Immediate Reconstruction After Mastectomy: Factors in Patient Selection

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Immediate Reconstruction After MastectomyFactor
s in Patient Selection

• Lisa Publicover
• Med III

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Overview

• Basic Breast Cancer review
• Options for Post-Mastectomy Breast Reconstruction
• Patient Selection in Immediate Reconstruction

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Epidemiology

• 1 in 9 Canadian women are affected by breast
  cancer1.
• 1 in 27 Canadian women will die from breast
  cancer1.
• Risk Factors include
• Age
• Sex
• Family History
• Estrogen Exposure
• etc
• Metastasis bone gt lungs gt pleura gt liver gt brain1

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Types of Breast Cancer

• Non-Invasive
• DCIS Ductal Carcinoma In Situ
• LCIS Lobular Carcinoma In Situ
• Invasive
• Infiltrating Ductal Carcinoma (80)
• Invasive Lobular Carcinoma
• Inflammatory Carcinoma
• Pagets Disease
• Male Other

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Stages of Breast Cancer
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BCS Breast Conserving Surgery
RAD Radiation
MAST Mastectomy
CHEMOChemotherapy
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Who are We Talking About?

• Any Woman with Stage I-III breast cancer who
  chooses Mastectomy

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Options for Reconstruction

• Immediate vs Delayed
• Prosthetic vs. Autogenous

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Options for Reconstruction

• Immediate vs Delayed
• Prosthetic vs. Autogenous

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Immediate Reconstruction

• Benefits
• Single Operation
• Single Hospitalization
• Better Psychological Adjustment
• Better Aesthetic Results
• Drawbacks
• Increased Length of Operation/Recovery
• Difficult Logistics
• More Complex Surgery
• Post-Op Radiation Complications2

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Autogenous Reconstruction

• Several donor site options
• TRAM
• Latissimus Dorsi
• Gluteus Maximus

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Autogenous ReconstructionTRAM

• A flap is created from the transverse rectus
  abdominus muscle.
• This is the Gold Standard in breast
  reconstruction.

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Autogenous ReconstructionTRAM
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Autogenous ReconstructionTRAM
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Autogenous ReconstructionTRAM

• Benefits
• No Prosthesis required
• Good Versatility
• Tissue can withstand post-op radiation
• Can be performed on radiated tissue
• Drawbacks
• Time Consuming
• Abdominal Scar
• Complications associated with long operation (eg.
  DVT, Pneumonia, ARDS, etc) 3

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TRAM Patient Selection

• Contraindications2
• Patient Refusal
• Elderly
• Lack of Adequate Donor Tissue
• Stage IV cancer

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TRAM Patient Selection

• Risk Factors2
• Weight gt 25 Ideal
• Smoking
• Diabetes
• Autoimmune Disease
• Psychological Condition
• Prior Abdominal Surgery
• Systemic Disease (COPD, HTN, IDDM, Obesity, CVD)

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TRAM Patient Selection

• Oncological Considerations
• High Risk for Recurrence
• Post-Op Chemotherapy
• Post-Op Radiation Therapy

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High Risk for Recurrence

• Once believed that there was a delay in detection
  of local recurrence in patients with immediate
  reconstruction.
• Recent evidence suggests that there in NO DELAY
  in detecting local recurrence in reconstructed
  breasts2
• No significant difference in survival between
  reconstructed and non-reconstructed breasts2.

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Post-Mastectomy Chemotherapy

• The majority of research suggests NO delay in the
  administration of adjuvant chemotherapy2,
  although some reports suggest that there is a
  delay5.
• No evidence of increased morbidity with
  reconstruction2.
• No significant adverse effect of chemotherapy on
  aesthetic outcome2.

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Post Mastectomy Radiation

• Who receives Radiation after Mastectomy??
• Those with T3/T4 disease at presentation
• Those with Stage III disease
• Those with pathologic involvement of 4 or more
  nodes.4

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Immediate Reconstruction Post-Mastectomy
Radiation

• Controversial
• Some report no increase in complications of
  TRAMRAD as compared to TRAM alone2, while others
  do4.
• TRAM RAD does not result in aesthetically poor
  outcome and the majority of patients are
  satisfied with the reconstruction2.
• I-TRAM does not delay the delivery of radiation,
  but it may interfere with optimal radiation
  administration3,4.

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References

• 1. Toronto Notes (2005). General Surgery
• 2. Malata, McIntosh Purushotham.(2000).
  Immediate breast reconstruction after mastectomy
  for cancer. British Journal of Surgery, 87,
  1455-1472.
• 3. Kronowitz Robb. (2004) Breast reconstruction
  with postmastectomy radiation therapy current
  issues. Plastic Reconstructive Surgery, 114(4),
  950-960.
• 4. Schechter, Strom, Perkins, et al. (2005).
  Immediate breast reconstruction can impact
  postmastectomy irradiation. American Journal of
  Clinical Oncology, 28(5), 485-494.
• 5. Barreau-Pouhaer, Le, et al (1992). Risk
  factors for failure of immediate breast
  reconstruction with prosthesis after mastectomy.
  Eur J Surg Oncol, 18, 119-23.