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PubMed2006

The course of distress in women at increased risk of breast and ovarian cancer due to an (identified) genetic susceptibility who opt for prophylactic mastectomy and/or salpingo-oophorectomy.

The levels and course of psychological distress before and after prophylactic mastectomy (PM) and/or prophylactic salpingo-oophorectomy (PSO) were studied in a group of 78 women. General distress was measured through the hospital anxiety and depression scale (HADS), cancer-related distress using the impact of events scale (IES). Measurement moments were baseline (2-4 weeks prior to prophylactic surgery), and 6 and 12 months post-surgery. After PM, anxiety and cancer-related distress were significantly reduced, whereas no significant changes in distress scores were observed after PSO. At one year after prophylactic surgery, a substantial amount of women remained at clinically relevant increased levels of cancer-related distress and anxiety. We conclude that most women can undergo PM and/or PSO without developing major emotional distress. More research is needed to further define the characteristics of the women who continue to have clinically relevant increased scores after surgery, in order to offer them additional counselling.

Adult↗
PubMed2006

Partner experiences of breast reconstruction post mastectomy.

The aim of this small-scale, qualitative study was to explore partners' experiences of breast reconstruction after mastectomy. Interviews with 6 men, analysed using thematic analysis identified key themes of Involvement in the Decision-Making Process, Giving and Seeking Support, Opportunity to Talk, and Adapting Behaviour. Whilst most participants wanted to be involved in the decision-making process, they reported having experienced barriers to this, including difficulty in talking to others and expressing their true feelings about the surgery. Participants described difficulties with intimate contact after their partner had undergone surgery due to reactions to the appearance and feel of the reconstructed breast and a fear of hurting their partner and of reopening scars. This study highlights the need to recognise the role of the partner's involvement and of their own experiences during this time. The findings are of value to healthcare professionals, in particular specialist nurses, who work with women undergoing breast reconstruction and indicate areas where further research is needed.

Adaptation, Psychological↗
PubMed2004

A comparative study of envelope mastectomy and immediate reconstruction (EMIR) with standard latissimus dorsi immediate breast reconstruction.

BACKGROUND: Latissimus dorsi breast reconstruction has problems with scars at the donor site and on the reconstructed breast. We report the feasibility and aesthetic results of Envelope Mastectomy and Immediate Reconstruction (EMIR), which utilises a single lateral mammary fold incision. PATIENTS AND METHODS: Between 2001 and 2002, 20 EMIRs were performed in 19 patients, one as a staged bilateral procedure. Twenty consecutive patients, matched for body habitus, who had undergone standard latissimus dorsi breast reconstruction by the same surgeon from 1996 to 2000 were used as controls. Patient satisfaction was assessed using a validated Body Image Scale. Standard post-operative photographs were scored by three independent observers. RESULTS: Length of stay and complication rates were equivalent between both groups. Cosmetic self-assessment scores on the Body Image Scale and scores by the independent observers were satisfactory for both groups but no statistically significant difference was observed between groups. CONCLUSIONS: EMIR is a technically feasible and cosmetically acceptable method of immediate breast reconstruction.

Breast Neoplasms↗
PubMed2004

Cyclooxygenase-2 expression correlates with diminished survival in invasive breast cancer treated with mastectomy and radiotherapy.

PURPOSE: To evaluate the relationship between cyclooxygenase-2 (COX-2) expression and pathologic features and outcome in invasive breast cancer. METHODS AND MATERIALS: Formalin-fixed, paraffin-embedded tumor specimens from 23 women with invasive breast cancer were stained for COX-2 expression. All women underwent mastectomy and locoregional radiotherapy. The distribution (percentage of positive staining cells) and intensity of COX-2 expression within the tumor cells were compared with clinical factors, including stage, grade, lymph node involvement, and outcome. RESULTS: For invasive breast cancer, the distribution and intensity of COX-2 tumor expression correlated significantly with diminished overall survival. The 5-year overall survival rate was 100% for patients with <75% of breast cancer cells expressing COX-2 compared with 49% for patients with > or =75% (p = 0.044). The 5-year overall survival rate was 100% for patients with COX-2 intensity <80 compared with 60% for patients with COX-2 intensity > or =80 (p = 0.018). The percentage and intensity of COX-2 expression also correlated significantly with disease-free survival. The percentage of cells expressing COX-2 was significantly greater in women <40 years old than in women > or =40 years old (81% vs. 59%, respectively, p = 0.04). CONCLUSION: Both the distribution and the intensity of COX-2 expression correlated significantly with disease-free and overall survival in patients with invasive breast cancer. Younger patients with invasive breast cancer may have a greater percentage of COX-2 expression in their tumors.

Adult↗
PubMed2005

Patient subsets with T1-T2, node-negative breast cancer at high locoregional recurrence risk after mastectomy.

PURPOSE: To identify patient subsets with T1-T2N0 breast cancer at high risk of locoregional recurrence (LRR) who may warrant consideration for postmastectomy radiotherapy. METHODS AND MATERIALS: Data were analyzed for 1505 women referred between 1989 and 1999 with pathologic T1-T2N0M0 breast cancer treated with mastectomy with clear margins and no adjuvant radiotherapy. Logistic regression analysis was performed to identify statistically significant factors associated with LRR. Recursive partitioning was used to develop a classification tree model for LRR given the prognostic variables. RESULTS: The median follow-up was 7.0 years. The 10-year Kaplan-Meier LRR rate was 7.8%. On logistic regression analysis, the statistically significant factors predicting LRR were histologic grade (p <0.0001), lymphovascular invasion (LVI) (p <0.0001), T stage (p = 0.05), and systemic therapy use (p = 0.01). In the recursive partitioning model, the first split in the classification tree was histologic grade. For 972 patients without high-grade histologic features, the 10-year Kaplan-Meier LRR rate was 5.5%. For 533 patients with Grade 3 disease (LRR rate 12.1%), the concomitant presence of LVI was associated with a LRR rate of 21.2% (n = 126). In patients with Grade 3 disease without LVI, T2 tumors conferred a LRR rate of 13.4% (n = 194), which increased to 23.2% for patients who did not receive systemic therapy (n = 63). CONCLUSION: Women with pT1-T2N0 breast cancer experienced a LRR risk of approximately 20% in the presence of Grade 3 disease with LVI or Grade 3 disease, T2 tumors, and no systemic therapy. These subsets of node-negative patients warrant consideration of for postmastectomy radiotherapy.

Adult↗
PubMed2005

Locoregional recurrence rates and prognostic factors for failure in node-negative patients treated with mastectomy: implications for postmastectomy radiation.

PURPOSE: Postmastectomy radiation therapy (PMRT) reduces locoregional recurrence (LRR) of breast cancer. Survival appears improved in patients at higher risk for LRR. This study addresses whether subsets of node-negative patients with sufficiently high risk of LRR might benefit from PMRT. METHODS: Retrospective analysis of a cohort of 877 cases of node-negative breast cancer treated with mastectomy, without adjuvant radiation, from 1980 to 2000. RESULTS: Median follow-up was 100 months. Ten-year cumulative incidence of LRR as first event was 6.0%. Size greater than 2 cm, margin less than 2 mm, premenopausal status, and lymphovascular invasion (LVI) were independently significant prognostic factors. Ten-year LRR was 1.2% for those with 0 risk factors, 10.0% for those with 1 risk factor, 17.9% for those with 2 risk factors, and 40.6% for those with 3 risk factors. The chest wall was the site of failure in 80% of patients. CONCLUSION: Postmastectomy radiation therapy has not been recommended for node-negative patients because the LRR rate is low in that population overall. This study suggests, however, that node-negative patients with multiple risk factors, including close margins, T2 or larger tumors, premenopausal status, and LVI, are at higher risk for LRR and might benefit from PMRT. Because the chest wall is the most common site of failure, treating the chest wall alone in these patients to minimize toxicity is reasonable.

Analysis of Variance↗
PubMed2004

Some cases of severe post-mastectomy pain syndrome may be caused by an axillary haematoma.

Post-mastectomy pain syndrome (PMPS) is experienced by 20-65% of patients who undergo breast surgery for cancer. The etiology of this chronic neuropathic pain syndrome is unclear and most likely multi-factorial. Symptoms may be mild, not requiring treatment, or severe, considerably restricting quality of life. The effectiveness of available pharmacological and pain management therapies is unknown. Certainly, some women remain under-treated with poor pain control. We report three women undergoing wide local excision for cancer of the breast and block dissection of axillary lymph nodes who subsequently developed severe PMPS. In these cases the symptoms were completely relieved by the aspiration or formal drainage of an encapsulated haematoma in the axilla. The removal of a minimal amount of blood brought instant improvement suggesting that pressure within the haematoma could be an etiological factor. An axillary haematoma, which may not be clinically obvious, should be considered as a possible cause of PMPS.

Aged↗
PubMed2006

Loco-regional recurrence after mastectomy in high-risk breast cancer--risk and prognosis. An analysis of patients from the DBCG 82 b&c randomization trials.

BACKGROUND AND PURPOSE: In the DBCG 82 b&c trials, 3,083 patients with stages II and III breast cancer were randomised to receive post-mastectomy radiotherapy (RT) versus no RT in addition to systemic therapy. The study showed a decrease in loco-regional recurrences and an improved survival in patients receiving RT. The aim of the present study was to identify risk factors for loco-regional recurrence (LRR), to evaluate the treatment of LRR and to examine the prognosis after LRR. PATIENTS AND METHODS: The 18-year probabilities of LRR were calculated for different prognostic factors using the Kaplan-Meier method. The efficacy of different LRR treatments was compared. The 5-year survival and distant metastases (DM) probability after LRR was calculated with regard to initial randomization group, primary tumor and recurrence related variables. RESULTS: Of the 3,083 patients, 535 had a LRR alone as first site of failure. In univariate analyses, large primary tumor size, ductal carcinoma, high malignancy grade, fascia invasion, few removed nodes, many positive nodes and extracapsular invasion were all risk factors for developing LRR. Combined treatment with surgery and RT at the time of LRR increased the persistent loco-regional control. The 5-year probability of subsequent DM was 73% irrespective of initial randomization group. In multivariate analysis, large primary tumor size, many positive nodes, extracapsular invasion, supra/infraclaviculary failures, multiple LRR and a short interval less than 2 years to first LRR were poor prognostic factors for survival. CONCLUSIONS: Twenty-seven percent of LRR patients had no DM 5 years after failure. Initial randomization group did not alter the prognosis after LRR. Combined treatment of the LRR with surgery and RT improved persistent loco-regional control compared with surgery or RT alone.

Adult↗
PubMed2003

The use of skin sparing mastectomy in the treatment of breast cancer: The Emory experience.

INTRODUCTION: Long-term follow-up of the use of skin sparing mastectomy (SSM) in the treatment of breast cancer is presented to determine the impact of local recurrence (LR) on survival. METHODS: 565 cases of breast cancer were treated by SSM and IBR from 1/1/1989-12/31/1998. The AJCC pathological staging was Stage 0 175 (31%), Stage I 135 (23.9%), Stage II 173 (30.6%), Stage III 54 (9.6%), Stage IV 8 (1.4%), recurrent 20 (3.5%). Forty-one patients received postoperative adjuvant radiation therapy. RESULTS: Thirty-one patients developed a LR during the follow-up including five who received adjuvant radiation. The distribution of LR stratified by cancer stage was Stage 0 1 (3.2%), Stage I 5 (16.1%), Stage II 17 (54.8%), Stage III 6 (19.4%), and recurrent 2 (6.5%). The overall LR was 5.5%. Isolated LRs were treated with surgical resection and radiation therapy if not previously administered. Twenty-four patients (77.4%) developed a systemic relapse and 7 (22.6%) patients remained free of recurrent disease at a mean follow-up of 78.1 months. The cancer stage of those remaining disease free was Stage 0 1, Stage I 4, and Stage II 2. CONCLUSIONS: LR of breast cancer after SSM is not always associated with systemic relapse.

Adult↗
PubMed1994

Determinants of hospital stay after modified radical mastectomy.

The most expeditious way of reducing surgical costs is through reducing hospital stay. Multivariate analysis was used to identify potentially alterable factors affecting postoperative hospital stay for 73 consecutive patients undergoing modified radical mastectomy by 6 surgeons during a 12-month period. Stepwise logistic regression was used to identify independently significant preoperative variables associated with hospital stays equal to or greater than the median of 5 days. Intraoperative techniques and postoperative management were then evaluated using Cox proportional hazards model, with length of stay as the dependent variable after consideration for the significant independent preoperative factors. Age, history of heart disease, hypertension, diabetes, obesity, and American Society of Anesthesiologists (ASA) risk were significantly associated with prolonged stay (more than 4 days) in univariate analysis. Only age (P < 0.001) and cardiac history (P = 0.013) were significant independent predictors of hospital stay in multivariate analysis. After consideration for age and cardiac history, the only significant intraoperative or postoperative factor associated with hospital stay was the use of dressings incorporating Steri-Strips. This study suggests that the attribution of the reduction in hospital stay to discharge with drains in place is due to numerous factors, only one of which is the willingness to send patients home with the drains.

Age Factors↗
PubMed1988

Eliminating the dog-ear in modified radical mastectomy.

Inadequate attention has been paid to optimal closure of the postmastectomy incision in patients not desirous of breast reconstruction. Herein, we describe the use of a basic plastic surgical technique at the time of mastectomy to eliminate the dog-ear deformity at the axillary end of the incision. The technique is conceptually simple and expedient, and gives an excellent cosmetic result.

Humans↗
PubMed2003

Skin-sparing mastectomy.

The cosmetic appearance of the reconstructed breast is largely dependent upon the quantity of breast skin which remains after mastectomy. Leaving behind as much skin as is possible significantly improves the natural appearance of the reconstruction and reduces procedures required on the contralateral breast to achieve symmetry. SSM with immediate reconstruction offers superior aesthetic results to NSSM, with similar LR rates. As most recurrences will occur in chest wall skin, the ability to detect local recurrence is not impaired. The incidence of local wound complications with SSM is comparable to NSSM. It has been demonstrated that sentinel lymph node biopsy and axillary dissection can be performed adequately in SSM. There is no contraindication to postoperative adjuvant chemotherapy and radiation therapy. There are some groups of patients for whom SSM is not indicated, such as patients with inflammatory carcinoma. SSM should be considered for selected patients with breast cancer in conjunction with all types of immediate reconstruction. In conclusion, numerous studies support the use of SSM on selected patients as an oncologically acceptable procedure with superior cosmetic results when compared with traditional NSSM.

Breast Neoplasms↗
PubMed1984

Modified radical mastectomy.

Surgical management in the treatment of potentially curable breast cancer has changed from a radical to a more conservative approach. The most common procedure used at the present time is the modified mastectomy, which is discussed in detail in this article.

Axilla↗
PubMed1984

Partial mastectomy without radiation therapy.

Partial mastectomy without radiation therapy has been used at The Cleveland Clinic as a treatment option for selected patients with breast cancer since 1957. Our experience with 322 patients has been reviewed; survival results are equal to or better than the other operative procedures we have employed for the treatment of breast cancer. These results, we believe, relate more to the selection of patients with small tumors and at a more favorable stage of the disease than to the benefit of the operative procedure itself.

Axilla↗
PubMed1985

Subcutaneous mastectomy. Promises and pitfalls.

The subcutaneous mastectomy is constantly being reevaluated and its place in the treatment of breast dysplasias debated. Our indications for the procedure and the techniques, which we believe provide a thorough, safe, and cosmetically satisfactory result, are presented.

Adult↗
PubMed1990

Reconstruction after mastectomy.

Advances in materials and techniques, especially those involving transposition of muscle and skin flaps, have made breast reconstruction possible for most women who undergo mastectomy for breast cancer. The availability of this option can alleviate the breast and chest wall deformity that results from virtually all local treatment of breast cancer. It is essential that the reconstruction surgeon be part of the breast cancer management team from the beginning of treatment planning and that this surgeon work closely with the general surgeon, medical oncologist, and radiation therapist as well as the adjunctive treatment team members. The patient's clinical status and the type of local treatment will be significant determinants of the reconstructive options. For women with stage I breast cancer, these decisions may be based largely on the oncologist's local and adjunctive therapy procedures and the woman's desire to proceed or delay. For women with systemic disease, all members of the breast management team may need to agree on the advisability and timing of reconstruction. Central to all of the numerous decisions described in this paper regarding the timing, type, and extent of breast reconstruction is the primary goal of the entire team: the best possible management of the breast cancer itself. The promise of attractive, symmetric, and natural appearing breasts, complete with a symmetric nipple-areolar complex, has eased somewhat the diminishment of self-esteem and the threat to femininity that can accompany the loss of a breast. By lowering fear, the widely recognized availability of breast reconstruction may encourage more women to monitor their breasts and seek diagnosis of changes and may influence selection of the type of local treatment if cancer is detected. Because of the psychological and cultural significance of the breast, the reconstructive surgeon must be particularly sensitive to the psychological and aesthetic expectations of the patient. Even in those patients with metastases and limited life expectancy, breast reconstruction can enhance the quality of life.

Breast↗