Browsing by Subject "Mastectomy"
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Item An Alternative Technique for Immediate Direct-to-Implant Breast Reconstruction-A Case Series(Wolters Kluwer, 2016-07-22) Downs, Ronald K.; Hedges, Kellee; Department of Surgery, IU School of MedicineBACKGROUND: The practice of breast reconstruction continues to evolve with the introduction of new technologies. The authors describe a unique approach allowing immediate direct-to-implant reconstruction that can be performed on an outpatient basis. METHODS: After a nipple-sparing mastectomy, acellular dermal matrix (ADM)-covered implants are placed in a prepectoral position in an immediate reconstruction. Assessment of results was performed via a retrospective review of demographic and procedural data. RESULTS: Forty-five patients (79 breasts), mean age 46.8 years, were treated with direct-to-implant reconstruction using ADM-wrapped implants placed above the muscle with mean follow-up of 23.1 months (median 22 mo). Mean body mass index was 24.3, and 15 patients (33.3%) were current or former smokers. Twenty-seven patients (60%) had prior breast surgery with 22 (49%) exposed to chemotherapy and 34 (76%) radiation. Procedure time averaged 155 minutes and hospital length of stay averaged 0.6 days. Complications included flap necrosis in 22 cases (28%), seroma in 12 (15%), infection in 8 (10%), rippling in 28 (35%), and contracture in 8 (10%). In 14 breasts (18%), postoperative wound complications (flap necrosis or infection) led to implant loss. CONCLUSIONS: The availability of ADM and cohesive gel implants has allowed us to perform above-the-muscle implant breast reconstruction in reduced time and often on an outpatient basis. Complication rates were comparable to expected results of standard expander-to-implant, staged breast reconstruction. This technique is a viable option delivering clinically and aesthetically acceptable results in select patients.Item ASO Author Reflections: Homing in on Safety-Home Recovery After Mastectomy(Springer, 2022) Ludwig, Kandice K.; Rao, Roshni; Surgery, School of MedicineItem Association Between Surgery Preference and Receipt in Ductal Carcinoma In Situ After Breast Magnetic Resonance Imaging: An Ancillary Study of the ECOG-ACRIN Cancer Research Group (E4112)(American Medical Association, 2022-05-02) Fazeli, Soudabeh; Snyder, Bradley S.; Gareen, Ilana F.; Lehman, Constance D.; Khan, Seema A.; Romanoff, Justin; Gatsonis, Constantine A.; Corsetti, Ralph L.; Rahbar, Habib; Spell, Derrick W.; Blankstein, Kenneth B.; Han, Linda K.; Sabol, Jennifer L.; Bumberry, John R.; Miller, Kathy D.; Sparano, Joseph A.; Comstock, Christopher E.; Wagner, Lynne I.; Carlos, Ruth C.; Surgery, School of MedicineImportance: Guiding treatment decisions for women with ductal carcinoma in situ (DCIS) requires understanding patient preferences and the influence of preoperative magnetic resonance imaging (MRI) and surgeon recommendation. Objective: To identify factors associated with surgery preference and surgery receipt among a prospective cohort of women with newly diagnosed DCIS. Design, setting, and participants: A prospective cohort study was conducted at 75 participating institutions, including community practices and academic centers, across the US between March 25, 2015, and April 27, 2016. Data were analyzed from August 2 to September 24, 2021. This was an ancillary study of the ECOG-ACRIN Cancer Research Group (E4112). Women with recently diagnosed unilateral DCIS who were eligible for wide local excision and had a diagnostic mammogram within 3 months of study registration were included. Participants who had documented surgery and completed the baseline patient-reported outcome questionnaires were included in this substudy. Exposures: Women received preoperative MRI and surgeon consultation and then underwent wide local excision or mastectomy. Participants will be followed up for recurrence and overall survival for 10 years from the date of surgery. Main outcomes and measures: Patient-reported outcome questionnaires assessed treatment goals and concerns and surgery preference before MRI and after MRI and surgeon consultation. Results: Of the 368 participants enrolled 316 (86%) were included in this substudy (median [range] age, 59.5 [34-87] years; 45 women [14%] were Black; 245 [78%] were White; and 26 [8%] were of other race). Pre-MRI, age (odds ratio [OR] per 5-year increment, 0.45; 95% CI, 0.26-0.80; P = .007) and the importance of keeping one's breast (OR, 0.48; 95% CI, 0.31-0.72; P < .001) vs removal of the breast for peace of mind (OR, 1.35; 95% CI, 1.04-1.76; P = .03) were associated with surgery preference for mastectomy. After MRI and surgeon consultation, MRI upstaging (48 of 316 [15%]) was associated with patient preference for mastectomy (OR, 8.09; 95% CI, 2.51-26.06; P < .001). The 2 variables with the highest ORs for initial receipt of mastectomy were MRI upstaging (OR, 12.08; 95% CI, 4.34-33.61; P < .001) and surgeon recommendation (OR, 4.85; 95% CI, 1.99-11.83; P < .001). Conclusions and relevance: In this cohort study, change in patient preference for DCIS surgery and surgery received were responsive to MRI results and surgeon recommendation. These data highlight the importance of ensuring adequate information and ongoing communication about the clinical significance of MRI findings and the benefits and risks of available treatment options.Item 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 MedicineIntroduction: 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.Item Comparison of Breast Reconstruction Outcomes Using Oxychlorosene versus Triple Antibiotic Solution for Pocket Irrigation(Wolters Kluwer, 2022-08-18) Bamba, Ravinder; Tran, Phu C.; Mailey, Brian A.; Lin, Jenny; DeBrock, William; Dawson, Steven; Sinha, Mithun; Hartman, Brett C.; Hadad, Ivan; Lester, Mary E.; Hassanein, Aladdin H.; Surgery, School of MedicineBackground: Breast pocket irrigation with antiseptic solutions is performed to reduce contamination with breast implants. The optimal antiseptic irrigation solution and the efficacy of individual practices are unclear. Oxychlorosene sodium is frequently used at our institution. Oxychlorosene is bactericidal with a mechanism of action of oxidation and hypochlorination. The purpose of our study was to compare the outcomes of oxychlorosene sodium irrigation with triple antibiotic solution (TAS) in implant-based breast reconstruction. Methods: All patients who underwent implant-based reconstruction after mastectomy were reviewed. The primary predictive variable was type of solution used for pocket irrigation (TAS or oxychlorosene). Outcome variables included surgical site infection, device removal, and wound complications. Results: Between 2013 and 2018, 331 implant-based breast reconstructions were performed. Of these, 62% (n = 206) received oxychlorosene for surgical pocket irrigation (group I), and 38% (n = 125) received TAS (group II). Group I had an 11.7% (n = 24) 90-day surgical site infection rate, with 4.9% (n = 10) requiring oral antibiotics, 2.4% (n = 5) requiring intravenous antibiotics without device removal, and 4.4% (n = 9) requiring prosthetic removal. Group II had an 11.2% (n = 14) 90-day infection rate, with 5.6% (n = 7) requiring oral antibiotics, 2.4% (n = 3) requiring intravenous antibiotics without device removal, and 3.2% (n = 4) requiring removal (P = 0.90). When comparing the cost of oxychlorosene irrigation with TAS irrigation, oxychlorosene was less expensive. Conclusions: Oxychlorosene and TAS have similar surgical site infection rates in prosthetic breast reconstruction. Ease of preparation and cost make oxychlorosene a more favorable option for antibiotic irrigation in reconstructive breast surgery with prosthetic devices.Item 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 MedicinePurpose: 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.Item Direct-to-Implant in the Era of Prepectoral Breast Reconstruction: Evaluation of the National Trend in 59,313 Patients(Wolters Kluwer, 2025-03-18) Ahmed, Shahnur; Baril, Jackson A.; Fisher, Carla S.; Danforth, Rachel M.; Bamba, Ravinder; Lester, Mary E.; Hassanein, Aladdin H.; Surgery, School of MedicineItem Multi-protein spatial signatures in ductal carcinoma in situ (DCIS) of breast(Springer Nature, 2021) Badve, Sunil S.; Cho, Sanghee; Gökmen-Polar, Yesim; Sui, Yunxia; Chadwick, Chrystal; McDonough, Elizabeth; Sood, Anup; Taylor, Marian; Zavodszky, Maria; Tan, Puay Hoon; Gerdes, Michael; Harris, Adrian L.; Ginty, Fiona; Pathology and Laboratory Medicine, School of MedicineBackground: There is limited knowledge about DCIS cellular composition and relationship with breast cancer events (BCE). Methods: Immunofluorescence multiplexing (MxIF) was used to image and quantify 32 cellular biomarkers in FFPE DCIS tissue microarrays. Over 75,000 DCIS cells from 51 patients (median 9 years follow-up for non-BCE cases) were analysed for profiles predictive of BCE. K-means clustering was used to evaluate cellular co-expression of epithelial markers with ER and HER2. Results: Only ER, PR and HER2 significantly correlated with BCE. Cluster analysis identified 6 distinct cell groups with different levels of ER, Her2, cMET and SLC7A5. Clusters 1 and 3 were not significant. Clusters 2 and 4 (high ER/low HER2 and SLC7A5/mixed cMET) significantly correlated with low BCE risk (P = 0.001 and P = 0.034), while cluster 6 (high HER2/low ER, cMET and SLC7A5) correlated with increased risk (P = 0.018). Cluster 5 (similar to cluster 6, except high SLC7A5) trended towards significance (P = 0.072). A continuous expression score (Escore) based on these 4 clusters predicted likelihood of BCE (AUC = 0.79, log-rank test P = 5E-05; LOOCV AUC = 0.74, log-rank test P = 0.006). Conclusion: Multiplexed spatial analysis of limited tissue is a novel method for biomarker analysis and predicting BCEs. Further validation of Escore is needed in a larger cohort.Item Pain Control in Breast Surgery: Survey of Current Practice and Recommendations for Optimizing Management—American Society of Breast Surgeons Opioid/Pain Control Workgroup(Springer, 2020-04) Rao, Roshni; Jackson, Rubie Sue; Rosen, Barry; Brenin, David; Cornett, Wendy; Fayanju, Oluwadamilola M.; Chen, Steven L.; Golesorkhi, Negar; Ludwig, Kandice; Ma, Ayemoethu; Koslow Mautner, Starr; Sowden, Michelle; Wilke, Lee; Wexelman, Barbara; Blair, Sarah; Gary, Monique; Grobmyer, Stephen; Hwang, E. Shelley; James, Ted; Kapoor, Nimmi S.; Lewis, Jaime; Lizarraga, Ingrid; Miller, Megan; Neuman, Heather; Showalter, Shayna; Smith, Linda; Froman, Joshua; Medicine, School of MedicineIntroduction: The opioid epidemic in the United States is a public health crisis. Breast surgeons are obligated to provide good pain control for their patients after surgery but also must minimize administration of narcotics to prevent a surgical episode of care from becoming a patient's gateway into opioid dependence. Methods: A survey to ascertain pain management practice patterns after breast surgery was performed. A review of currently available literature that was specific to breast surgery was performed to create recommendations regarding pain management strategies. Results: A total of 609 surgeons completed the survey and demonstrated significant variations in pain management practices, specifically within regards to utilization of regional anesthesia (e.g., nerve blocks), and quantity of prescribed narcotics. There is excellent data to guide the use of local and regional anesthesia. There are, however, fewer studies to guide narcotic recommendations; thus, these recommendations were guided by prevailing practice patterns. Conclusions: Pain management practices after breast surgery have significant variation and represent an opportunity to improve patient safety and quality of care. Multimodality approaches in conjunction with standardized quantities of narcotics are recommended.Item Parathyroid hormone-related peptide induced hypercalcemia of pregnancy due to mammary hyperplasia(Oxford University Press, 2024-06-20) Jodeh, Wade; Sparks, Payton J.; Higgins, Jasmine M.; Tom, Alan; Anilovich, Natanie; Moit, Harley; Korff, Lisa; Hadad, Ivan; Wang, Xiaoyan; Imel, Erik A.; Donegan, Diane M.; Surgery, School of MedicineMaternal Parathyroid Hormone-related Protein (PTHrP) is involved in the placental transport of calcium. Autonomous overproduction of PTHrP is a rare cause of hypercalcemia in pregnancy. Prior cases of PTHrP-induced hypercalcemia in pregnancy have been managed with either dopamine agonists, fetal delivery, termination of pregnancy, or mastectomy. However, PTHrP level normalization following mastectomy has not previously been documented. Herein, we present a 39-year-old female hospitalized at 19 weeks of gestation for acute encephalopathy due to PTHrP induced hypercalcemic crisis (calcium 15.8 mg/dL, PTHrp 46.5 pmol/L [normal 0-3.4]). Mammary hyperplasia resulting in gigantomastia significantly impaired her ability to ambulate and perform activities of daily living. She remained hypercalcemic during hospitalization despite aggressive hydration, calcitonin, and 2 weeks of dopamine agonist treatment. Bisphosphonate therapy was not administered due to pregnancy and potential effects on the fetus. Our patient underwent bilateral mastectomy along with excision of a large axillary mass. The pathology of all three specimens revealed mammary stromal hyperplasia. PTHrP was undetectable on post-op day 2 and calcium normalized by post-op day 3. At discharge, she was able to ambulate independently. To our knowledge, this is the first reported case of PTHrP induced hypercalcemia related to gigantomastia, documenting resolution of hypercalcemia, and PTHrP levels following mastectomy. Mastectomy is a potential option in the second trimester for pregnant patients with PTHrP induced severe hypercalcemia due to gigantomastia, refractory to treatment with dopamine agonist therapy.