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Oncologic outcomes after immediate breast reconstruction following mastectomy: comparison of implant and flap using propensity score matching.

ABSTRACT: BACKGROUND:Although immediate breast reconstruction has been reported to be oncologically safe, no affirmative study comparing the two reconstruction methods exists. We investigated breast cancer recurrence rates in two breast reconstruction types; implant reconstruction and autologous flap reconstruction. METHODS:A retrospective cohort study was performed on propensity score-matched (for age, stage, estrogen receptor status) patients who underwent IBR after mastectomy at Seoul National University Hospital between 2010 and 2014. The main outcomes determined were locoregional recurrence-free interval (LRRFI) and disease-free interval (DFI). RESULTS:We analyzed 496 patients among 731 patients following propensity score matching (Median age 43, 247 implant reconstruction and 249 flap reconstruction). During median follow-up of 58.2?months, DFI was not different between the two groups at each tumor stage. However, flap reconstruction showed inferior DFI compared to implant reconstruction in patients with high histologic grade (p?=?0.012), and with high Ki-67 (p?=?0.028). Flap reconstruction was related to short DFI in multivariate analysis in aggressive tumor subsets. Short DFI after flap reconstruction in aggressive tumor cell phenotype was most evident in hormone positive/Her-2 negative cancer (p?=?0.008). LRRFI, on the other hand, did not show difference according to reconstruction method regardless of tumor cell aggressiveness. CONCLUSION:Although there is no difference in cancer recurrence according to reconstruction method in general, flap-based reconstruction showed higher systemic recurrence associated with histologically aggressive tumors.

SUBMITTER: Ha JH

PROVIDER: S-EPMC6993337 | biostudies-literature | 2020 Jan

REPOSITORIES: biostudies-literature

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Oncologic outcomes after immediate breast reconstruction following mastectomy: comparison of implant and flap using propensity score matching.

Ha Jeong Hyun JH Hong Ki Yong KY Lee Han-Byoel HB Moon Hyeong-Gon HG Han Wonshik W Noh Dong-Young DY Lim Joonho J Yoon Sehoon S Chang Hak H Jin Ung Sik US

BMC cancer 20200130 1

<h4>Background</h4>Although immediate breast reconstruction has been reported to be oncologically safe, no affirmative study comparing the two reconstruction methods exists. We investigated breast cancer recurrence rates in two breast reconstruction types; implant reconstruction and autologous flap reconstruction.<h4>Methods</h4>A retrospective cohort study was performed on propensity score-matched (for age, stage, estrogen receptor status) patients who underwent IBR after mastectomy at Seoul Na ...[more]

PMID: 32000718

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Project description:BackgroundImplant-based breast reconstruction (IBBR) is the most commonly performed reconstructive procedure following mastectomy. IBBR techniques are evolving rapidly, with mesh-assisted subpectoral reconstruction becoming the standard of care and more recently, prepectoral techniques being introduced. These muscle-sparing techniques may reduce postoperative pain, avoid implant animation and improve cosmetic outcomes and have been widely adopted into practice. Although small observational studies have failed to demonstrate any differences in the clinical or patient-reported outcomes of prepectoral or subpectoral reconstruction, high-quality comparative evidence of clinical or cost-effectiveness is lacking. A well-designed, adequately powered randomised controlled trial (RCT) is needed to compare the techniques, but breast reconstruction RCTs are challenging. We, therefore, aim to undertake an external pilot RCT (Best-BRA) with an embedded QuinteT Recruitment Intervention (QRI) to determine the feasibility of undertaking a trial comparing prepectoral and subpectoral techniques.Methods and analysisBest-BRA is a pragmatic, two-arm, external pilot RCT with an embedded QRI and economic scoping for resource use. Women who require a mastectomy for either breast cancer or risk reduction, elect to have an IBBR and are considered suitable for both prepectoral and subpectoral reconstruction will be recruited and randomised 1:1 between the techniques.The QRI will be implemented in two phases: phase 1, in which sources of recruitment difficulties are rapidly investigated to inform the delivery in phase 2 of tailored interventions to optimise recruitment of patients.Primary outcomes will be (1) recruitment of patients, (2) adherence to trial allocation and (3) outcome completion rates. Outcomes will be reviewed at 12 months to determine the feasibility of a definitive trial.Ethics and disseminationThe study has been approved by the National Health Service (NHS) Wales REC 6 (20/WA/0338). Findings will be presented at conferences and in peer-reviewed journals.Trial registration numberISRCTN10081873.

Project description:BACKGROUND:Fluid management of the surgical patient has undergone a paradigm shift over the past decade. A change from 'wet' to 'dry' to a 'goal-directed' approach has been witnessed. The fluid management of patients undergoing free flap reconstruction is particularly challenging. This is typically a long operation with minimal surgical stimulation, and hypotension often ensues. The use of vasopressors in these cases is contraindicated to maintain adequate flow to the flap. Hypotension is often treated with intravenous fluid boluses. However, aggressive fluid administration to maintain adequate blood pressure can result in flap edema, venous engorgement and, ultimately, flap loss. OBJECTIVE:The primary objective of the present study was to determine whether goal-directed fluid therapy, titrated to maintain stroke volume variation ?13%, with the use of an arterial pulse contour device results in improved postoperative cardiac index (CI) and stroke volume index (SVI) with reduced amounts of intravenous fluid. The primary end points studied were CI, SVI and cumulative crystalloid/colloid administration. METHODS:Twenty female patients undergoing simultaneous microvascular free flap reconstruction immediately following mastectomy were studied. Preoperative and intraoperative care were standardized. Each patient received intra-arterial blood pressure monitoring. In all patients, cardiac output measurement occurred throughout the intraoperative period using the arterial pulse contour device. Control patients had their fluid administered at the discretion of the anesthesiologist (blinded to results from the cardiac output device). Patients in the intervention group had a baseline crystalloid infusion of 5 mL/kg/h, with intravenous colloid boluses to maintain a stroke volume variation ?13%. RESULTS:There was no difference in heart rate or mean arterial pressure between groups at the end of the operation. However, at the end of the operation, the intervention group had significantly higher mean (± SD) CI (3.8±0.8 L/min/m(2) versus 3.0±0.5 L/min/m(2); P=0.02) and SVI (51.4±2.4 mL/m(2) versus 43.3±2.3 mL/m(2); P=0.03). This improved CI and SVI was achieved with similar amounts of administered intraoperative fluid (5.8±0.5 mL/kg/h versus 5.0±0.7 mL/kg/h, control versus intervention). The intervention group required less postoperative fluid resuscitation during the early postoperative period (total fluid administered from end of operation to midnight of the operative day, 6.4±1.9 mL/kg/h versus 10.2±3.3 mL/kg/h, intervention versus control, respectively, P<0.01). DISCUSSION:Goal-directed fluid therapy using minimally invasive cardiac output monitoring resulted in improved end-operative hemodynamics, with less 'rescue' fluid administration during the perioperative period.

Project description:BackgroundAlthough video-assisted breast surgery is gaining popularity, endoscopic reconstruction after mastectomy is still facing lots of problems, bring about that endoscopic method has not yet become a standard procedure for breast cancer reconstruction. Here, we introduce a novel surgical technique of video-assisted transaxillary nipple-sparing mastectomy and immediate implant-based breast reconstruction and describe the detailed surgical procedure using this technique.MethodsDetailed steps of surgical procedure, the patient characteristics and the mean operative time of this new technique were described in this article. All patients were asked to score their satisfaction with their reconstructed breasts preoperatively, 1 month, 3 months, 6 months and 12 months postoperatively using the BREAST-Q.ResultsAt first, we used our "conventional method" and performed on 10 patients from April 2017 to June 2020; the operative time was 324.80 ± 66.39 minutes. After improving several procedures of the technique, the "optimized method" was performed on 14 cases from July 2020 to November 2020; the operative time decreased to 193.71 ± 28.75 minutes with shortest was 133 minutes; the optimized method was novel and easy to learn and be generalized. Most of the patients were satisfied with the reconstruction results. There was no significant difference between preoperative scores and scores at 3 months, 6 months and 12 months (p = 0.364). Since there is no wound on the breast dome, no obvious postoperative complications were observed except for one patient presented with infection.ConclusionsThis new technique has allowed surgeons to achieve excellent and reproducible outcomes in a single-stage procedure and represents an excellent technique for patients who wish to have a scarless and aesthetically pleasing appearance after mastectomy for breast cancer. This article also highlights the mean operative time (193.71 ± 28.75 minutes) that has been made possible with this new technique.Level of evidence vThis journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors http://www.springer.com/00266 .

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Oncologic outcomes after immediate breast reconstruction following mastectomy: comparison of implant and flap using propensity score matching.

Publications

Oncologic outcomes after immediate breast reconstruction following mastectomy: comparison of implant and flap using propensity score matching.

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