Summary
Deep serratus anterior plane block has been widely adopted as an analgesic adjunct for patients undergoing breast surgery, but robust supporting evidence of efficacy is lacking. We randomly ...allocated 40 patients undergoing simple or partial mastectomy with sentinel node biopsy to receive either a pre‐operative deep serratus anterior plane block (serratus group) or a placebo injection (sham group), in addition to systemic analgesia. The primary outcome measure was the quality of recovery score at discharge, as assessed by the quality of recovery‐15 questionnaire at various time‐points. Secondary analgesic outcomes included: pain severity; postoperative opioid consumption; opioid‐related side‐effects; patient satisfaction up to 7 days postoperatively; and persistent postoperative pain up to 3 months after surgery. All patients who were recruited completed the study. There were no differences in the quality of recovery‐15 scores between patients in the serratus and control groups, with mean (SD) scores of 96 (14) and 102 (20) for the control and serratus groups, respectively. We were also unable to detect differences in any of the secondary analgesic outcomes examined. The addition of a deep serratus anterior plane block to systemic analgesia does not enhance quality of recovery in patients undergoing ambulatory breast cancer surgery.
Background
The growing volume of studies of robot‐assisted nipple‐sparing mastectomy requires critical assessment. This review synthesizes the data on safety, feasibility, oncological and cosmetic ...outcomes, and patient‐reported outcome measures (PROMs) for robot‐assisted nipple‐sparing mastectomy.
Methods
A systematic review was performed using MEDLINE, MEDLINE In‐Process/ePubs, Embase/Embase Classic, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, LILACS, PubMed, ClinicalTrials.Gov, WHO ICTRP and the grey literature. Original studies reporting on patients with breast cancer or at increased risk of breast cancer undergoing robot‐assisted nipple‐sparing mastectomy were included. Risk of bias was assessed using the Institute of Health Economics Case Series Quality Appraisal Checklist.
Results
Of 7177 titles screened, eight articles were included, reporting on 249 robot‐assisted nipple‐sparing mastectomies in 187 women. The indication was either therapeutic (58·6 per cent) or prophylactic (41·4 per cent), with immediate reconstruction performed in 96·8 per cent. Surgical techniques followed a similar approach, with variations in incision, robot models, camera and insufflation. Postoperative morbidity included skin complications, lymphocele, infection, seroma, haematoma and skin ischaemia/necrosis. Complications specific to the nipple–areolar complex included ischaemia and necrosis. There were two conversions owing to haemorrhage, but no intraoperative deaths. Three patients had positive margins. Follow‐up time ranged from 3·4 to 44·8 months. Locoregional recurrences were not observed. PROMs and objective cosmetic outcomes were reported inconsistently. Data on nipple sensitivity were not reported.
Conclusion
Robot‐assisted nipple‐sparing mastectomy is feasible with acceptable short‐term outcomes but it remains in the assessment phase.
Antecedentes
El volumen creciente de estudios en los que se realiza una mastectomía con preservación de pezón asistida por robot requiere una evaluación crítica. Esta revisión sintetiza la seguridad, factibilidad y los resultados oncológicos, estéticos y percibidos por la paciente (patient‐reported outcome measures, PROMs) tras la mastectomía con preservación del pezón asistida por robot.
Métodos
Se realizó una revisión sistemática utilizando Medline, Medline In‐Process/ePubs, Embase/Embase Classic, el registro Cochrane Central de ensayos clínicos, la base de datos Cochrane de revisiones sistemáticas, LILACS, PubMed, ClinicalTrials.Gov, WHO ICTRP y la literatura gris (desde su inicio hasta el 3/5/2020). Se incluyeron los estudios originales en los que se realizaba una mastectomía con preservación de pezón asistida por robot en pacientes con cáncer de mama o con un aumento del riesgo de cáncer de mama. La posibilidad de sesgo se evaluó mediante la lista de verificación para la evaluación de la calidad de series de casos del Instituto de Economía de la Salud (Institute of Health Economics).
Resultados
De 7.177 artículos identificados, se seleccionaron 8 con 249 mastectomías con preservación de pezón asistidas por robot en 187 mujeres. La indicación fue terapéutica (58,6%) o profiláctica (41,4%) y la reconstrucción se realizó de forma inmediata en el 96,8% de los casos. La mediana de seguimiento más larga fue de 19 meses (rango 1,3‐44 meses), y no se detectaron recidivas locorregionales. La técnica quirúrgica siguió un esquema similar, con diferencias en la incisión, modelo de robot, cámara e insuflación. Las complicaciones incluyeron complicaciones cutáneas, como necrosis, linfocele, infección de heridas, hematoma, seroma y necrosis del pezón. Hubo dos conversiones por hemorragia, pero ningún caso de mortalidad intraoperatoria. La presentación de datos respecto a los PROMs y los resultados cosméticos fue irregular.
Conclusión
La mastectomía con preservación de pezón asistida por robot es segura, factible y tiene resultados oncológicos aceptables a corto plazo. El procedimiento sigue siendo experimental y es preciso evaluar los resultados oncológicos a largo plazo y los PROMs en ensayos prospectivos comparativos y aleatorizados.
This study synthesizes the data on safety, feasibility, and oncological, cosmetic and patient‐reported outcomes of robotic nipple‐sparing mastectomy (RNSM). Among eight included studies reporting on 249 procedures in 187 women, RNSM was reported as safe and feasible, and had acceptable short‐term oncological outcomes. RNSM remains experimental; there is a need to evaluate long‐term oncological and patient‐reported outcomes in future prospective comparative and randomized studies.
Still experimental
Given numerous publications and clinical trials regarding axillary management in breast cancer, we sought to summarize this complex literature to help clarify this field for clinicians. This ...systematic review focuses on the role of irradiation of the axillary nodes (locoregional nodal irradiation LRNI) in the management of the axilla in patients with early-stage breast cancer in various clinical settings.
We searched MEDLINE and EMBASE databases, the Cochrane library, the proceedings of the ASCO, the ASTRO, the ESMO, the ESTRO, and the San Antonio Breast Cancer Symposium (2016–2019) meetings. The quality of the studies was assessed with design-specific tools. The study was registered in PROSPERO.
We included one systematic review, one individual patient data (IPD) meta-analysis, and five randomized controlled trials (RCTs). After axillary lymph node dissection (ALND), LRNI resulted in small benefits in breast cancer specific mortality, locoregional recurrence, and distant metastases-free survival but not overall survival. After a positive sentinel node biopsy (SLNB), LRNI may provide equivalent locoregional control and disease-free survival (DFS) compared to ALND with a lower risk of lymphedema. No randomized data is available for the neoadjuvant setting.
The summary of the role of radiation, is relevant to radiation oncologists for choosing the correct cohort of patient requiring LRNI and to surgeons making clinical decisions regarding the timing and type of breast reconstruction offered to patients.
•Node positive patients have modest benefits from regional radiation.•Some node negative patient subsets may also benefit modestly from regional radiation.•Regional nodal irradiation may be equivalent to axillary node dissection with less lymphedema.•The optimal locoregional approach in the neoadjuvant setting is the subject of ongoing clinical trials.
Abstract Objectives The information needs of cancer patients are highly variable. Literature suggests an improved ability to modulate personalised stress, increased patient involvement with decision ...making, greater satisfaction with treatment choices and reduced anxiety levels in cancer patients who have access to information. The aim of this project was to evaluate the effects of a mobile information application on anxiety levels of patients undergoing surgery for breast cancer. Materials and methods An application was developed for use with Apple iPad containing information on basic breast cancer biology, different treatments used and surgical techniques. Content and face validity studies were performed. A randomized control trial was designed, with a 1:2 allocation. Data collected include basic demographics and type of surgery. Questionnaires used included: the HADS, Mini-MAC, information technology familiarity and information satisfaction. Results A total of 39 women participated. 13 women had access to an iPad containing additional information and 26 women acted as controls. The mean age was 54 and technology familiarity was similar among both groups. Anxiety and depression scores at seven days were significantly lower in control patients without access to the additional information provided by the mobile application (p = 0.022 and 0.029 respectively). Conclusion Anxiety and depression in breast cancer patients is both multifactorial and significant, with anxiety levels directly correlating with reduced quality of life. Intuitively, information should improve anxiety levels, however, we have demonstrated that surgical patients with less information reported significantly lower anxiety. We advise the thorough testing and auditing of information initiatives before deployment.
Background
Papillary lesions of the breast are a relatively rare, but heterogeneous group ranging from benign to atypical and malignant. Debate exists regarding the optimal management of these ...lesions. In the absence of more accurate risk-stratification models, traditional management guidelines recommend surgical excision, despite the majority of lesions proving benign. This study sought to determine the rate of malignancy in excised breast papillomas and to elucidate whether there exists a population in which surgical excision may be unnecessary.
Methods
A multicenter international retrospective review of core biopsy diagnosed breast papillomas and papillary lesions was performed between 2009 and 2013, following institutional ethical approval. Patient demographics, histopathological, and radiological findings were recorded. All data was tabulated, and statistical analysis performed using Stata.
Results
A total of 238 patients were included in the final analysis. The age profile of those with benign pathology was significantly younger than those with malignant pathology (
p
< 0.001). Atypia on core needle biopsy was significantly associated with a final pathological diagnosis of malignancy (OR = 2.73). The upgrade rate from benign core needle biopsy to malignancy on the final pathological sample was 14.4 %; however, only 3.7 % had invasive cancer.
Conclusions
This international dataset is one of the largest in the published literature relating to breast papillomas. The overall risk of malignancy is significantly associated with older age and the presence of atypia on core needle biopsy. It may be possible to stratify higher-risk patients according to age and core needle biopsy findings, thereby avoiding surgery on low-risk patients.
Purpose
In this study, we aimed to describe the real-life practice outcomes of pertuzumab–trastuzumab–taxane (PTT) combination in visceral organ metastatic, trastuzumab-naive breast cancer (BC) ...patients.
Methods
This study was conducted by Turkish Oncology Group and included 317 patients’ data from 36 centers.
Results
Median age was 51 (22–82). Median PFS was 28.5 months, while median OS was 40.3 months. Patients with brain metastases (
n
: 13, 4.1%) had worse PFS (16.8 m vs. 28.5 m;
p
= 0.002) and OS (26.7 m vs. 40.3 m;
p
= 0.009). Patients older than 65 years of age (
n
: 42, 13.2%) had significantly lower OS results (19.8 m vs. 40.3 m;
p
= 0.01). Two hundred sixty-eight patients (86.7%) received docetaxel while 37 patients (11.7%) received paclitaxel. PFS and OS were similar between taxane groups. In eight patients (2.5%), 5–40% ejection fraction decrement from baseline was detected without any clinical sign of heart failure.
Conclusions
Our RLP trial included only visceral metastatic, trastuzumab-naïve BC patients including cases with brain involvement who received PTT combination in the first-line treatment. Regardless of negative prognostic characteristics, our results are in parallel with pivotal trial. Further strategies for brain metastasis should be developed to improve outcomes despite encouraging results with PTT treatment. Taxane selection can be personalized and endocrine maintenance may further improve outcomes after taxanes were discontinued. To our knowledge, this is the largest scale real-life clinical practice study of pertuzumab–trastuzumab–taxane therapy to date.
Background
Breast cancer is the most common female cancer in North America. Axillary lymph node dissection (ALND) is important for staging, prognosis, and adjuvant treatment decisions. The purpose of ...this study was to identify factors that affect the number of lymph nodes (LN) retrieved in ALND for breast cancer.
Methods
All patients who underwent ALND for breast cancer at Sunnybrook Health Sciences Centre and Women’s College Hospital between July 1999 and June 2006 were included. The number of LN retrieved was identified from pathology reports. Univariate and multivariate analysis was undertaken to identify variables influencing this outcome.
Results
1084 patients were identified with a mean number of LN of 14.5. In multivariate analyses, significant covariates included sentinel LN biopsy (
P
= 0.011), degree of extranodal extension (
P
= 0.005), tumor grade (
P
= 0.058), and age (
P
= 0.043). Thirteen percent of the variation in LN yield was accounted for by institutional, provider, patient, and tumor related factors, leaving 87% attributable to inherent biological or other differences between patients.
Conclusion
The yield of ALND may be influenced by multiple factors, often not related to the surgery. In settings where >10 LNs are routinely retrieved at ALND, biological variation between patients should be recognized as major a contributor to the LN yield. Adjuvant treatment decisions based on this outcome should take this into consideration.
Abstract
Aims
To evaluate the relationship between HbA
1c
and fasting plasma glucose (FPG) and postprandial plasma glucose (PPG) levels, and to estimate the mean plasma glucose (mPG) derived from ...FPG and PPG that would predict Type 2 diabetic subjects with poor glycaemic control.
Methods
FPG, PPG and HbA
1c
values from 565 Type 2 diabetic patients (247 men and 318 women) were recorded. Linear regression analysis and Pearson's correlation was used to determine the relationship between HbA
1c
, FPG and PPG. FPG and PPG were included as explanatory variables of HbA
1c
in linear regression analysis.
Results
The American Diabetes Association's objective of achieving an HbA
1c
level < 7.0% was obtained in 26.2% of the patients. The coefficients of FPG and PPG which determined HbA
1c
were similar. Therefore, mPG was calculated using the equation (FPG + PPG)/2. Pearson's correlation coefficient for HbA
1c
and FPG, PPG and mPG were 0.723 (
P <
0.0001), 0.734 and 0.761 (
P <
0.0001), respectively. A mPG cut‐off value of 10 mmol/l predicted an HbA
1c
> 7% in the whole population, with a sensitivity of 84.2% and specificity of 80.4%. The area was high (0.90) in receiver‐operating characteristic (ROC) curve analysis performed to examine the performance of mPG to predict HbA
1c
> 7%.
Conclusions
The mPG derived from FPG and PPG correlates strongly with HbA
1c
. We therefore suggest that using a cut‐off of 10 mmol/l for mPG may be appropriate in diabetes management in the primary‐care setting, where most management of Type 2 diabetes occurs.
Making a differential diagnosis between malignant and non-malignant ascites is an important clinical issue, but cytological examination has a relatively low diagnostic sensitivity. This study aimed ...to find a discriminative model that distinguished between malignancy-related and non-malignant ascites. The study included 107 patients: 50 with non-malignant and 57 with malignant ascites. Ascites was analysed using a range of tumour markers and standard cytology. Standardized canonical discriminant function coefficients were used to distinguish between ascites types. The combination of carbohydrate antigen (CA) 15-3, carcinoembryonic antigen (CEA) and cytokeratin 19 fragments (CYFRA-21.1) discriminated between malignancy-related ascites and non-malignant ascites with an accuracy of 98.8% compared with an accuracy of 77.8% for cytological examination. In conclusion, the use of a discriminant function constructed from a combination of CA15-3, CEA and CYFRA-21.1 could distinguish malignant from non-malignant ascites with greater accuracy than cytological examination. Further studies in larger population groups are warranted.
Abstract
Background:Less than 14% of older women undergo post-mastectomy breast reconstruction. A major reason for the low rate is the concern about post-operative complications. A thorough analysis ...of surgical complications by age group is limited in previous studies. The aim of this study is to determine the surgical complication rates of older women (≥70 years old) with breast cancer who underwent breast reconstruction and compare them to younger women (18–69 years old).
Methods: Data from the National Surgical Quality Improvement Program (NSQIP) database were used to identify women with carcinoma in situ and invasive breast cancer who underwent delayed or immediate breast reconstruction (2005-2016). The primary outcome was 30-day post-operative surgical complications; the secondary outcome was 30-day mortality.Patient demographics, comorbidities, and 30-day postoperative complications and mortality rates were compared across age groups and each type of reconstruction.
Results: Of 42,929 women who underwent breast reconstruction, 2,615 (6.1%) were older women. Although compared to young women, older women were more likely to have medical comorbidities their American Society of Anesthesiologists' (ASA) classification was lower.Tumor histology distribution was similar in both groups. Lymph node surgery and neoadjuvant chemotherapy was significantly less frequent among older women. Compared to young women, older women more frequently underwent immediate breast reconstruction (IBR) n=2,405 (92%) versus n=33,580 (88.3%), p<0.0001 but less frequently underwent delayed breast reconstruction n=209 (8%) versus n=4,734 (11.7%), p<0.0001. Prosthesis-based reconstruction was the most common technique in both age groups. Autologous reconstruction was significantly less common amongst older women than young women n=517 (19.8%) versus n=10,011 (24.8%), p<0.0001. Older women experienced higher rates of superficial surgical site infection (SSI) n=69 (2.6%) versus n=716, (1.8%), p=0.002 and urinary tract infection n=15 (0.6%) versus n=101 (0.3%) p =0.005. However, the rates of deep SSI, dehiscence, pneumonia, thromboembolism, renal complications, cardiac events, and sepsis were similar between both groups. Older women had significantly lower rates of events of bleeding requiring transfusion n=27 (1%) versus n=736 (1.8%), p=0.002 and flap failure n=2 (0.4%) versus n=210 (2.1%), p=0.006). Return to the operating room within 30-days was similar between older and young women n=171 (6.5%) versus n=2,821 (7.0%,) p=0.4. Thirty-day deaths were rare events older n=3 (0.1%) and young n=10 (0.02%), p=0.05.
Conclusions: Overall, 30-day postoperative complications in older women who undergo breast reconstruction are extremely low. Infection rates were slightly higher in the older group however; severe complications such as flap failure, bleeding, reoperation, and death were more common in young women. Age alone did not confer an increased risk of complications after breast reconstruction. Breast reconstruction can be safely offered to older women undergoing breast cancer treatment.
Citation Format: Angarita FA, McCready DR, Cil T. Is breast reconstruction safe in women over 70? An analysis of the national surgical quality improvement program (NSQIP) database abstract. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P5-16-01.
