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Browsing by Author "Ludwig, Kandice K."

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    65. Prophylactic Absorbable Antibiotic Beads: Effect on Tissue Expander Reconstruction Outcomes Following Mastectomy Skin Necrosis
    (Wolters Kluwer, 2025-04-24) Ahmed, Shahnur; Zaidi, Shozaf S.; Fisher, Carla S.; Ludwig, Kandice K.; Imeokparia, Folasade O.; VonDerHaar, R. Jason; Bamba, Ravinder; Danforth, Rachel M.; Hassanein, Aladdin H.; Lester, Mary E.; Surgery, School of Medicine
    PURPOSE: Mastectomy skin necrosis is problematic in tissue expander reconstruction with rates between 7 to 30%. Partial or full-thickness skin necrosis may harbor bacterial colonization promoting infection and risk of implant loss. Absorbable antibiotic-impregnated calcium-sulfate antibiotic beads have been described to reduce tissue expander (TE)/implant infection when used prophylactically for prepectoral breast reconstruction. The purpose of this study is to evaluate the effect of absorbable antibiotic beads on outcomes in patients who develop mastectomy skin necrosis after immediate postmastectomy tissue expander breast reconstruction. METHODS: A single-center retrospective review was performed for patients who underwent mastectomy, immediate prepectoral TE reconstruction on the same day (2018-2024). Patients who developed mastectomy skin necrosis were included. Patients were divided into two groups: Group 1 (absorbable antibiotic beads with TE placement) and Group 2 (no antibiotic beads with TE). Demographical information was recorded. Surgical-site infection (90-days) and implant removal were the outcome variables. RESULTS: The study included 61 patients (75 total breasts with necrosis) who underwent prepectoral TE breast reconstruction following mastectomy and developed mastectomy skin necrosis. The patients included in the study with mastectomy skin necrosis were 12 patients in Group 1 (16 breasts) and 49 patients in Group 2 (59 breasts). Baseline characteristics were not significantly difference between groups (p=1). There was no difference between nipple-sparing mastectomy or skin-sparing mastectomy between groups (p=0.1094). Acellular dermal matrix was used in 66.7% (8/12) of Group 1 compared to 83.7% (41/49) of Group 2 (p=0.2285). Operative management of mastectomy skin necrosis including debridement and reclosure was required in 50% (6/12) of Group 1 compared to 69.4% (34/49) of Group 2 patients (p=0.3093). There was one occurrence (6.3%, 1/16 TEs) of surgical-site infection in Group 1 and 35.6% (21/59 TEs) in Group 2 (p=0.0288). TE removal resulted in 6.3% (1/16 TEs) in Group 1 and 33.9% (20/59 TEs) in Group 2 (p=0.0310). The mean follow-up time was 189 days (range 146-236 days). CONCLUSIONS: Patients who develop mastectomy skin necrosis after prepectoral tissue expander reconstruction may experience lower rates of TE removal and infection when prophylactic absorbable antibiotic-impregnated beads are used. Patients who develop mastectomy skin necrosis are at high risk for infection and TE loss. Prophylactic antibiotic beads used at the time of mastectomy with prepectoral TE reconstruction decrease the risk of infection and TE loss in patients who experience mastectomy skin necrosis.
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    ASO Author Reflections: Homing in on Safety-Home Recovery After Mastectomy
    (Springer, 2022) Ludwig, Kandice K.; Rao, Roshni; Surgery, School of Medicine
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    Breast Cancer Cell Detection and Characterization from Breast Milk-Derived Cells
    (American Association for Cancer Research, 2020-11) Bhat-Nakshatri, Poornima; Kumar, Brijesh; Simpson, Ed; Ludwig, Kandice K.; Cox, Mary L.; Gao, Hongyu; Liu, Yunlong; Nakshatri, Harikrishna; Surgery, School of Medicine
    Radiologic techniques remain the main method for early detection for breast cancer and are critical to achieve a favorable outcome from cancer. However, more sensitive detection methods to complement radiologic techniques are needed to enhance early detection and treatment strategies. Using our recently established culturing method that allows propagation of normal and cancerous breast epithelial cells of luminal origin, flow cytometry characterization, and genomic sequencing, we show that cancer cells can be detected in breast milk. Cells derived from milk from the breast with cancer were enriched for CD49f+/EpCAM-, CD44+/CD24-, and CD271+ cancer stem-like cells (CSC). These CSCs carried mutations within the cytoplasmic retention domain of HDAC6, stop/gain insertion in MORF4L1, and deletion mutations within SWI/SNF complex component SMARCC2. CSCs were sensitive to HDAC6 inhibitors, BET bromodomain inhibitors, and EZH2 inhibitors, as mutations in SWI/SNF complex components are known to increase sensitivity to these drugs. Among cells derived from breast milk of additional ten women not known to have breast cancer, two of them contained cells that were enriched for the CSC phenotype and carried mutations in NF1 or KMT2D, which are frequently mutated in breast cancer. Breast milk-derived cells with NF1 mutations also carried copy-number variations in CDKN2C, PTEN, and REL genes. The approach described here may enable rapid cancer cell characterization including driver mutation detection and therapeutic screening for pregnancy/postpartum breast cancers. Furthermore, this method can be developed as a surveillance or early detection tool for women at high risk for developing breast cancer. SIGNIFICANCE: These findings describe how a simple method for characterization of cancer cells in pregnancy and postpartum breast cancer can be exploited as a surveillance tool for women at risk of developing breast cancer.
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    Breast Implant Reconstruction in the Ptotic Patient: Evaluation of Wise and Vertical Skin Sparing Mastectomy
    (Sage, 2024-03-12) Holohan, M. Margaret; Diaz, Stephanie M.; Newsom, Keeley; Smith, Alex; Fan, Betty; Imeokparia, Folasade O.; Fisher, Carla S.; Ludwig, Kandice K.; Lester, Mary E.; Hassanein, Aladdin H.; Surgery, School of Medicine
    Introduction: Post-mastectomy reconstruction in patients with severe breast ptosis can be challenging. Traditionally, a skin sparing mastectomy (SSM) with a circumareolar incision or a horizontal elliptical extension results in a long, horizontally-oriented scar in the central breast. The Wise pattern SSM with an inferiorly-based dermal flap addresses skin redundancy and provides added vascularized implant coverage in ptotic patients with macromastia. The purpose of this study is to compare outcomes in ptotic patients undergoing SSM with Wise pattern and a modified vertical technique which also uses de-epithelialized excess skin under the incision. Methods: A retrospective chart review was performed on patients that underwent SSM using a Wise or vertical skin reducing technique. The Wise pattern was performed using an inferiorly-based dermal flap and the vertical method used a laterally-based dermal flap covering the implant/tissue expander (TE). Results: SSM with the use of autoderm was performed in 42 patients (67 breasts) using either the Wise (n = 49 breasts) or vertical (n = 18 breasts) method. Both groups had similar BMI (35.4). The prepectoral plane was used in 93.5% of Wise pattern patients and all vertical patients. All cases of seroma and hematoma occurred in the Wise pattern group (10.2%). Mastectomy skin necrosis requiring unplanned return to surgery for debridement occurred in 20.4% of those undergoing Wise pattern SSM and 11.1% undergoing the vertical pattern (p = 0.49). Conclusion: Severely ptotic patients undergoing SSM have a high risk of skin necrosis. A dermal flap under the closure has the advantage of vascularized tissue reinforcing the wound in implant based reconstruction. The vertical pattern SSM using a laterally-based dermal flap may be a safe, simple alternative to the Wise pattern in select patients.
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    Contemporary Multi-Institutional Cohort of 550 Cases of Phyllodes Tumors (2007-2017) Demonstrates a Need for More Individualized Margin Guidelines
    (American Society of Clinical Oncology, 2021) Rosenberger, Laura H.; Thomas, Samantha M.; Nimbkar, Suniti N.; Hieken, Tina J.; Ludwig, Kandice K.; Jacobs, Lisa K.; Miller, Megan E.; Gallagher, Kristalyn K.; Wong, Jasmine; Neuman, Heather B.; Tseng, Jennifer; Hassinger, Taryn E.; King, Tari A.; Jakub, James W.; Surgery, School of Medicine
    Purpose: Phyllodes tumors (PTs) are rare breast neoplasms, which have little granular data on margins. Current guidelines recommend ≥ 1 cm margins; however, recent data suggest narrower margins are sufficient, and for benign PT, a negative margin may not be necessary. Methods: We performed an 11-institution contemporary (2007-2017) review of PT practices. Demographics, surgical, and histopathologic data were captured. Logistic regression was used to estimate the association of select covariates with local recurrence (LR). Results: Of 550 PT patients, the majority underwent excisional biopsy (55.3%, n = 302/546) or lumpectomy (wide excision) (38.5%, n = 210/546). Median tumor size was 30 mm, 68.9% (n = 379) were benign, 19.6% (n = 108) borderline, and 10.5% (n = 58) malignant. Surgical margins were positive in 42% (n = 231) and negative in 57.3% (n = 311). A second operation was performed in 38.0% (n = 209) of the total cohort, including 51 patients with an initial negative margin (82.4% with < 2 mm), and 157 with an initial positive margin, with residual disease only found in six (2.9%). Notably, 32.0% (n = 74) of those with an initial positive margin did not undergo a second operation, among whom only 2.7% (n = 2) recurred. Recurrence occurred in 3.3% (n = 18) of the total cohort (n = 15 LR, n = 3 distant), at median follow-up of 36.7 months. LR (all PT grades) was not reduced with wider negative margin width (≥ 2 mm v < 2 mm: odds ratio [OR] = 0.39; 95% CI, 0.07 to 2.10; P = .27) or final margin status (positive v negative: OR = 0.96; 95% CI, 0.26 to 3.52; P = .96). Conclusion: In current practice, many patients are managed outside of current guidelines. For the entire cohort, a wider margin width was not associated with a reduced risk of LR. We do not recommend re-excision of a negative margin for benign PT, regardless of margin width, as a progressively wider surgical margin is unlikely to reduce LR.
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    Germline Genetic Mutations in a Multi-Center Contemporary Cohort of 550 Phyllodes Tumors: An Opportunity for Expanded Multi-Gene Panel Testing
    (Springer Nature, 2020) Rosenberger, Laura H.; Thomas, Samantha M.; Nimbkar, Suniti N.; Hieken, Tina J.; Ludwig, Kandice K.; Jacobs, Lisa K.; Miller, Megan E.; Gallagher, Kristalyn K.; Wong, Jasmine; Neuman, Heather B.; Tseng, Jennifer; Hassinger, Taryn E.; Jakub, James W.; Surgery, School of Medicine
    Background: A paucity of data exists regarding inherited mutations associated with phyllodes tumors (PT); however, some are reported (TP53, BRCA1, and RB1). A PT diagnosis does not meet NCCN criteria for testing, including within Li-Fraumeni Syndrome (TP53). We sought to determine the prevalence of mutations associated with PT. Methods: We performed an 11-institution review of contemporary (2007-2017) PT practice. We recorded multigenerational family history and personal history of genetic testing. We identified patients meeting NCCN criteria for genetic evaluation. Logistic regression estimated the association of select covariates with likelihood of undergoing genetic testing. Results: Of 550 PT patients, 59.8% (n = 329) had a close family history of cancer, and 34.0% (n = 112) had ≥ 3 family members affected. Only 6.2% (n = 34) underwent genetic testing, 38.2% (n = 13) of whom had only BRCA1/BRCA2 tested. Of 34 patients tested, 8.8% had a deleterious mutation (1 BRCA1, 2 TP53), and 5.9% had a BRCA2 VUS. Of women who had TP53 testing (N = 21), 9.5% had a mutation. Selection for testing was not associated with age (odds ratio [OR] 1.01, p = 0.55) or PT size (p = 0.12) but was associated with grade (malignant vs. benign: OR 9.17, 95% CI 3.97-21.18) and meeting NCCN criteria (OR 3.43, 95% confidence interval 1.70-6.94). Notably, an additional 86 (15.6%) patients met NCCN criteria but had no genetic testing. Conclusions: Very few women with PT undergo germline testing; however, in those selected for testing, a deleterious mutation was identified in ~ 10%. Multigene testing of a PT cohort would present an opportunity to discover the true incidence of germline mutations in PT patients.
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    The Implications of Insurance Status on Presentation, Surgical Management and Mortality among Non-Metastatic Breast Cancer Patients in Indiana
    (Elsevier, 2018-12) Obeng-Gyasi, Samilia; Timsina, Lava; Miller, Kathy D.; Ludwig, Kandice K.; Fisher, Carla S.; Haggstrom, David A.; Obstetrics and Gynecology, School of Medicine
    Background The National Breast and Cervical Cancer Early Detection Program seeks to reduce health care disparities by providing uninsured and underinsured women access to screening mammograms. The objective of this study is to identify the differences in presentation, surgical management, and mortality among nonmetastatic uninsured patients diagnosed through Indiana's Breast and Cervical Cancer Program compared with patients with private and government (Medicare or Medicaid) insurance. Methods Study data were obtained using the Indiana state cancer registry and Indiana's Breast and Cervical Cancer Program. Women aged 50 to 64 with an index diagnosis of stage 0 to III breast cancer from January 1, 2006 to December 31, 2013, were included in the study. Bivariate intergroup analysis was conducted. Kaplan-Meier estimates between insurance types were compared using the log rank test. All-cause mortality was evaluated using a mixed effects model. Results The groups differed significantly for sociodemographic and clinical variables. Uninsured Indiana Breast and Cervical Cancer Program patients presented with later disease stage (P < .001) and had the highest overall mortality (hazard ratio 2.2, P = .003). Surgical management only differed among stage III patients (P = .012). Conclusion To improve insurance-based disparities in Indiana, implementation of the Breast and Cervical Cancer Program in conjunction with expansion of insurance coverage to vulnerable low-income populations need to be optimized.
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    Limited Reporting of Histopathologic Details in a Multi- MultiInstitutional Academic Cohort of Phyllodes Tumors: Time for Standardization
    (Springer, 2021) Rosenberger, Laura H.; Quintana, Liza M.; Thomas, Samantha M.; Nimbkar, Suniti N.; Hieken, Tina J.; Ludwig, Kandice K.; Jacobs, Lisa K.; Miller, Megan E.; Gallagher, Kristalyn K.; Wong, Jasmine; Neuman, Heather B.; Tseng, Jennifer; Hassinger, Taryn E.; King, Tari A.; Jakub, James W.; Bentley, Rex C.; Schnitt, Stuart J.; Surgery, School of Medicine
    Background: Phyllodes tumors are rare fibroepithelial neoplasms that are classified by tiered histopathologic features. While there are protocols for the reporting of cancer specimens, no standardized reporting protocol exists for phyllodes. Methods: We performed an 11-institution contemporary review of phyllodes tumors. Granular histopathologic details were recorded, including the features specifically considered for phyllodes grade classification. Results: Of 550 patients, median tumor size was 3.0 cm, 68.9% (n = 379) of tumors were benign, 19.6% (n = 108) were borderline, and 10.5% (n = 58) were malignant. All cases reported the final tumor size and grade classification. Complete pathologic reporting of all histopathologic features was present in 15.3% (n = 84) of cases, while an additional 35.6% (n = 196) were missing only one or two features in the report. Individual details regarding the degree of stromal cellularity was not reported in 53.5% (n = 294) of cases, degree of stromal atypia in 58.0% (n = 319) of cases, presence of stromal overgrowth in 56.2% (n = 309) of cases, stromal cell mitoses in 37.5% (n = 206) of cases, and tumor border in 54.2% (n = 298) of cases. The final margin status (negative vs. positive) was omitted in only 0.9% of cases, and the final negative margin width was specifically reported in 73.8% of cases. Reporting of details was similar across all sites. Conclusion: In this academic cohort of phyllodes tumors, one or more histopathologic features were frequently omitted from the pathology report. While all features were considered by the pathologist for grading, this limited reporting reflects a lack of reporting consensus. We recommend that standardized reporting in the form of a synoptic-style cancer protocol be implemented for phyllodes tumors, similar to other rare tumors.
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    Prophylactic Buried Dermal Flap: A Simple Method for Axillary Reconstruction after Lymph Node Dissection
    (Wolters Kluwer, 2024-09-12) Fallah, Kasra N.; Ahmed, Shahnur; Venardi, Andrew S.; Hulsman, Luci A.; Fisher, Carla S.; Ludwig, Kandice K.; Lester, Mary E.; Hassanein, Aladdin H.; Surgery, School of Medicine
    Breast cancer-related lymphedema is characterized by progressive limb enlargement and occurs in up to 30% of breast cancer patients following axillary lymph node dissection (ALND). Immediate lymphatic reconstruction (ILR) is a preventative technique used to reduce lymphedema rates by performing lymphovenous anastomoses of disrupted afferent lymphatics. This study presents a novel method of axillary reconstruction following ALND using a buried dermal flap that provides local tissue with intact subdermal lymphatics to the axillary dead space. A single-center retrospective review was performed to assess breast cancer patients who underwent modified radical mastectomy without reconstruction between 2018 and 2023. Groups were divided into those who had ILR alone (group 1) and those who had buried dermal flap with attempted ILR (group 2). There were 31 patients included in this study: 18 patients in group 1 and 13 patients in group 2. Patient demographics, comorbidities, and breast cancer history were similar between the groups. There was no significant difference in the mean number of lymphovenous anastomoses performed (1.6 versus 1.7, P = 0.84). Mean operative time of 224.4 ± 51.9 minutes in group 1 was similar to 223.4 ± 30.4 minutes in group 2 (P = 0.95). We introduce a novel method of axillary reconstruction following ALND using a buried dermal flap that is inset into the axillary dissection space and over the area of ILR. We propose that it is an efficient accessory procedure to augment ILR by providing supplementary intact lymphatic channels to the area of lymphatic injury, while obliterating the axillary dead space.
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    Racial-Ethnic Variations in Phyllodes Tumors among a Multi-Center United States Cohort
    (Wiley, 2023) Nash, Amanda L.; Thomas, Samantha M.; Nimbkar, Suniti N.; Hieken, Tina J.; Ludwig, Kandice K.; Jacobs, Lisa K.; Miller, Megan E.; Gallagher, Kristalyn K.; Wong, Jasmine; Neuman, Heather B.; Tseng, Jennifer; Hassinger, Taryn E.; King, Tari A.; Hwang, E. Shelley; Jakub, James W.; Rosenberger, Laura H.; Surgery, School of Medicine
    Background and objectives: Previous studies have identified racial-ethnic differences in the diagnostic patterns and recurrence outcomes of women with phyllodes tumors (PT). However, these studies are generally limited in size and generalizability. We therefore sought to explore racial-ethnic differences in age, tumor size, subtype, and recurrence in a large US cohort of women with PT. Methods: We performed an 11-institution retrospective review of women with PT from 2007 to 2017. Differences in age at diagnosis, tumor size and subtype, and recurrence-free survival according to race-ethnicity. Results: Women of non-White race or Hispanic ethnicity were younger at the time of diagnosis with phyllodes tumor. Non-Hispanic Other women had a larger proportion of malignant PT. There were no differences in recurrence-free survival in our cohort. Conclusions: Differences in age, tumor size, and subtype were small. Therefore, the workup of young women with breast masses and the treatment of women with PT should not differ according to race-ethnicity. These conclusions are supported by our finding that there were no differences in recurrence-free survival.
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