Introduction

Breast cancer currently affects one in eight women in the United States. A diagnosis of breast cancer presents the patient not only with physical challenges but emotional concerns with respect to body image and sexuality. With improved screening and early detection, approximately 80% of these women present with small tumors that are amenable to breast conservation. Until the 1970s, breast cancer was treated with radical mastectomy involving removal of the breast, axillary lymph nodes, and pectoralis muscle. This was extremely disfiguring for patients and did not lend itself to optimal reconstructive options. In the 1970s, modified radical mastectomy was introduced, which preserved the pectoralis muscle and improved the contour of the chest wall, as well as increased the reconstructive possibilities. In the 1980s, a large randomized study conducted by the National Surgical Adjuvant Breast and Bowel Project (NSABP) was able to prove that breast conservation plus radiation had equivalent outcome to mastectomy.

Since that time, breast conservation has become increasingly popular. As a personal choice, however, some patients with small tumors still opt for mastectomy. Many of these women are resistant to radiation as part of therapy and seek to avoid that by choosing mastectomy. For women with recurrent or multifocal cancer, or a history of radiation therapy to the breast, mastectomy remains the gold standard. With the discovery of the BRCA genes and the up-to 85% lifetime incidence of breast cancer associated with a gene mutation, women carrying a BRCA mutation often opt for bilateral prophylactic mastectomies. Women with a diagnosis of breast cancer that are found to carry a BRCA mutation are usually offered bilateral mastectomies at the time of diagnosis. It is clear, that in certain cases, mastectomy is the best surgical option for a subset of patients, and the development of improved breast reconstruction techniques has significantly reduced the psychological stress faced by patients who often see mastectomy as losing a part of their body image. It is critical that all breast cancer patients who require a mastectomy are given the opportunity to consult with a plastic surgeon to discuss reconstructive options. This chapter will address the oncologic considerations for women who opt for breast reconstruction.

Background on the Diagnosis and Treatment of Breast Cancer

Breast cancer may initially present as a mammographic finding or a palpable mass. It is always optimal to obtain a tissue diagnosis with a core needle biopsy rather than an open excisional biopsy if at all possible. In this way the diagnosis can be discussed with the patient prior to any surgical procedures and also no unnecessary incisions are made in the breast or tissue removed that might impact both the oncologic and cosmetic outcome. All of our new breast cancer patients undergo breast magnetic resonance imaging (MRI). This is much more sensitive than mammogram in measuring the extent of disease as well as multifocal or contralateral breast cancer. This information is important as it affects the surgical recommendations for patients.

Up until the 1970s, breast cancer was treated with radical mastectomy, which involved removal of the breast, pectoralis muscle, and axillary lymph node levels I to III. This was quite disfiguring for the patient and so in the 1970s, modified radical mastectomy came in to use, which preserved the pectoralis muscle, thereby improving somewhat the contour of the chest wall. In addition, only level I and II axillary lymph nodes were removed, which reduced the incidence of lymphedema in these patients. In the 1980s breast conservation (lumpectomy or partial mastectomy) combined with radiation therapy to the breast was found to be equivalent in survival to modified radical mastectomy. Today, approximately 80% of patients are found to be candidates for breast conservation.

In the 1990s, the technique of sentinel lymph node dissection was adopted in efforts to spare women with negative lymph nodes the morbidity of a full axillary lymph node dissection. The technique involves injecting radiolabeled colloid and/or lymphazurin blue dye into the breast and allowing it to travel to the axillary lymph nodes. All the radioactive and/or blue lymph nodes are removed and, in our institution, evaluated by frozen section. If these sentinel lymph nodes do not contain tumor on frozen section, then the patient is spared a complete axillary lymph node dissection. If the frozen section does reveal cancer in the sentinel lymph nodes, then a complete axillary lymph node dissection is performed during the same operation. If a patient has clinically positive lymph nodes before surgery, a sentinel lymph node dissection is not performed and the patient undergoes a complete axillary lymph node dissection.

Timing of Reconstruction

Although many patients are able to be treated with breast conservation, a subset of patients will either require a mastectomy or choose mastectomy as their surgical option. For these patients, the plastic surgeon is critical in helping the patient determine whether they wish to have breast reconstruction. However, controversy exists regarding the timing of breast reconstruction – immediate versus delayed. Immediate reconstruction employs the skin-sparing mastectomy technique that was developed by Toth and Lappert in 1991¹ and offers several advantages. The reconstructed breast has an improved cosmetic outcome following immediate reconstruction due to preservation of the skin envelope. Psychologically, the patient wakes up with a breast mound rather than a flat chest wall. The patient has one hospital stay and one anesthetic for the majority of the surgery followed by additional outpatient procedures for revisions, nipple reconstruction, etc. The skin-sparing mastectomy technique has been evaluated from an oncologic perspective and there does not appear to be any increased risk for local or distant recurrence.^2–7 Rozen et al performed a Medline literature review to evaluate the psychosocial need for immediate breast reconstruction and the issues surrounding oncologic safety. The authors’ review of previous studies concluded that immediate reconstruction does not increase local recurrence rates and does not delay the initiation of adjuvant chemotherapy or radiation. There was not a higher rate of complications in the setting of chemotherapy although there was a higher rate of complications in patients receiving adjuvant radiation therapy. Immediate breast reconstruction did have a positive effect on psychosocial outcomes including depression, anxiety, body image, self-esteem, self-image, emotional function, social function and sexual function.⁸

The oncologic safety of immediate reconstruction was also reviewed by Taylor et al.⁹ This was also a literature review and included analysis of 84 papers. The authors’ analysis concluded that there was not an increased risk of local or distant recurrence (although the studies reviewed were small and retrospective), and that detection of recurrence was not impaired by immediate reconstruction. In addition, no delay in the delivery of adjuvant chemotherapy was identified. With respect to radiation, there was a significantly higher rate of complications (capsular contracture, implant rupture, wound infections) in patients undergoing mastectomy and expander or implant placement who had radiation before or after reconstruction. With respect to autologous tissue reconstruction, complication rates were similar between patients undergoing radiation followed by TRAM reconstruction versus patients undergoing immediate reconstruction followed by radiation. However, fat necrosis and flap volume loss were more common in the immediate reconstruction group.⁹

As outlined above, there are several concerns regarding immediate reconstruction. The major issue involves postmastectomy radiation, which will be discussed in greater detail in the following section. Immediate reconstruction still may be undertaken in patients who will more than likely require postmastectomy radiation. However, the oncologic surgeon and plastic surgeon need to discuss this preoperatively and inform the patient of the possible cosmetic sequelae from this approach. Another concern regarding immediate reconstruction is the possibility of delay in adjuvant chemotherapy. If a patient undergoes autologous tissue reconstruction and develops postoperative wound complications, the chemotherapy may need to be delayed until the wound problems are resolved. Although the studies detailed above have not found any significant delays in adjuvant chemotherapy, it is unknown what type of impact this might have on a patient’s overall survival. In our practice, many of our patients with Stage II and certainly Stage III breast cancer, undergo neoadjuvant chemotherapy, which negates this concern. We feel that most patients should be considered for immediate reconstruction and that this should be a joint decision made by the oncologic surgeon, plastic surgeon, and patient. Inflammatory breast cancer, with its poor prognosis and rapidity of recurrence, is a subtype of breast cancer that should not be considered suitable for immediate reconstruction. Additionally, patients with locally advanced breast cancer who do not undergo neoadjuvant therapy, or those with a poor response to chemotherapy, may also need to delay their reconstruction.

Delayed reconstruction is a more commonly employed technique. These patients typically complete their adjuvant therapy and then are evaluated by plastic surgeons for their reconstruction options. The advantage to this approach is that the final pathology is known prior to any reconstructive procedures. If any additional surgery is required, this can be undertaken without the anatomic or technical considerations that would result following reconstruction. Patients have time to consider whether or not they want reconstruction without the uncertainty of their stage of disease and following completion of therapy. They are able to use a prosthesis and decide if that is adequate for them.

The disadvantages are the advantages stated above for immediate reconstruction: possible inferior cosmetic result, additional anesthetic/hospital stay and the psychological distress of absence of a breast. Postmastectomy radiation does impact the outcome of the reconstruction and needs to be discussed with the patient.

Postmastectomy Radiation

Current recommendations for postmastectomy radiation include four or more positive lymph nodes or advanced tumors (T3, T4, skin involvement). Close or positive margins are another indication for postmastectomy radiation. Based on recent Danish and Canadian trials, postmastectomy radiation for patients with one to three positive lymph nodes is becoming more common and therefore the overall use of postmastectomy radiation is increasing.^10–12 The radiation may adversely affect the cosmetic outcome of the immediate reconstruction (Fig. 2.1) and there is some concern that the reconstructed breast may result in technical difficulties in the delivery of radiation therapy. This includes increased doses of radiation to the lungs or reduced radiation delivery to the internal mammary lymph nodes. If breast reconstruction is delayed until after radiation, however, the mastectomy skin is often compromised, and the shape of the native breast skin envelope lost. Delayed breast reconstruction with implants following postmastectomy radiation can result in wound healing problems, capsular contracture with subsequent implant displacement, and painful constriction against the chest wall.¹⁰ Many plastic surgeons will opt for autologous tissue when delayed reconstruction after radiation is performed.

Fig. 2.1 Radiated TRAM reconstruction.

To address this problem, surgeons at MD Anderson have described and published their experience with a two-stage approach that they have termed ‘delayed-immediate reconstruction.’ Stage 1 consists of a skin-sparing mastectomy with subpectoral insertion of a completely filled saline tissue expander to preserve the shape of the breast skin envelope. After review of the final pathology, patients who do not need radiation undergo immediate reconstruction within two weeks from the time of mastectomy (Stage 2). Patients who require radiation undergo therapy with the expander deflated to the chest wall. After radiation is complete, patients undergo re-expansion of the preserved breast skin.¹³

Nahabedian and Momen analyzed the local recurrence rate and survival of patients undergoing radiation therapy either before or after breast reconstruction. The patient cohort included 146 women who underwent breast reconstruction and radiation with a follow-up of at least 12 months. Tumor recurrence, survival, loss of implant and total flap necrosis were analyzed.¹⁴ The 59 women who underwent radiation after breast reconstruction had a higher local recurrence rate versus the 87 women who underwent radiation therapy prior to breast reconstruction (27% versus 15%). In addition there was a higher loss of life in the group undergoing breast reconstruction before radiation versus the group undergoing reconstruction after radiation (12% versus 7%). This raises concerns regarding the potential impact of immediate reconstruction on radiation delivery. This is a small study and it is difficult to draw definitive conclusions from this data. These questions may be better answered by a prospective trial.

BRCA Positive Patients

Women who carry a BRCA1 or BRCA2 mutation have an up-to 85% chance of developing breast cancer in their lifetime. In addition, there is up to a 65% cumulative lifetime risk that these women will develop ovarian cancer. The management of these women involves a multidisciplinary approach among breast surgeons, plastic surgeons and gynecologists. While many of the patients opt for aggressive clinical follow-up including physical exams, breast MRI, pelvic ultrasounds, serum CA-125 levels and possibly tamoxifen, prophylactic surgery is a reasonable approach that is effective in significantly reducing the risk of breast and ovarian cancer.

In these women who choose prophylactic surgery, consideration should be given to a coordinated approach for the mastectomies and bilateral salpingo-oophorectomies (BSO). Batista et al identified 12 patients who underwent combined mastectomies and BSO between 1996 at 2003. Ten of these patients underwent bilateral autologous tissue reconstruction. Six of these ten patients also underwent total abdominal hysterectomy during the same procedure. In this small retrospective study, there were no significant complications related to the gynecologic procedures.¹⁵ Therefore, it is important that these patients are cared for by a multidisciplinary team who can determine whether a combined approach is feasible.

Many of the BRCA positive patients are quite young, and given this is a prophylactic procedure, they are most concerned with the cosmetic results. In this group, it is critical that the plastic surgeon be able to offer these women any and all reconstructive options. This should include autologous tissue reconstruction with latissimus dorsi, transverse rectus abdominis, or possibly gluteal flaps. Tissue expanders or immediate implant placement are other options to discuss. These patients need to be counseled that based on their genetic predisposition, there is a chance that occult cancer will be found at the time of surgery. Therefore, all these patients should receive preoperative MRI to look for abnormalities and bilateral axillary sentinel lymph node dissections at the time of mastectomies. It is critical that the patient and her oncologic and plastic surgeons discuss this preoperatively in case adjuvant therapy is required that might impact the reconstruction performed.

Many patients have a strong family history of breast cancer but test negative for the BRCA mutation. This could mean that they have another hereditary cancer syndrome such as Cowden or Li–Fraumeni, or carry a genetic mutation that has not yet been discovered. Further, some patients have watched relatives undergo breast cancer treatment and possible recurrence and wish to have prophylactic surgery to reduce their risk as much as possible. In these patients, it is important to have a long discussion about prophylactic surgery and the reconstructive options. If the patient elects to pursue this option, then it is reasonable to have them meet with the plastic surgeon. All patients need to know that mastectomy removes approximately 97% of the breast tissue not 100% of the breast and so they will still need clinical exams in follow-up for the small amount of tissue remaining.

Young Patients Considering Future Child-Bearing

Young women with breast cancer present additional challenges with respect to surgical options and reconstruction. Some of these patients will carry a BRCA mutation and may consider undergoing bilateral prophylactic mastectomy as discussed earlier. There also exists the issue of future pregnancy after autologous tissue reconstruction. Collin and Coady reported a case of a 33-year-old female who underwent a free transverse rectus abdominis myocutaneous (TRAM) reconstruction and subsequently became pregnant 1 year later. She was able to successfully carry her infant to term without any abdominal wall complications including width of donor site scar.¹⁶ Patients need to be counseled about the potential risks of pregnancy after TRAM including fascial tears, herniation, and scar widening. The exact safe time interval between TRAM and pregnancy is unknown. For breast cancer patients, we generally advise them to wait 2 years post treatment prior to considering pregnancy.

Locally Advanced Breast Cancer/Inflammatory Breast Cancer

Many patients have concerns regarding the oncologic safety of immediate reconstruction in the face of locally advanced breast cancer. This was addressed in a study by Newman et al, in which 540 patients undergoing immediate reconstruction following mastectomy were evaluated. Fifty of these patients had locally advanced breast cancer and all underwent postoperative chemotherapy. Forty percent of these patients underwent postoperative radiation therapy. At median follow-up of 58.5 months, there was no difference in local or distant recurrence between these 50 patients and 72 matched controls with locally advanced breast cancer who did not undergo reconstruction.¹⁷

In today’s paradigm, most patients with locally advanced breast cancer are treated with neoadjuvant chemotherapy. This allows not only for evaluation of how the chosen chemotherapy regimen is working on a patient’s particular tumor type, but it may shrink the tumor such that subsequent surgery is technically easier to perform. It also eliminates the concern about postoperative wound complications delaying the delivery of chemotherapy. Patients who develop wound infections or necrotic tissue must be completely healed prior to commencing chemotherapy.¹⁸ In patients with aggressive tumors, this can lead to concern regarding spread of disease.

Inflammatory breast cancer is a very aggressive subtype of cancer with involvement of the dermal lymphatics. Despite multi-modality treatment of chemotherapy followed by mastectomy and then radiation, the overall 5-year survival is 46%.¹⁹ These patients tend to have a high-rate of local recurrence, which is why they have traditionally not been considered candidates for immediate breast reconstruction. Two studies have recently challenged this recommendation. Slavin et al evaluated 10 patients with inflammatory breast cancer who underwent immediate reconstruction with a myocutaneous flap. Six of these patients developed local recurrence, however there was no effect on patient survival.²⁰ In another study by Chin et al, 23 women underwent breast reconstruction after surgery for inflammatory breast cancer. Fourteen patients had immediate reconstruction while 9 patients had delayed reconstruction. At median follow-up of 44 months, there were no differences in outcome between the two treatment groups.²¹

Despite these small studies with positive results, we are currently not offering immediate reconstruction to our patients with inflammatory breast cancer. If the patient shows no evidence of disease one to two years post treatment, they are then referred to a plastic surgeon for discussion of possible reconstruction.

Nipple-sparing Mastectomy

A recent phenomenon is the increased use of nipple-sparing mastectomy or total skin-sparing mastectomy in patients undergoing either prophylactic surgery or treatment for breast cancer. This procedure involved ‘coring-out’ the ductal tissue from within the nipple–areola complex to reduce the likelihood of a recurrence in the area of the nipple. Recent studies have addressed the concerns regarding nipple–areola recurrences as well as technical issues related to nipple necrosis. Sacchini et al analyzed data on 123 patients who underwent nipple-sparing mastectomy with breast reconstruction. Forty-four patients had invasive cancer, 20 had ductal carcinoma in situ (DCIS), and four had phylloides tumors. There were two local recurrences with one being DCIS and the other invasive cancer. Two patients developed breast cancer after prophylactic mastectomy. None of these recurrences or new cancers was in the nipple–areola complex. Eleven percent of patients developed nipple necrosis but this was minimal in 59% of patients.²² The authors concluded that local relapse after nipple-sparing mastectomy was very low and that this procedure might be feasible in select patients.

Garwood et al recently compared the first 64 patients undergoing total skin-sparing mastectomy at University of California, San Francisco between 2001 and 2005 to 106 patients undergoing total skin-sparing mastectomy between 2005 and 2007. The first cohort was analyzed in 2005 and techniques were altered to minimize risk factors for complications. An incision involving 30% or less of the nipple areolar complex resulted in improved nipple viability. Between cohort 1 and cohort 2, nipple survival rates rose from 80% to 95% and complication rates declined. These included necrotic complications, implant loss and wound infections. Local recurrence at median follow-up of 13 months was 0.6% with no recurrences in the nipple–areolar complex.²³ The authors concluded that total skin-sparing mastectomy is oncologically safe with high nipple viability.

Patients should be counseled regarding the potential risks and benefits of proceeding with nipple-sparing mastectomy. Clearly, technique is critical in obtaining an optimal cosmetic result. It seems reasonable to be conservative when offering this option to women who have a diagnosis of breast cancer as no definitive long term data is currently available for this technique. Nipple-sparing mastectomy appears to be a safe alternative for prophylactic surgery providing that the ductal tissue within the nipple is removed.

Breast Imaging Following Breast Reconstruction

Confusion exists regarding the role for mammography following bilateral mastectomies with reconstruction. Many primary care physicians are unclear about the necessity of routine screening mammography in a patient who clinically appears to have breasts but has undergone mastectomy and reconstruction particularly in the case of autologous tissue transfer. A study by Lee et al aimed to determine the role of mammography after TRAM reconstruction in women treated for breast cancer. In this retrospective review, 264 patients who had undergone mastectomy with TRAM reconstruction and subsequent bilateral screening mammograms were evaluated. Over a median follow-up period of 4.9 years, the rate of detection of recurrent non-palpable cancer in TRAM reconstructions was 0%.²⁴ In our practice, we do not perform routine mammograms of a breast that has undergone mastectomy followed by reconstruction. These patients should have yearly mammograms on the contralateral breast if prophylactic mastectomy has not been performed. Women who have undergone mastectomy with reconstruction have clinical breast exams and diagnostic imaging of any areas of concern. This imaging may include mammogram, ultrasound or MRI. The management of breast cancer local recurrence after mastectomy with reconstruction can be challenging and usually involves a combination of wide local excision, chemotherapy and radiation.

Conclusions

The treatment of breast cancer has become increasingly complex as more options have become available to patients. A multidisciplinary approach to breast cancer care, including the involvement of an oncologic surgeon, plastic surgeon, medical oncologist, radiation oncologist, mammographer, and often genetic counselor, is critical to ensure that the patient achieves an optimal outcome. The role of breast reconstruction often plays a crucial role in the patient’s recovery and has a significant positive impact on their psychological well-being.