Oncological aspect of immediate breast reconstruction in mastectomy patients

Treatment of Implant Exposure due to Skin Necroses after Skin Sparing Mastectomy: Initial Experiences Using a Not Selective Random Epigastric Flap

Breast prostheses exposure is probably the most devastating complication after a skin sparing mastectomy (SSM) and implant-based, one-stage, breast reconstruction. This complication may occur in the immediate post-operative period or in the weeks and even months after the procedure. In most cases, the cause is poor skin coverage of the implant due to skin necrosis.

PATIENTS AND METHODS

Eight consecutive cases of implant exposure (or risk of exposure) due to skin necrosis in SSM patients over a period of 5 years, all patients were treated using a random epigastric rotation flap, executed by the same medical team.

RESULTS

A random epigastric flap (island or conventional rotation flap) was used to cover the skin defect. All the patients completed the procedure and all prostheses were saved; there were no cases of flap necrosis or infection.

CONCLUSIONS

Cases of skin necrosis after SSM and immediate implant reconstruction, in which the implant is at risk of exposure, can be successfully treated with a random epigastric rotation flap.

The prognosis of breast cancer patients after mastectomy and immediate breast reconstruction: a meta-analysis

BACKGROUND

An increasing number of patients with breast cancer are being offered immediate breast reconstruction (IBR). The aim of this study was to analyze the impact of IBR on the prognosis of patients with breast cancer.

METHODS

We searched the electronic databases of Medline (Pubmed), ISI Web of Knowledge, Embase, and Google Scholar databases for studies reporting the overall recurrence, disease-free survival (DFS), and overall survival (OS) of patients after mastectomy only and mastectomy with IBR. With these data, we conducted a meta-analysis of the clinical outcomes.

RESULTS

Fourteen studies, including 3641 cases and 9462 controls, matched our criteria. Relevant information was extracted from these 14 studies. There was no significant heterogeneity (P for Q-statistic > 0.10 and I2 < 25%). Patients who underwent IBR showed no increased risk of overall recurrence of breast cancer (RR = 0.89; 95% confidence interval [CI]: 0.75, 1.04; P = 0.14). Furthermore, patients receiving IBR had similar DFS (RR = 1.04; 95%CI: 0.99, 1.08); P = 0.10) and OS (RR = 1.02; 95%CI: 0.99, 1.05; P = 0.24)) as those of control patients.

CONCLUSION

This meta-analysis provides evidence that IBR does not have an adverse effect on prognosis. These data suggest that IBR is an appropriate and safe choice for patients with breast cancer.

Local breast cancer recurrence after mastectomy and immediate breast reconstruction for invasive cancer: a meta-analysis

BACKGROUND

The main priorities in the surgical treatment of patients with breast cancer are to achieve cure, local control and prevent recurrence. It is increasingly important to address quality of life and self-image with women undergoing surgical intervention for breast cancer. There is a lack of consensus as to the oncologic safety of immediate breast reconstruction (IBR). The purpose of this paper is to systematically review the literature and compare the frequency of recurrence in patients with and without IBR following mastectomy for breast cancer.

METHODS

Two independent investigators searched PubMed, Embase, and the Cochrane database using predefined search terms. After application of inclusion and exclusion criteria, 10 articles remained. Each article was assessed for quality. Relevant data was collected including recurrence rates, cancer stage, type of mastectomy and reconstruction, adjuvant treatments, and duration of follow-up.

RESULTS

Inter-rater reliability was good at 74% (95% CI: 0, 93%). There was no evidence of study heterogeneity (p for Q-statistic=0.34 and I(2)=12%). The OR ratio for recurrence of breast cancer for mastectomy with IBR as compared to mastectomy alone was 0.98 (95% CI: 0.62, 1.54).

CONCLUSION

This meta-analysis demonstrated no evidence for increased frequency of local breast cancer recurrence with IBR compared with mastectomy alone.

Breast reconstructive surgery in medically underserved women with breast cancer: the role of patient-physician communication

BACKGROUND

Breast reconstructive surgery can improve mastectomy patients' emotional relationships and social functioning, but it may be underutilized in low-income, medically underserved women. This study assessed the impact of patient-physician communication on rates of breast reconstructive surgery in low-income breast cancer (BC) women receiving mastectomy.

METHODS

A cross-sectional, California statewide survey was conducted of women with income less than 200% of the Federal Poverty Level and receiving BC treatment through the Medicaid Breast and Cervical Cancer Treatment Program. A subset of 327 women with nonmetastatic disease who underwent mastectomy was identified. Logistic regression was used for data analysis. The chief dependent variable was receipt of or planned breast reconstructive surgery by patient report at 6 months after diagnosis; chief independent variables were physician interactive information giving and patient perceived self-efficacy in interacting with physicians.

RESULTS

Greater physician information giving about BC and its treatment and greater patient perceived self-efficacy positively predicted breast reconstructive surgery (OR=1.12, P=.04; OR=1.03, P=.01, respectively). The observed negative effects of language barriers and less acculturation among Latinas and lower education at the bivariate level were mitigated in multivariate modeling with the addition of the patient-physician communication and self-efficacy variables.

CONCLUSIONS

Empowering aspects of patient-physician communication and self-efficacy may overcome the negative effects of language barriers and less acculturation for Latinas, as well as of lower education generally, on receipt of or planned breast reconstructive surgery among low-income women with BC. Intervening with these aspects of communication could result in breast reconstructive surgery rates more consistent with the general population and in improved quality of life among this disadvantaged group.

Technical aspects of immediate breast reconstruction with implants: Five year follow-up

We describe the technical aspects of 249 patients who had immediate breast reconstruction with implants and a follow-up of at least five years. The type of reconstruction was permanent expander prostheses (n=208), permanent prostheses (n=32), and temporary expander prostheses (n=9). The median total number of operations required to complete the reconstruction was 3 (range 1-6) with nipple-reconstruction included. Thirty-two patients developed local complications (13%) and three had systemic complications (1%). Eighteen implants were lost, so the failure rate of reconstruction was 7%. The technique of immediate breast reconstruction with implants is associated with a low overall morbidity. This, combined with earlier reported psychological advantages, no increased risk of cancer relapse, and reasonable cost, indicates the importance of immediate reconstruction with implants in the treatment of breast cancer.

Breast reconstruction with alloplastic implants

This article reviews immediate and delayed breast reconstruction with prosthetic implants, and the effect of irradiation therapy. Despite widespread use of breast conserving surgery for early breast cancer, many breast cancer patients still undergo mastectomy. Some of these patients choose breast reconstruction. Over the last 30 years, techniques for breast reconstruction have evolved significantly with new alternative techniques and improved surgical devises. Immediate or delayed breast reconstruction with silicone prosthesis can be an excellent option. Implant reconstruction may be single or two stage procedures. Traditionally, small breasts with minimal ptosis are suited for single-stage reconstruction. Large breasts or inadequate skin require expanders followed by implants. Minimal excision mastectomy and biological spacers are allowing larger breast single stage reconstruction and improved aesthetics for two stage procedures. With recent studies suggesting survival advantage of post-mastectomy irradiation, many candidates for breast reconstruction are receiving radiotherapy, which complicates healing after breast reconstruction.

Complications analysis of 266 immediate breast reconstructions

The purpose of this study was to describe the complications of immediate breast reconstruction, to compare their rates with respect to the surgical procedure and to patient's characteristics, in order to improve surgical indications and patient information. We carried out a retrospective study of 266 immediate breast reconstructions (249 women) over a 12-year period (latissimus dorsi myocutaneous flap with implant 61%, autologous latissimus dorsi myocutaneous flap 15%, subpectoral implant 24%). Mean age was 48 and the median follow-up was seven years (2-14). The overall complication rate was 49% (128), and there were 10 reconstruction failures. The most frequent complications were dorsal seroma 26% (70), capsular contracture 10% (27), skin necrosis 8.3% (22), and haematoma 5.6% (15). The complication rate for immediate breast reconstruction with implant alone (39%) was lower than that associated with latissimus dorsi with or without implant (51%), but the difference was not significant (Chi-square: p=0.07). The risk factors for complications were smoking (skin necrosis, Fisher: p=0.02), obesity (infection, Fisher: p=0.004), and radiotherapy (capsular contracture, Chi-square: p=2.6 x 10(-5)). Smoking was found as the only risk factor of reconstruction failure (Fisher: p=0.015). Capsular contractures were more frequent when implants were used alone (25%) as well as when used along with a flap (6.8%) (Chi-square: p=2 x 10(-5)). Infections were also higher in the non-flap group than in the flap group (Fisher: p=0.02). In our opinion, latissimus dorsi myocutaneous flap with or without an implant is a good compromise between complication risk and necessity of good cosmetic result requirement. These results have led us to delay or contraindicate reconstruction in the case of obesity or heavy smoking. In the case of probable post-operative radiotherapy, we prefer to delay the breast reconstruction.

Radiotherapy for breast cancer in patients undergoing breast reconstruction or augmentation

Due to increasing indications for postmastectomy radiotherapy and a growing demand for breast reconstruction or augmentation, increasing numbers of patients are currently being exposed to both these treatments. In view of the wide range of available techniques for breast reconstruction, either prosthetic or autologous, and their various sequencing in relation to radiotherapy, physicians can be faced with numerous clinical situations requiring comprehensive knowledge of the topic. This review discusses physical, radiobiological and clinical aspects of combining breast reconstruction and radiotherapy. The available data indicate the feasibility of such combinations, although at the expense of increased risk of complications and less satisfactory cosmesis. Of the two methods of breast reconstruction: using autologous tissue or prosthesis, the former seems to provide better cosmesis and a lower risk of complications in conjunction with radiotherapy. To minimize the risk of unfavourable outcome, the techniques and timing of both breast reconstruction and radiotherapy should be given meticulous attention.

Reconstructions mammaires après mastectomie pour cancer du sein : quelles indications retenir ?

Post-mastectomy breast reconstruction represents a surgical option that may improve psychosocial outcome without modifying patients' survival. Psychosocial impact of used surgical technique and moment of realization of breast reconstruction remains unclear. However, complications are negatively related to patients' satisfaction. There is no guideline for BR indications. Therefore, a review of clinical and cosmetic outcomes of different breast reconstruction modalities was necessary. It permitted to propose a shared decision-making algorithm for the choice of moment and technique of BR according to the presence of radiotherapy that appears to be the main risk factor of clinical outcome of breast reconstruction. It also disclosed some limits in information reliability about clinical outcome of particular associations of breast reconstruction and radiotherapy. Proportion of women pursuing breast reconstruction, and particularly immediate breast reconstruction, is rising. Clinical surveys assessing relation between radiotherapy and clinical and psychosocial outcome of breast reconstruction are urgently expected.

Mastectomy by inverted drip incision and immediate reconstruction: data from 510 cases

BACKGROUND

Immediate reconstruction of the breast can be performed in selected cases after mastectomy for breast cancer or after prophylactic mastectomy in patients with a high risk of developing breast cancer. Despite the frequency with which these procedures are performed, data from large series of subpectoral implantation of silicone prostheses in combination with a skin-saving approach are lacking.

METHODS

In this retrospective study, data on complications and late surgical interventions in 356 patients who underwent 510 mastectomies with an inverted drip incision and immediate reconstruction (MIDIIR) were analyzed to determine potential prognostic factors of early complications.

RESULTS

In 82% of the MIDIIRs, the postoperative course was uneventful. In 18%, the complications were infection (32 cases), necrosis of the skin flap (29 cases), bleeding (31 cases), and protrusion of the prosthesis (20 cases), resulting in surgery in 9, 12, 15, and 20 cases, respectively. At the end of the follow-up period, 30 (6%) prostheses were definitively removed. Age, size of the prostheses, radiotherapy, previous lumpectomy, and indication for mastectomy were not significant factors for the prognosis of early complications.

CONCLUSIONS

With the right technique and indications, MIDIIR is a very safe procedure and should be one of the surgical treatments that can be offered in the overall management of patients with, or at high risk for, breast cancer.

Immediate breast reconstruction with saline-filled implants: no interference with the oncologic outcome?

The possible adverse effects on cancer control due to immediate breast reconstruction have been addressed recently for both silicone-filled implants and flap reconstruction. To evaluate those possible effects after immediate breast reconstruction with saline-filled implants, 49 patients reconstructed with saline-filled breast implants at the Jules Bordet Cancer Institute were studied. Selection was only based on the possibility to find a matched patient. These patients were matched with a control group of 49 matched women with breast cancer treated in the same center by mastectomy without any type of breast reconstruction. The two groups were comparable according to age at diagnosis (within 3 years), year of diagnosis (same year), stage of the tumor, histology, and nodal status. The only difference between the two groups was that radiation therapy was applied to some of the patients who were not reconstructed (due to tumor location). The results show, in terms of local recurrences, distant metastasis, and deaths, no significant difference between the two groups, even for the irradiated patients, within a mean follow-up period of 72 months (range, 24 to 108) months.

Postmastectomy radiotherapy: clinical practice guidelines of the American Society of Clinical Oncology

OBJECTIVE

To determine indications for the use of postmastectomy radiotherapy (PMRT) for patients with invasive breast cancer with involved axillary lymph nodes or locally advanced disease who receive systemic therapy. These guidelines are intended for use in the care of patients outside of clinical trials.

POTENTIAL INTERVENTION

The benefits and risks of PMRT in such patients, as well as subgroups of these patients, were considered. The details of the PMRT technique were also evaluated.

OUTCOMES

The outcomes considered included freedom from local-regional recurrence, survival (disease-free and overall), and long-term toxicity.

EVIDENCE

An expert multidisciplinary panel reviewed pertinent information from the published literature through July 2000; certain investigators were contacted for more recent and, in some cases, unpublished information. A computerized search was performed of MEDLINE data; directed searches based on the bibliographies of primary articles were also performed.

VALUES

Levels of evidence and guideline grades were assigned by the Panel using standard criteria. A "recommendation" was made when level I or II evidence was available and there was consensus as to its meaning. A "suggestion" was made based on level III, IV, or V evidence and there was consensus as to its meaning. Areas of clinical importance were pointed out where guidelines could not be formulated due to insufficient evidence or lack of consensus.

RECOMMENDATIONS

The recommendations, suggestions, and expert opinions of the Panel are described in this article.

VALIDATION

Seven outside reviewers, the American Society of Clinical Oncology (ASCO) Health Services Research Committee members, and the ASCO Board of Directors reviewed this document.

Immediate breast reconstruction after mastectomy for cancer

BACKGROUND

Immediate breast reconstruction after mastectomy has increased over the past decade following the unequivocal demonstration of its oncological safety and the availability of reliable methods of reconstruction. Broadly, it is undertaken in the treatment of breast cancer, after prophylactic mastectomy in high-risk patients, and in the management of treatment failure after breast-conserving surgery and radiotherapy. Immediate breast reconstruction can be achieved reliably with a variety of autogenous tissue techniques or prosthetic devices. Careful discussion and evaluation remain vital in choosing the correct technique for the individual patient.

METHODS

This review is based primarily on an English language Medline search with secondary references obtained from key articles.

RESULTS AND CONCLUSION

Immediate breast reconstruction is a safe and acceptable procedure after mastectomy for cancer; there is no evidence that it has untoward oncological consequences. In the appropriate patient it can be achieved effectively with either prosthetic or autogenous tissue reconstruction. Patient selection is important in order to optimize results, minimize complications and improve quality of life, while simultaneously treating the malignancy. Close cooperation and collaboration between the oncological breast and reconstructive surgeons is desirable in order to achieve these objectives.

Is mammography useful in screening for local recurrences in patients with TRAM flap breast reconstruction after mastectomy for multifocal DCIS?

BACKGROUND

Skin-sparing mastectomy with immediate transverse rectus abdominis musculocutaneous (TRAM) flap reconstruction is being used more often for the treatment of breast cancer. Mammography is not used routinely to evaluate TRAM flaps in women who have undergone mastectomy. We have identified the potential value of its use in selected patients.

METHODS AND RESULTS

We report on four women who manifested local recurrences in TRAM flaps after initial treatment for ductal carcinoma in situ (DCIS) or DCIS with microinvasion undergoing skin-sparing mastectomy and immediate reconstruction. All four patients presented with extensive, high-grade, multifocal DCIS that precluded breast conservation. Three of four mastectomy specimens demonstrated tumor close to the surgical margin. Three of the four recurrences were detected by physical examination; the remaining local recurrence was documented by screening mammography. The recurrences had features suggestive of malignancy on mammography.

CONCLUSION

We conclude that all patients undergoing mastectomy and TRAM reconstruction for extensive, multifocal DCIS should undergo regular routine mammography of the reconstructed breast. Our experience with this subgroup of patients raises concern about the value of skin-sparing mastectomy with immediate reconstruction for therapy. Adjuvant radiation therapy should be recommended for those patients with negative but close surgical margins.

Role of surgery in invasive breast cancer

Surgery is still the single most important treatment modality for breast cancer. Even if some patients with early stage cancer are treated, and in a clinical sense cured, by surgery alone, adjuvant local and systemic treatments are required for most patients for the best possible tumor control. Surgery must be compatible and timed with other treatment modalities. It helps provide local control, which in some cases is enough for cure but in others is limited to being a means of palliation. Surgery provides the clinical team with material for diagnosis, for prognostication and for help in clinical decision making. The choice of the surgical procedure and its performance should be handled by surgeons, knowledgeable and interested in the field in order to obtain the best possible functional and cosmetic results. An algorithm for deciding the appropriate surgical treatment of the breast is presented. Surgical treatment of the axilla is controversial. Current debate indicates that exploration of the axilla can be safely omitted in some patient groups, but more research is needed. Other important areas for clinical surgical research are use of immediate breast reconstruction, choice of management when margins are involved with tumor growth after breast-sparing operations, and surgical approach to tumors which have been treated with chemotherapy preoperatively.

Psychologic and cosmetic self-assessments of breast conserving therapy compared with mastectomy and immediate breast reconstruction

Cosmetic and psychologic morbidity was evaluated by patients' self-assessment in 42 patients who underwent breast conserving therapy (BCT) and 48 patients who underwent mastectomy with immediate breast reconstruction (MIBR). Although sexual adjustment and fear of cancer recurrence were not significantly different between the two groups, body image was rated as significantly better in the BCT group. Additionally, in the MIBR group, nine patients expressed concern about abdominal or back scars and 15 related abdominal or back pain. Eighty-three percent of the BCT group indicated BCT as a future choice of treatment, whereas only 38% of the MIBR group indicated MIBR as a future choice of treatment. Therefore, body image and patients' satisfaction were thought to have been improved by BCT, but psychologic morbidity was the same in both groups.