than those by the specialists and by the software, with no statistical difference between the groups. CONCLUSIONS: Excellent aesthetic results were more frequent in the OP group according to BCCT.core software analysis and specialists. In addition, some clinical conditions and tumor locations in the breast can be considered risky factors for poor aesthetic outcomes in lumpectomy.

Quimioterapia neoadjuvante e resposta patológica: coorte retrospectiva / Neoadjuvant chemotherapy and pathologic response: a retrospective cohort

OBJETIVO: Avaliar a taxa de resposta patológica completa atingida pelas pacientes com diagnóstico de câncer de mama localmente avançado submetidas à quimioterapia neoadjuvante baseada no esquema doxorrubicina/ciclofosfamida seguido de paclitaxel. MÉTODOS: Coorte retrospectiva de pacientes admitidas no Hospital de Câncer de Barretos com câncer de mama localmente avançado entre 2006 e 2008 submetidas ao protocolo de doxorrubicina/ciclofosfamida seguido de paclitaxel (4 ciclos de doxorrubicina 60mg/m² e ciclofosfamida 600mg/m² a cada 21 dias; 4 ciclos de paclitaxel 175mg/m² a cada 21 dias). As seguintes variáveis foram avaliadas: idade, menopausa, performance status, estadiamento clínico inicial, dados antropométricos, quimioterapia (dose - duração), perfil de toxicidade, estadiamento clínico pós-tratamento, cirurgia, resposta patológica completa, sobrevida livre de doença e características anatomopatológicas (tipo e grau histológico, perfil hormonal e comprometimento linfonodal). A análise estatística foi realizada considerando-se o nível de significância de 5%. RESULTADOS: Das 434 pacientes avaliadas, 136 foram excluídas por erro no estadiamento ou por terem recebido outro tipo de quimioterapia. A mediana de idade foi 50 anos, todas com performance status 0-1. A mediana do tamanho clínico inicial do tumor foi 65mm e a mediana do tamanho clínico final do tumor foi 22mm. Apresentaram resposta patológica completa 51 (17,1%) pacientes. Aquelas que apresentavam perfil hormonal negativo ou que eram triplo-negativas (Her-2 e perfil hormonal negativos) tiveram impacto favorável na resposta patológica completa. CONCLUSÃO: Quimioterapia neoadjuvante com doxorrubicina/ciclofosfamida seguidas de paclitaxel ofereceu taxa de resposta patológica completa na população estudada de acordo com a literatura. Pacientes triplo-negativas tiveram maior chance de atingir essa resposta.

OBJECTIVE: To evaluate the complete pathologic response attained by patients diagnosed with locally advanced breast cancer submitted to neoadjuvant chemotherapy based on the doxorubicin/cyclophosphamide regimen followed by paclitaxel. METHODS: A retrospective cohort of patients with locally advanced breast cancer, admitted to the Hospital de Câncer de Barretos between 2006 and 2008 submitted to the doxorubicin/cyclophosphamide protocol followed by paclitaxel (4 cycles of doxorubicin 60mg/m² and cyclophosphamide 600mg/m² every 21 days; 4 cycles of paclitaxel 175mg/m² every 21 days). The following variables were assessed: age, menopause, performance status, initial clinical staging, anthropometric data, chemotherapy (dose - duration), toxicity profile, post-treatment staging, surgery, pathologic complete response rate, disease-free survival, and pathological characteristics (type and histological degree, hormonal profile and lymph node involvement). Statistical analysis was performed using a 5% level of significance. RESULTS: Of the 434 patients evaluated, 136 were excluded due to error in staging or because they had received another type of chemotherapy. Median age was 50 years, all with performance status 0-1. Median initial clinical size of tumor was 65mm and the median final clinical size of the tumor was 22mm. Fifty-one (17.1%) patients experienced a pathologic complete response. Those with a negative hormonal profile or who were triple-negative (negative Her-2 and hormonal profile) experienced a favorable impact on the pathologic complete response. CONCLUSION: Neoadjuvant chemotherapy with doxorubicin/cyclophosphamide followed by paclitaxel provided a pathologic complete response in the population studied in accordance with that observed in the literature. Triple-negative patients had a greater chance of attaining this response.