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BackgroundDespite high success rates, flap failure remains an inherent risk in microvascular breast reconstruction. Identifying patients who are at high risk for flap failure would enable us to recommend alternative reconstructive techniques. However, as flap failure is a rare event, identification of risk factors is statistically challenging. Machine learning is a form of artificial intelligence that automates analytical model building. It has been proposed that machine learning can build superior prediction models when the outcome of interest is rare.MethodsIn this study we evaluate machine learning resampling and decision-tree classification models for the prediction of flap failure in a large retrospective cohort of microvascular breast reconstructions.ResultsA total of 1012 patients were included in the study. Twelve patients (1.1%) experienced flap failure. The ROSE informed oversampling technique and decision-tree classification resulted in a strong prediction model (AUC 0.95) with high sensitivity and specificity. In the testing cohort, the model maintained acceptable specificity and predictive power (AUC 0.67), but sensitivity was reduced. The model identified four high-risk patient groups. Obesity, comorbidities and smoking were found to contribute to flap loss. The flap failure rate in high-risk patients was 7.8% compared with 0.44% in the low-risk cohort (p = 0.001).ConclusionsThis machine-learning risk prediction model suggests that flap failure may not be a random event. The algorithm indicates that flap failure is multifactorial and identifies a number of potential contributing factors that warrant further investigation.

Chronic postsurgical pain (CPSP), an often unanticipated result of necessary and even life-saving procedures, develops in 5-10% of patients one-year after major surgery. Substantial advances have been made in identifying patients at elevated risk of developing CPSP based on perioperative pain, opioid use, and negative affect, including depression, anxiety, pain catastrophizing, and posttraumatic stress disorder-like symptoms. The Transitional Pain Service (TPS) at Toronto General Hospital (TGH) is the first to comprehensively address the problem of CPSP at three stages: 1) preoperatively, 2) postoperatively in hospital, and 3) postoperatively in an outpatient setting for up to 6 months after surgery. Patients at high risk for CPSP are identified early and offered coordinated and comprehensive care by the multidisciplinary team consisting of pain physicians, advanced practice nurses, psychologists, and physiotherapists. Access to expert intervention through the Transitional Pain Service bypasses typically long wait times for surgical patients to be referred and seen in chronic pain clinics. This affords the opportunity to impact patients' pain trajectories, preventing the transition from acute to chronic pain, and reducing suffering, disability, and health care costs. In this report, we describe the workings of the Transitional Pain Service at Toronto General Hospital, including the clinical algorithm used to identify patients, and clinical services offered to patients as they transition through the stages of surgical recovery. We describe the role of the psychological treatment, which draws on innovations in Acceptance and Commitment Therapy that allow for brief and effective behavioral interventions to be applied transdiagnostically and preventatively. Finally, we describe our vision for future growth.

Future climate projections show a marked increase in Greenland Ice Sheet (GrIS) runoff during the 21 st century, a direct consequence of the Polar Amplification signal. Regional climate models (RCMs) are a widely used tool to downscale ensembles of projections from global climate models (GCMs) to assess the impact of global warming on GrIS melt and sea level rise contribution. Initial results of the CMIP6 GCM model intercomparison project have revealed a greater 21 st century temperature rise than in CMIP5 models. However, so far very little is known about the subsequent impacts on the future GrIS surface melt and therefore sea level rise contribution. Here, we show that the total GrIS sea level rise contribution from surface mass loss in our high-resolution (15 km) regional climate projections is 17.8  ±  7.8 cm in SSP585, 7.9 cm more than in our RCP8.5 simulations using CMIP5 input. We identify a +1.3 °C greater Arctic Amplification and associated cloud and sea ice feedbacks in the CMIP6 SSP585 scenario as the main drivers. Additionally, an assessment of the GrIS sea level contribution across all emission scenarios highlights, that the GrIS mass loss in CMIP6 is equivalent to a CMIP5 scenario with twice the global radiative forcing. The potential contribution of Greenland Ice Sheet to sea level rise in the future is known to be substantial. Here, the authors undertake new modelling showing that the Greenland Ice Sheet sea level rise contribution is 7.9 cm more using the CMIP6 SSP585 scenario compared to CMIP5 using multiple RCP8.5 simulations.

BackgroundResection of soft-tissue sarcomas from the adductor compartment is associated with significant complications. Free/pedicled flaps often are used for wound closure, but their effect on healing is unclear. We compared wound complications, oncologic, and functional outcomes for patients undergoing flap reconstruction or primary closure following resection of adductor sarcomas.MethodsA total of 177 patients underwent resection of an adductor sarcoma with primary closure (PrC) or free/pedicled flap reconstruction (FR). Patient, tumor, and treatment characteristics were compared, as well as wound complications, oncologic, and functional outcomes (TESS/MSTS87/MSTS93). To examine the relative benefit of flap reconstruction, number needed to treat (NNT) was calculated. ResultsIn total, 143 patients underwent PrC and 34 had FR, 68% of which were pedicled. There were few differences in demographic, tumor, or treatment characteristics. No significant difference was found in the rate of wound complications. Length of stay was significantly longer in FR (18 days vs. PrC 8 days; p < 0.01). Oncologic and functional outcomes were similar over 5 years follow-up. Uncomplicated wound healing occurred more often in FR compared with PrC for tumors with ≥15 cm (NNT = 8.4) or volumes ≥ 800 ml (NNT = 8.4). Tumors ≤ 336 ml do not benefit from a flap, whereas those > 600 ml are 1.5 times more likely to heal uneventfully after flap closure.ConclusionsAlthough flap use prolonged hospitalization, it decreased wound healing complications for larger tumors, and in all sized tumors, it demonstrated similar functional and oncologic outcomes to primary closure. Our size-based treatment criteria can help to identify patients with large adductor sarcomas who could benefit from flap reconstruction.Level of Evidence III(Retrospective cohort study)

IntroductionRates of bilateral mastectomy are rising in women with unilateral, nonhereditary breast cancer. We aim to characterize how psychosocial outcomes evolve after breast cancer surgery.Patients and MethodsWe performed a prospective cohort study of women with unilateral, sporadic stage 0–III breast cancer at University Health Network in Toronto, Canada between 2014 and 2017. Women completed validated psychosocial questionnaires (BREAST-Q, Impact of Event Scale, Hospital Anxiety & Depression Scale) preoperatively, and at 6 and 12 months following surgery. Change in psychosocial scores was assessed between surgical groups using linear mixed models, controlling for age, stage, and adjuvant treatments. P < .05 were significant.ResultsA total of 475 women underwent unilateral lumpectomy (42.5%), unilateral mastectomy (38.3%), and bilateral mastectomy (19.2%). There was a significant interaction (P < .0001) between procedure and time for breast satisfaction, psychosocial and physical well-being. Women having unilateral lumpectomy had higher breast satisfaction and psychosocial well-being scores at 6 and 12 months after surgery compared with either unilateral or bilateral mastectomy, with no difference between the latter two groups. Physical well-being declined in all groups over time; scores were not better in women having bilateral mastectomy. While sexual well-being scores remained stable in the unilateral lumpectomy group, scores declined similarly in both unilateral and bilateral mastectomy groups over time. Cancer-related distress, anxiety, and depression scores declined significantly after surgery, regardless of surgical procedure (P < .001).ConclusionsPsychosocial outcomes are not improved with contralateral prophylactic mastectomy in women with unilateral breast cancer. Our data may inform women considering contralateral prophylactic mastectomy.

Purpose Breast cancer survivors who make preference-sensitive decisions about postmastectomy breast reconstruction often have large gaps in knowledge and undergo procedures that are misaligned with their treatment goals. We evaluated the feasibility and effect of a pre-consultation educational group intervention on the decision-making process for breast reconstruction. Methods We conducted a pilot randomized controlled trial (RCT) where participants were randomly assigned to the intervention with routine education or routine education alone. The outcomes evaluated were decisional conflict, decision self-efficacy, satisfaction with information, perceived involvement in care, and uptake of reconstruction following surgical consultation. Trial feasibility and acceptability were evaluated, and effect sizes were calculated to determine the primary outcome for the full-scale RCT. Results Of the 41 patients enrolled, recruitment rate was 72 %, treatment fidelity was 98 %, and retention rate was 95 %. The Cohen’s d effect size in reduction of decisional conflict was moderate to high for the intervention group compared to routine education (0.69, 95 % CI = 0.02–1.42), while the effect sizes of increase in decision self-efficacy (0.05, 95 % CI = −0.60–0.71) and satisfaction with information (0.11, 95 % CI = −0.53–0.76) were small. A higher proportion of patients receiving routine education signed informed consent to undergo breast reconstruction (14/20 or 70 %) compared to the intervention group (8/21 or 38 %) P  = 0.06. Conclusions A pre-consultation educational group intervention improves patients’ shared decision-making quality compared to routine preoperative patient education. A full-scale definitive RCT is warranted based on high feasibility outcomes, and the primary outcome for the main trial will be decisional conflict.

Purpose To compare psychosocial function outcomes in early breast cancer patients treated with breast-conserving surgery (BCS), mastectomy alone (MA), and mastectomy with immediate breast reconstruction (IBR) at 1 year after surgery. Methods Early-stage (stage 0–2) breast cancer patients treated with BCS, MA, and IBR at the University Health Network, Toronto, Ontario, Canada between May 1 2015 and July 31 2016 were prospectively enrolled. Their changes in psychosocial functioning from baseline to 12 months following surgery were compared by using the BREAST-Q, Hospital Anxiety and Depression Scale, and Impact of Event Scale with ANOVA and linear regression. Results There were 303 early-stage breast cancer patients: 155 underwent BCS, 78 MA, and 70 IBR. After multivariable regression accounting for age, baseline score, income, education, receipt of chemoradiation or hormonal therapy, ethnicity, cancer stage, and unilateral versus bilateral surgery, breast satisfaction was highest in BCS (72.1, SD 19.6), followed by IBR (60.0, SD 18.0), and MA (49.9, SD 78.0) at 12 months, p  < 0.001. Immediate breast reconstruction had similar psychosocial well-being (69.9, SD 20.6) compared with BCS (78.5, SD 20.6), p  = 0.07. Sexual and chest physical well-being were similar between IBR, BCS, and MA, p  > 0.05. Conclusions Our study found that in a multidisciplinary breast cancer centre where all three breast ablative and reconstruction options are available to early breast cancer patients, either BCS or IBR can be used to provide patients with a higher degree of satisfaction and psychosocial well-being compared with MA in the long-term.

BackgroundFlap reconstruction plays an important role in limb preservation after wide resection of extremity soft tissue sarcoma (ESTS), but can be associated with high rates of postoperative wound complications. Currently, no standardized system exists for the classification of these complications. This study aimed to develop a standardized classification system for wound complications after ESTS flap reconstruction. MethodsOutcomes of ESTS flap reconstructions were analyzed in a retrospective cohort of 300 patients. All wound- and flap-related complications were identified and categorized. Based on these data, a scoring system was developed and validated with a prospective cohort of 100 patients who underwent ESTS flap reconstruction. ResultsA 10-point scoring system was developed based on the level of intervention required to treat each complication observed in the retrospective cohort. Raters applied the scoring system to the prospective patient cohort. Validation studies demonstrated excellent inter-rater and intra-rater reliability (weighted Cohen’s kappa range, 0.82 [95% CI, 0.5–1.0] to 0.99 [95% CI, 0.98–1.0] and 0.95 [95% CI, 0.84–1.0] to 0.97 [95% CI, 0.92–1.0], respectively). The majority of the raters reported the score to be simple, objective, and reproducible (respective mean scores, 4.76 ± 0.43, 4.53 ± 0.62, and 4.56 ± 0.56 on 5-point Likert scales).ConclusionThe Toronto Sarcoma Flap Score (TSFS) is a simple and objective classification system with excellent inter- and intra-rater reliability. Universal adoption of the TSFS could standardize outcome reporting in future studies and aid in the establishment of clinical benchmarks to improve the quality of care in sarcoma reconstruction.

Inadequate vascularization of in vitro –engineered tissue constructs after implantation is a major problem in most tissue-engineering applications. In this study we evaluated whether adipose tissue–derived stromal cells (ASCs), similar to bone marrow–derived stromal cells (BMSCs), can support the organization of endothelial cells into prevascular-like structures using an in vitro model. In addition, we investigated the mechanisms leading to the support of endothelial organization by these cells. We cultured human umbilical vein endothelial cells (HUVECs), ASCs, and BMSCs either alone or in combination in fibrin-embedded spheroids for 14 days. We found that BMSCs and ASCs formed cellular networks that expressed α smooth muscle actin and, in the case of ASCs, also CD34. Further, BMSCs and ASCs secreted hepatocyte growth factor and tissue inhibitor of metalloproteinase 1 and 2. In addition, ASC-conditioned medium induced HUVEC outgrowth, whereas BMSC-conditioned medium and hepatocyte growth factor–supplemented medium did not. Finally, both BMSCs and ASCs supported HUVEC organization into prevascular-like structures when cocultured. Our results suggest that both BMSCs and ASCs can support the formation of prevascular-like structures in vitro . Further, our findings indicate that cell–cell contacts and reciprocal signaling play an important role in the formation of these prevascular structures.

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is a rare disease that has been diagnosed in an extremely small proportion of women with breast implants. The pathogenesis of this disease is currently poorly understood, but it appears to be related to textured implants. Recent high-profile media coverage of this rare clinical entity is likely to cause considerable anxiety for breast cancer patients who have undergone alloplastic breast reconstruction. The purpose of this review is to provide surgical oncologists with an evidence-based overview of the incidence, diagnosis, and management of BIA-ALCL with a particular emphasis on breast reconstruction cases. It is essential that surgical oncologists are familiar with BIA-ALCL, because although it is extremely rare, early recognition and surgical resection will be curative in many cases.