Breast Reconstruction after Bilateral Prophylactic Mastectomy in Women at High Risk for Breast Cancer

Abstract:  Several studies have shown the effectiveness of bilateral prophylactic mastectomies (BPM) at reducing the risk of developing breast cancer in women by more than 90%. A growing number of women at high risk for breast cancer are electing to undergo prophylactic mastectomy as part of a risk reduction strategy. This unique group of women frequently chooses to undergo reconstructive surgery as a part of their immediate treatment plan. Breast reconstruction after BPM has profound physiological and emotional impact on body image, sexuality, and quality of life. These factors should be taken into consideration and addressed when consulting the patient prior to BPM and reconstructive surgery. The timing of reconstructive surgery, the type of mastectomy performed, the reconstructive modalities available, and the possibility to preserve the nipple–areola complex, should all be discussed with the patient prior to surgery. In this article, we review our experience and the current existing literature on breast reconstruction for high-risk women after BPM.     

Breast Reconstruction after Radical Mastectomy1

In younger women particularly, who have undergone radical mastectomy for carcinoma, the psychological sequel? can be profound. These can be avoided by breast reconstruction in the immediate postoperative period. The technique of this procedure, and the details of the indications for its performance, are discussed. The reconstruction can also be carried out years after the mastectomy, if the psychological impact of this has been such as to render the procedure indicated.     

Breast Reconstruction and Tissue Expansion in Irradiated Versus not Irradiated Women After Mastectomy

Thirty-five women whose breast cancer had been treated by radiation and 111 in whom it had not underwent unilateral breast reconstruction with the tissue expansion technique after modified radical mastectomy. Their records were reviewed and in a questionnaire the patients reported their own opinion on the results. The two groups differed significantly, because those patients who had been irradiated had a more painful course of expansion and a less over-expansion. Their reconstructed breasts were harder, had more deformities, and they required significantly more capsulotomies. The irradiated group also reported less satisfaction with the cosmetic results and more unfulfilled expectations. Tissue expansion cannot therefore be recommended as a routine procedure for breast reconstruction in patients after irradiation. However, our results do not show whether other methods are better for these patients.     

吲哚菁绿血管造影在乳腺癌术后乳房重建中的应用

目的探讨乳房重建术中判断组织血供的可视化方法。方法 2014年7月至2015年1月,在4例乳腺癌患者的乳房重建手术中,应用吲哚菁绿(ICG)荧光血管造影技术,在血液灌注可视化的情况下对皮瓣进行修整。结果ICG造影结果与组织血供的临床判断一致,3例患者未出现皮瓣血运障碍,1例患者出现皮瓣部分血运障碍。结论 ICG血管造影可应用于各种类型的乳房切除术后乳房重建,有助于降低皮瓣坏死的发生率和严重性。     

Reconstruction Patterns in a Single Institution Cohort of Women Undergoing Mastectomy for Breast Cancer

Objectives

The purpose of the current study was to conduct a patient-centered investigation of reconstruction practices following mastectomy at our institution.

Methods

A questionnaire was administered to patients who underwent unilateral or bilateral mastectomy for breast cancer from 2006 to 2010. The survey queried on demographics, surgical choices, and rationale for those choices. Data were summarized by contingency tables and compared by chi-square test or Fisher??s exact test, as appropriate.

Results

Of 321 patients queried, 185 (58?%) underwent unilateral mastectomy and 136 (42?%) underwent bilateral mastectomy (mean age 56?±?12?years). Overall, 189 (59?%) women underwent breast reconstruction, and 132 (41?%) did not. Immediate breast reconstruction was performed in 125 of 189 (69?%) women, whereas 67 of 189 (31?%) underwent delayed reconstruction. The method of definitive reconstruction included 143 of 189 (75?%) prostheses, 32 of 189 (17?%) abdominal tissue flap, 12 of 189 (6?%) latissimus flap (±implant), and 5 of 189 (2?%) with a combination of prostheses and tissue flaps. Of the 114 patients who did not undergo reconstruction, 68 (60?%) reported lack of desire for reconstruction as their motive, and the remaining 46 (40?%) reported medical contraindications for reconstruction or did not report a specific reason.

Conclusions

A significant percentage of women undergoing unilateral or bilateral mastectomy for breast cancer at our institution elect to undergo reconstruction. Prosthetic reconstruction was the most common method utilized. The impetus for referral to the reconstructive surgeon was nearly always initiated by the surgical oncologist.     

背阔肌肌皮瓣联合假体在乳腺癌术后二期乳房再造中的应用

目的探讨背阔肌肌皮瓣联合假体植入在乳腺癌术后二期乳房再造术中的临床应用。方法 2009年至2013年,共8例乳腺癌术后年轻患者接受二期乳房再造手术。术前以排水法测定健侧乳房体积,根据患者健侧乳房形状、大小及背部组织情况,设计胸背部供区皮瓣,术中测量移植皮瓣的容积,然后根据健侧乳房和移植皮瓣的容积差,选择大小合适的乳房假体,将假体埋植于背阔肌-胸大肌后间隙,利用背阔肌肌皮瓣移植联合乳房硅胶假体进行二期乳房再造。结果本组患者术后随访6个月至4年,再造乳房外形较佳,效果满意,供区无明显并发症。结论对于年轻有生育要求的乳腺癌术后乳房缺失患者,健侧乳房较大,利用背阔肌肌皮瓣联合假体进行乳房再造,可取得良好的手术效果。     

Contralateral Prophylactic Mastectomy Provides No Survival Benefit in Young Women with Estrogen Receptor-Negative Breast Cancer

Background

Several studies have shown that contralateral prophylactic mastectomy (CPM) provides a disease-free and overall survival (OS) benefit in young women with estrogen receptor (ER)-negative breast cancer. We utilized the National Cancer Data Base to evaluate CPM’s survival benefit for young women with early -stage breast cancer in the years that ER status was available.

Methods

We selected 14,627 women ≤45 years of age with American Joint Committee on Cancer stage I–II breast cancer who underwent unilateral mastectomy or CPM from 2004 to 2006. Five-year OS was compared between those who had unilateral mastectomy and CPM using the Kaplan–Meier method and Cox regression analysis.

Results

A total of 10,289 (70.3 %) women underwent unilateral mastectomy and 4,338 (29.7 %) women underwent CPM. Median follow up was 6.1 years. After adjusting for patient age, race, insurance status, co-morbidities, year of diagnosis, ER status, tumor size, nodal status, grade, histology, facility type, facility location, use of adjuvant radiation and chemohormonal therapy, there was no difference in OS in women <45 years of age who underwent CPM compared towith those who underwent unilateral mastectomy (hazard ratio [HR] = 0.93; p = 0.39). In addition, Tthere was no improvement in OS in women <45 years of age with T1N0 tumors who underwent CPM versus unilateral mastectomy (HR = 0.85; p = 0.37) after adjusting for the aforementioned factors. Among women ≤45 years of age with ER-negative tumors who underwent CPM, there was no improvement in OS compared with women who underwent unilateral mastectomy (HR = 1.12; p = 0.32) after adjusting for the same aforementioned factors.

Conclusions

CPM provides no survival benefit to young patients with early-stage breast cancer, and no benefit to ER-negative patients. Future studies with longer follow-up are required in this cohort of patients.     

Predictors of Mastectomy for Women with Breast Cancer in the Greater Western Region of Sydney

This population-based study examined predictors of mastectomy for women with breast cancer in the greater western region of Sydney (GWRS) in New South Wales (NSW), Australia in 1992. Patients with a first diagnosis of breast cancer in 1992, the year prior to population-based mammographic screening in the region, were identified through the NSW state cancer registry. Data on stage, treatment, and demographic and health service characteristics were obtained from hospital records for patients treated within the region. The 282 patients who received surgical treatment for operable disease were considered in this analysis. Logistic regression was used to determine the odds ratio (OR) for mastectomy in relation to predictor variables with adjustment for confounding where appropriate. Age was included in all regressions even though it was not statistically significant. The tumor characteristics that were significant predictors (age adjusted) of mastectomy were stage [I (referent); IIA: OR = 1.5 (ns); IIB / IIIA-B: OR = 6.3, p < 0.05] and tumor size [T0-1 (referent); T2: OR = 1.8, p < 0.05; T3: OR = 12.9, p < 0.05]. There was a significant linear trend (p < 0.05) for lower ORs for mastectomy in women treated by surgeons with a higher breast cancer caseload (adjusted for age and stage). Women from municipalities with high socioeconomic status had lower mastectomy rates than others (OR = 0.5, p < 0.05), adjusted for age, stage, and surgeon activity level. Distance of residence from the main referral hospital and radiotherapy unit did not affect mastectomy rates. This study documents factors, in addition to stage at diagnosis, that play an important part in decisions about surgery for women with operable breast cancer. The experience of the surgeon, measured by the number of breast cancer patients, had an effect, as did the socioeconomic status of the woman. The latter may act through educational characteristics and participation of women in decisions concerning surgery.     

单纯乳腺切除及乳腺内肿瘤切除后乳房成形术

目的 为了使单纯乳腺或乳腺内肿瘤切除术后患保持良好的胸部曲线及美学效果,探索新的手术方式并观察术式临床效果。方法 自1987年2月以来,采用横双蒂无垂直切口乳房成形术为13例女性24只乳房行保留乳头乳晕的单纯乳腺切除及乳腺内巨大肿瘤切除,并一期成形。结果 术后无一例发生感染、血肿,乳头、乳晕及皮瓣血运和感觉良好。结论 单纯乳腺切除或乳腺内肿瘤切除后采用本术式可保留女性的特点及曲线,是一种治疗乳腺良性病变及乳房下垂松驰较理想的手术方法。     

10-Year Survival after Breast-Conserving Surgery Compared with Mastectomy in Louisiana Women with Early-Stage Breast Cancer: A Population-Based Study

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基于假体和生物膜的乳房重建技术的临床应用研究

目的评价乳腺癌术后即刻应用假体和生物膜进行乳房Ⅰ期重建的临床效果。方法随访2012年至2014年28例保留皮肤的乳房腺体全切术(SSM)患者,其中Ⅰ期用硅胶假体置入胸大肌后生物膜重建乳房下皱襞的患者19例(A组);单纯硅胶假体置入,未使用生物膜的患者9例(B组)。比较两组患者术后1年内,假体外露、假体移位、血肿、包膜挛缩、感染和异物反应等并发症的发生率。结果 A组仅有1例发生血肿(5.26%),其他并发症均未发生;而B组有1例发生假体外露(11.11%)、2例发生假体移位(33.33%)、1例血肿(11.11%)、4例包膜挛缩(44.44%),未发生感染和异物反应。B组假体移位和包膜挛缩率明显高于A组(P<0.05)。术后随访1年,所有病例均无乳腺癌局部复发和远处转移。结论联合应用假体和生物膜重建乳房,形态良好,满意度较高,并发症少,是SSM术后安全有效的乳房重建方法。     

Outpatient Mastectomy and Breast Reconstructive Surgery

Background In the United States, post-mastectomy breast reconstruction is a state (all 51 jurisdictions) and federally mandated benefit. Outpatient mastectomy, which could lower use of breast reconstruction, may raise concerns about whether patients receive adequate post-mastectomy care. Methods Using linked surveillance, epidemiology, and end results (SEER)–Medicare data, we identified Medicare fee-for-service women aged 65–69 years, diagnosed with early-stage breast cancer, and receiving unilateral mastectomy from 1998–2002. The corresponding surgery delivery settings were determined from claims data. The outcome of interest was reconstruction within 4 months of diagnosis. We used multivariable logistic regression models to examine the association of outpatient mastectomy with the likelihood of post-mastectomy reconstruction, controlling for patient’s characteristics. Results Among the 3,419 patients in the sample, 717 (21%) patients received outpatient mastectomy. The proportions of patients receiving reconstruction were 13% for inpatient mastectomy patients and 4% for outpatient mastectomy patients. Outpatient mastectomy patients were younger and had less comorbidities than inpatient mastectomy patients. Multivariable regression analysis suggested that outpatient mastectomy patients were less likely to receive reconstruction (odds ratio = 0.247; 95% confidence interval (CI): 0.166–0.368). Additional analysis suggests that African American patients were less likely than white patients to undergo reconstruction (odds ratio = 0.515; 95% CI: 0.293–0.906) and that this ethnic difference was more manifest among patients undergoing inpatient mastectomies. Conclusions This study shows that outpatient mastectomy was associated with lower use of breast reconstruction. A better understanding of choice of delivery setting of mastectomy with a focus on younger and minority breast cancer patients should be explored in future research.     

Revisiting the Free Nipple Graft: An Opportunity for Nipple Sparing Mastectomy in Women with Breast Ptosis

Objective

Nipple areolar complex (NAC) sparing mastectomy improves the cosmetic outcome of patients with breast cancer. However, women with significant breast ptosis are not candidates for this technique due toexcessive skin flap length and ensuing risk of NAC ischemia.1 ^– 3 We report a novel technique using free nipple graft during skin sparing mastectomy for patients with significant ptosis while concurrently maintaining oncologic integrity.

Design

Case series.

Setting

Community and tertiary care hospital practices.

Patients

Women with breast cancer desiring NAC preservation who are otherwise candidates for nipple sparing mastectomy, but with significant breast ptosis that precludes NAC viability. All women underwent immediate, autologous breast reconstruction.

Interventions

Bilateral and unilateral free nipple grafts were harvested, placed on ice during skin sparing mastectomy and free flap reconstruction, grafted at the conclusion of the case and secured with a bolster.

Outcome Measures

Full or partial NAC preservation, ischemia time, local wound complications at NAC grafting site, pathologic outcomes.

Results

A total of three patients underwent free nipple grafting at the time of skin sparing mastectomy and free or pedicled flap for breast cancer between March and September 2012. Of five total nipple grafts, one had partial NAC loss but did not require operative debridement. Pathologic review of areolar tissue removed during intraoperative defatting of free nipple graft demonstrated residual duct epithelium.

Conclusions

Women with significant breast ptosis that would preclude them from NAC sparing mastectomy can successfully preserve their NAC using a free nipple graft. Duct epithelium present in defatted tissue during preparation of the free nipple graft suggests that oncologic integrity can also be maintained.     

乳腺癌改良根治术同期乳房重建的安全性和患者满意度评价

目的观察乳腺癌改良根治术同期行背阔肌肌皮瓣乳房重建的临床效果,评价患者满意度。方法选择病理确诊的乳腺癌患者22例(重建组),行腺癌改良根治术并同期行背阔肌肌皮瓣乳房重建术;匹配同龄、同学历、同TNM肿瘤分期的非乳房重建患者22例作对照(对照组),以Harris标准评价重建乳房的美容效果。随访3年,观察癌组织局部复发转移情况;对患者术后6个月、12个月、24个月和36个月的满意度进行评价。结果两组3年均无肿瘤局部复发及远处转移。乳房重建组优、良、一般分别为14例、5例和3例,患者满意度高于对照组(P0.05),时间因素和分组因素无交互作用(P>0.05)。结论乳腺癌改良根治术同期行背阔肌肌皮瓣乳房重建,不但保证了肿瘤治疗的效果,而且患者的形体美,满意度高。     

扩大背阔肌肌皮瓣在乳腺癌改良根治术后一期乳房再造中的应用

目的评价扩大背阔肌肌皮瓣在乳腺癌改良根治术后一期乳房再造中的应用价值。方法选取我科2008年1月至2009年6月期间收治的48例乳腺癌患者,根据所接受的术式分为扩大背阔肌肌皮瓣一期乳房再造（乳房再造）组（n=12）和单纯乳腺癌改良根治术（单纯根治）组（n=36）,对2组患者术后并发症、恢复情况以及生活质量进行对比,并对再造乳房外观形态进行评价。结果乳房再造组患者均成功行扩大背阔肌肌皮瓣乳房再造,再造乳房外形评价良好6例,中4例,差2例,明显优于单纯根治组（P〈0.001）。2组患者术后积液、皮瓣坏死、患肢及肩关节活动、住院时间、引流时间及开始辅助治疗时间差异均无统计学意义（P〉0.05）,但乳房再造组术后生活质量较好,与单纯根治组比较差异有统计学意义（P〈0.001）。乳房再造组有10例行术后辅助放化疗,未出现转移皮瓣坏死。2组患者随访2～17个月（中位时间8个月）,未见局部复发及转移。结论乳腺癌根治术后扩大背阔肌肌皮瓣一期再造乳房形态效果良好,手术操作简单,对早期乳腺癌是一种安全、可行的治疗方法 。