Local Management of Primary Breast Cancer

Preoperative planning of deep inferior epigastric artery perforator flap reconstruction with multislice-CT angiography: imaging findings and initial experience

BACKGROUND

Autologous breast reconstruction with abdominal tissue is one of the best options after mastectomy. Reconstruction with deep inferior epigastric perforator (DIEAP) flaps requires a precise location and preoperative evaluation of perforating vessels. The objective of this report is to demonstrate the usefulness of multislice-CT (MSCT) angiography for preoperative planning in patients undergoing DIEAP flap reconstruction.

METHODS

Six consecutive women were considered for breast reconstruction with DIEAP flaps after previous mastectomy for breast cancer. Preoperative MSCT angiography was performed to localise the arterial perforators. Axial images, multiplanar reconstructions (MPR) and 3D volume-rendered images were analysed. Findings were correlated with surgery. Initial experience and imaging findings will be described.

RESULTS

Accurate identification of the main perforators was achieved in all six patients with a very satisfactory concordance between MSCT angiography and surgical findings. No unreported vessels were found. Location, course, anatomical variations and relations of the superficial inferior epigastric artery were reported. The very small perforators, were equally evaluated and described.

CONCLUSIONS

Preoperative evaluation of perforator arteries with MSCT angiography is feasible in patients undergoing breast reconstruction. This technique provides a noninvasive global approach of the vascular anatomy and the entire anterior abdominal wall. However, more patients need to be evaluated in order to clarify the potential aspects pointed in this report.

Comparing the cost of delayed and immediate autologous breast reconstruction in Belgium

This study documents the cost of immediate and delayed DIEP flap breast reconstruction. Immediate reconstruction is more attractive from an economic perspective since it only requires one operation, one anaesthetic procedure and one recovery period in hospital. From the perspective of healthcare budget management, assessing the possible cost savings from immediate reconstruction yields interesting results. Since charges do not reflect the real costs of providing care, we calculated resource costs using the micro-costing method. About 95% of the initial mastectomy costs could be saved when performing an immediate breast reconstruction. This was about 35% of total standard direct and indirect costs due to mastectomy and delayed breast reconstruction. In a growing cost conscious environment of managed care, the economic evaluation should, therefore, encourage the trend towards more immediate reconstructions.

Immediate reconstruction after mastectomy for breast cancer does not prolong the time to starting adjuvant chemotherapy

BACKGROUND

Immediate breast reconstruction is often performed after mastectomy for breast cancer. There has been concern that this will result in a delay in initiating chemotherapy and, as a consequence, may adversely impact survival. In this study we sought to determine whether immediate breast reconstruction affects the interval between surgery and adjuvant chemotherapy.

METHODS

A single institution retrospective analysis was made using the institutional tumor registry and chart reviews.

RESULTS

Forty-nine patients were identified who had undergone mastectomy with immediate reconstruction followed by adjuvant chemotherapy. They were compared with 308 patients undergoing mastectomy without reconstruction. Patients who underwent reconstruction were overall younger (46 versus 55, P <0.001), and had more advanced disease. The time to chemotherapy was significantly longer in the group receiving no reconstruction: 53 versus 41 days (P = 0.039). The type of reconstruction did not affect the time to chemotherapy.

CONCLUSIONS

Immediate reconstruction after mastectomy does not increase the time to chemotherapy compared with mastectomy alone.

Controversies in Breast Cancer

BACKGROUND: A large number of controversies about the management of breast cancer produce uncertainties for patients and physicians alike. In addition, questions are constantly raised about the true value of new approaches or treatments. METHODS: The authors have conducted a critical review of the literature on several of these issues, and they present a balanced view that can be useful for clinical decision making. RESULTS: Although new staging systems for ductal carcinoma in situ have been proposed, a consensus has not yet been reached regarding the criteria to allow tumor excision alone. The extent of benefit of the main adjuvant therapies is becoming better established, and improvement in outcomes may accrue from dose-intensive treatments and autologous stem cell or hematopoietic growth factor support. CONCLUSIONS: Progress in breast cancer management continues to evolve. Several new approaches either reduce morbidity or improve outcomes.

Conservation Therapy of the Breast: Optimizing Long-term Results

BACKGROUND: Radiation therapy is a key component of breast conservation therapy for breast cancer. There is great interest in safety and long-term outcome issues for this still underutilized approach. METHODS: The author reviews a series of factors that may affect the end results of conservation therapy and highlights those that are likely to be of clinical significance. RESULTS: Daily dose fractions are usually less than 2 Gy and a homogeneous whole-breast dose is used. Care is needed with patients with collagen vascular diseases, large breasts, breast trauma, and prior infections, but these factors are not absolute contraindications to breast conservation therapy. Acute skin reactions are not predictive of long-term complications. CONCLUSIONS: With adherence to proper surgical and radiation techniques, most patients presenting with localized breast cancer can be managed safely and effectively with breast conservation.