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Background: Locoregional recurrence of the previously reconstructed breast poses a diagnostic and operative challenge. This study examines detection, management, and reconstructive strategies of locoregional recurrence following postmastectomy breast reconstruction. Methods: A retrospective review of records was performed on patients treated within the health system for breast cancer from January of 2000 to July of 2014. Of these patients, descriptive factors and operative details were collected for those that developed locoregional recurrence. Subsequent reconstructive operations were also examined. Using a multidisciplinary team, a surveillance/management algorithm was generated. Results: A total of 41 patients with locoregional recurrence were identified (mean time to recurrence, 4.6 years). Two- and 5-year survival following locoregional recurrence was 88 percent and 39 percent, respectively. Locoregional recurrence was found to occur in the following tissue planes: subcutaneous (27 percent), subcutaneous/pectoralis (24 percent), chest wall (37 percent), and axillary (12 percent). The most frequent method of detection was patient concern leading to examination. Older age at the time of locoregional recurrence ( p = 0.028), increased time to recurrence/detection ( p = 0.024), and chemotherapy before locoregional recurrence ( p = 0.014) were associated with the need for a secondary salvage flap. Patients who experienced a subcutaneous recurrence were far less likely to undergo a secondary flap ( p = 0.011). Factors associated with loss of the index reconstruction included lower body mass index ( p = 0.009), pectoralis invasion ( p = 0.05), and implant reconstruction ( p = 0.03). Conclusions: Detection and management of locoregional recurrence requires appropriate physical examination and imaging. Significant factors associated with failure to salvage the initial reconstruction included body mass index, plane of recurrence, and type of initial reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.
Background Nipple sparing mastectomy (NSM) is considered safe for select patients. Our objective was to examine quality of life (QOL) and satisfaction for NSM compared with skin sparing mastectomy (SSM). We aimed to evaluate these using the BREAST‐Q. Methods After IRB approval, we analyzed patients who underwent NSM and reconstruction between July 2010‐June 2015. NSM patients were matched with those after SSM based on age, race, and body mass index. Telephone interviews were prospectively conducted using the BREAST‐Q Mastectomy Postoperative Module. Bivariate analysis and a paired samples t ‐test were performed. Results We identified 43 patients meeting our inclusion criteria with a response rate 60% ( N = 26). NSM and SSM patients were matched well in age ( P = 1.00), race ( P = 1.00), and Body Mass Index ( P = 0.99). There were no significant differences in stage, estrogen and progesterone status, HER2 expression, reconstruction type and radiation. Mean BREAST‐Q scores did not vary between NSM and SSM in regards to satisfaction with breasts ( P = 0.604), psychosocial well‐being ( P = 0.146), physical well‐being ( P = 0.121), and satisfaction with surgeon ( P = 0.170). Sexual well‐being was significantly higher in NSM patients ( P = 0.011). Conclusion NSM provides patients with favorable results in psychosocial, sexual, and physical well‐being and overall satisfaction. Sexual well‐being showed significant improvement for NSM.
Randomized controlled trials (RCTs) have challenged the need for routine radiation therapy (RT) in women ≥ age 70 with favorable early stage breast cancer (BC) due to modest improvement in local control and no survival benefit. We studied practice patterns in RT among elderly women in the United States. We analyzed data from the National Cancer Database (NCDB) of women ≥age 70 diagnosed with T1 or T2 and N0 invasive BC treated with breast conservation surgery (BCS) between 2004 and 2014. Patients were divided into four groups: (1) no RT, (2) partial breast irradiation (PBI); (3) hypofractionation (HF); and (4) conventional whole breast RT (CWBI). Univariable and multivariable analyses (MVA) were performed to compare characteristics among the four RT groups. A subgroup analysis of women with favorable disease (T1N0 ER + HER2-) was also performed with similar statistical comparisons. Of the 66,126 meeting eligibility, 9,570 (14.5%) had PBI, 16,340 (24.7%) had HF, and 40,117 (60.7%) had CWBI. Only 99 patients (0.15%) had RT omitted. Omission of RT increased marginally from 0.04% in 2004 to 0.24% in 2014. MVA identified older age (OR 1.18, CI 1.08-1.28), more comorbidities (Charlson-Deyo Score of 1) (OR 3.36, CI 1.29-8.72), and no hormone therapy (OR 22.07, CI 5.79-84.07) as more likely to have RT omitted. The use of HF increased from 3.9% to 47.0%, P < .001 with a concomitant decrease in CWBI from 88% to 41%, P < .001. MVA identified older age, treatment location, and omission of chemotherapy as associated with HF. No significant differences from the larger cohort were found among the T1N0 subgroup analysis. Despite RCT evidence, omission of RT was rare in the United States, suggesting that more effective outreach methods to disseminate clinical guideline information may be needed.
