Post-mastectomy breast reconstruction
BMJ 2013; 347 doi: https://doi.org/10.1136/bmj.f5903 (Published 15 October 2013) Cite this as: BMJ 2013;347:f5903
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two distinct anatomic facts and two distinct pathologic (oncologic) facts relating to the breast will discourage me from encouraging my patient towards skin sparing, nipple conserving mastectomy even in early cancers;
anatomic;
a. there is a dense lymphatic plexus in both the subareolar region and the retromammary region
b. these lymphatics are largely valveless and so any cancer cells can travel in any direction whilst they are in these segments; easily able to radiate as it were 'to any point of the compass'.
pathologic;
c. lack of evidence of cancer cells in the nipple-areolar complex is not evidence of lack of cancer cells; occult cancers do occur
d. the skin sparing surgical dissection itself could turn out to have disseminative impact on the cancer cells between oncological planes and virgin tissues.
these possibilities being likely, it is to be expected that oncological clearance may suffer from being incomplete.
local recurrence rate therefore may come to accumulate epidemiologically as more and more of these types of resections are done.
add to this, the greater difficulty of picking up local recurrence or continuing disease cos of the new breast particularly if reliance is on clinical or mammographic tools (as opposed to say MRI or ?PET), then it becomes the graver responsibility to urge on a patient towards this type of mastectomies, no matter its immediate aesthetic appeal and facilitatory role in reconstructive work.
Competing interests: No competing interests
Re: Post-mastectomy breast reconstruction
Breast reconstruction is challenging to optimise in the face of optimum adjuvant therapy and we commend the authors on their recent review. "If radiotherapy is needed, delayed reconstruction minimises the risk of complications and improves aesthetic outcomes" is stated as a summary point; no evidence is presented to support this conclusion. Undoubtedly post mastectomy radiotherapy PMRT has a negative effect on tissue viability, compliance and elasticity; but delaying reconstruction till after radiotherapy does not avoid this.
Recent meta-analysis has demonstrated that PMRT has a detrimental effect on breast reconstruction with morbidity from breast reconstruction is 4 times more likely with PMRT than with no PMRT (odds ratio [OR] = 4.2; 95% CI, 2.4, 7.2) 1. However, when the effect of delaying reconstruction till after PMRT was examined no significant reduction in morbidity was seen (OR = 0.87; 95% CI, 0.47, 1.62) 1. Delaying reconstruction till after PMRT does not avoid morbidity and may only delay these problems till a second surgery. In addition delayed tissue expander based reconstruction is not feasible after PMRT, so this form of simple and effective reconstruction may be lost to patients if Thiruchelvam et al’s treatment plan is followed.
Its is imperative that patients are aware not only of the benefit of PMRT but also the negative effects it may have on breast reconstruction and that this is considered when deciding which type of reconstructive is best for individual patients.
Barry M, Kell MR. Radiotherapy and breast reconstruction: a meta-analysis. Breast Cancer Res Treat. 2011;127(1):15-22.
Competing interests: No competing interests