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.