Review article:
BREAST RECONSTRUCTION:
CURRENT FACTS AND THE LOCAL CONTEXT
AUTHOR: IGOR PEEV
INSTITUTION: UNIVERSITY CLINIC FOR PLASTIC AND RECONSTRUCTIVE SURGERY, MEDICAL FACULTY, SKOPJE
Skopje,
Feb. 2013
INTRODUCTION:
Breast cancer, beside skin and lung cancer, is the most common cancer in women. The highest worldwide incidence is in the western countries. Yet, in the last years, rates in central and eastern Europe, which have been comparatively low, had begun to rise rapidly, mainly because of lifestyle changes.(1,2) . Lifetime risk for a woman to develop breast cancer in western world is about 12%, meaning that 1 in 8 will eventually have it.(3) The incidence in Republic of Macedonia in the past few decades is increasing, though slowly, reaching the number of nearly 700 new cases per year.(4).
Incidence rates of localized breast cancer is increasing continuously due to introduction of mammography screening and other preventive measures applied in many countries, including Macedonia (3,4). On the other hand, broad and successful treatment modalities, comprising surgery, radiotherapy, new chemotherapeutics, hormonal therapies etc, all based on wide range of controlled and randomized trials in the past century, have shifted tremendously the treatment of breast cancer.(5) This improvement was paralleled by changing of the surgical methods as well, from the first Halsted mutilating operation to lumpectomy with minimal breast tissue lost, yet with the same or even better curative success when additional modalities applied.(5,6,7). However, about 40% of these patients will receive breast non - conserving surgery / mastectomy (52). Finally, this triggered plastic surgeons to think more often about breast reconstruction after mastectomies. Early diagnosis and good treatment modalities, in selected patients, can be accomplished with satisfying tissue reconstruction in order to obtain breast symmetry and better quality of life by restoring body image, improving vitality, femininity and sexuality. (8) Still, only few women will (51). Holistic treatment of breast cancer inevitable includes breast reconstruction.
The goal of breast reconstruction is to restore breast mould, improve woman's psychological health after cancer treatment and recall physiological body posturing (58). There are many techniques addressing this. Yet, in absence of well designed prospective randomized trials comparing the different reconstructive techniques, there are still many questions to be answered. (76) Uncertainties about best timing for reconstruction, reconstruction and radiotherapy issues, patient selection, best preferable technique, factors, donor site morbidity etc. still exist. This review will try to discuss them. The author will address factors that influence the low rate of breast reconstructions in Macedonia.
METHODS:
Historical review of the breast surgery and breast reconstruction after mastectomy, with advantages and disadvantages of the different techniques available has been carried out. Comprehensive search through current scientific literature on the topic, focusing on large series, long- term follow up studies and medical evidence included PubMed/Medline and Hinari search engines. Keywords were: breast cancer, mastectomy, breast reconstruction. Unformal personal communications, books, world wide web sources, media as well as observations were also used in the part regarding the local context.
DISSCUSSION:
Wiliam Halsted did the first radical mastectomy in 1889 and he thought that any attempt for breast reconstruction should be abolished in order to notice eventual local recurrence earlier. Furthermore, he stated that reconstructive procedure can upgrade biological behavior of the cancer to more aggressive (9). This set back breast reconstructions for decades. Still, first breast reconstruction for non - cancerous breast resection dates back to 1895, when Czerny transplanted a lipoma to the site of amputated breast.(10) A decade later, in 1906, Tanzini was the first to apply fascio - cutaneous flap for breast reconstruction.(11) As time passed, new evidence followed, especially in the 1960s resulting in less aggressive approaches in the surgical treatment of breast carcinoma. Milestone was the pioneer work at London’s Guy Hospital which showed that partial resections with adjacent radiotherapy are as effective as radical mastectomies alone (12). This, in contradiction to Halsted philosophy, shifted toward breast conservation surgeries, which was broadly accepted continuing today as early breast cancer standard care.(13) Nevertheless, many controlled trials followed thus opening the possibilities for breast reconstruction.(5) Cronin introduced silicone implant for breast augmentation in 1963.(14) Several years later, prosthesis started to be a modus for breast reconstruction in cases with sufficient overlying skin, as a delayed procedure (15) or immediate procedure (16), in both cases generally implantated under pectoral muscle. Later on, in cases with insufficient overlying skin, two - stage breast reconstruction was proposed, comprising tissue expansion with a temporary tissue expander (17) or inflatable breast implant with detachable reservoir (18) followed by exchange with a permanent prosthesis in the second act, when sufficient expanded skin envelope is present. Although technically not demanding with satisfying initial results, breast reconstruction with tissue expanders didn’t justify long term expectation concerning breast symmetry. Prospective studies showed unpredictable prosthesis aging, requiring many revisions and visits (19,20,21). This resulted in emerging interest in autologous breast reconstruction, meaning breast reconstruction with autologous viable tissue taken from other body region with its own blood supply. At first, it was the latissimus dorsi pediculed flap, self contained or combined with prosthesis to achieve greater volume (22). This was followed by usage of transverse rectus abdominis muscle (TRAM) pediculed flap with its massive volume content which became gold standard for single – stage breast reconstruction though with evident donor side morbidity (23,24). Kroll et al. introduced skin- spearing mastectomy, showing that in selected cases it can be as radical as Maden mastectomy (oncologicaly safe), leaving good – quality breast skin envelope that “only” has to be fulfilled with tissue.(25, 73-75) With this, mastectomy technique went from a “tissue-destroying” to a “tissue-sparing” paradigm. The mastectomy technique is likely the single most influential factor in the reconstructive outcome.(13). As result, free flaps for breast reconstruction were born: free TRAM flap (26), free perforator flaps such are superior and inferior gluteal artery (SGAP, IGAP) perforator flaps, (27,28), deep epigastric artery perforator (DIEP) flap (29). In summary, breast reconstruction can employ implants, autologeous tissue or combining the two techniques. Implant - based reconstruction can utilize permanent silicone prosthesis, temporary tissue expander with later permanent prosthesis (two – staged reconstruction) or adjustable permanent prosthesis. All of the techniques can be done as an immediate (primary) breast reconstruction, during the same act of mastectomy or as a delayed (secondary) procedure after a certain period. Implant - based methods are a simple and effective, but they may not be suitable for all patients, especially those who need or underwent radiotherapy. In contrast, autologous techniques are surgically by far more demanding and time consuming, but they consistently yield better aesthetic results, particularly when combined with skin sparing mastectomy. At the moment, desirous option for breast cancer treatment is skin sparing mastectomy and DIEP free flap as a reconstructive method, with a bikini, dermatolypectomy like scar in the lower abdomen. (54) However, regardless the technique and timing of reconstruction, there is no change of overall survival rate compared to mastectomy only, proven to be oncologicaly safe procedure. (5,25,86-88,98)
Comparison of the techniques is impossible as randomized studies are lacking. Each technique can be utilized after thorough patient examination, surgeon preference and factors stated further. In cohort studies, immediate reconstruction has shown superior results in terms of emotional stress of the patient, psychological morbidity, gaining anatomical breast landmarks (inframammary fold) as well as reduced cost (19,81-83). Satisfaction rate is high though some studies are conflicting (84). Patients with immediate reconstruction can be more demanding than patients with delayed reconstructions, since they have no experience of life without breasts thus expecting to have the same breast as before. (85) However, all of the breast reconstructive procedures bear an increased morbidity beyond that of mastectomy alone. Each procedure has advantages /disadvantages and complications that must be noted prior operation when reaching an appropriate decision with the patient. (8,85) These are summarized in Table 1. (48, 89 – 95, 97,98).
In general, most of the patients are candidate for breast reconstruction. Still , there are some limitations and contraindications. Factors influencing breast reconstruction can be grouped as tumor, patient or surgeon related.
Tumor size and the stage of cancer disease is the most predictive clinical factor. (30,31). Desirable tumor size is less then 5cm (Tis, T1, T2) with or without clinically positive axillary lymph node involvement or so called early breast cancer. According to American Joint Committee on Cancer (AJCC) staging system it refers stage I and stage II (32). The need of axillary lymph node dissection does not interfere with the reconstruction. Higher stage disease is not a contraindication for breast reconstruction, but patients or surgeons, or both, usually do not find this procedure as a high priority compared with treatment. Yet, there are papers presenting the oppositng results and reconstructions were made even in patients presenting with IIIb stage (33,34). Though on small number of cases, it concludes that patients with advanced cancer stage should be considered as equal as others in terms of reconstruction since the surgery does not interfere with chemotherapy or radiotherapy timing and with the same complication rates. Nevertheless, these patients should not be excluded initially and each case has to be exanimate individually. Still, majority of the patients seeking reconstruction after mastectomy in USA are women with carcinoma in situ or stage I breast cancer, this comprising nearly 88% of all reconstructions.(35) Metastatic disease (stage IV) should be considered as a contraindication for reconstruction, though sporadic cases showing conflicting conduct have been presented. (34)
Radiation therapy in breast cancer treatment has been increasingly implemented and its optimal timing related to breast reconstruction remains very important. (36). Need of additional radiation therapy is strongly linked with tumor size and free substrate margins. It can be planed preoperatively, if obvious or addressed later on, after pathohystologic examination of the resected tissue|; this determinates reconstruction timing. Thus, patients with stage I breast cancer and low risk of requiring post -mastectomy radiation, can receive immediate breast reconstruction, whereas delayed reconstruction is preferable in patients with radiation therapy considered. (stage II/ III breast cancer). In cases where post -mastectomy radiotherapy is not obviously clear, (usually stage II) , M. D. Anderson Cancer Center (Houston, USA) has proposed delayed - immediate technique (96). In one recent study, the need for radiation therapy was highly associated with decreased likelihood for breast reconstruction.(37) Radiotherapy effects negatively both implant- based or autologous tissue reconstruction: significant capsular contractures in the implants or severe atrophy and tissue mutilation of the tissue flap which has defective impact over the aesthetic outcome. (38,39) On the other hand, immediate reconstruction interferes with the irradiation if needed. It has been shown that delivery of sufficient irradiation is compromised and higher doses has to be addressed, which, in turn has unpredictable and unfavorable effect over the implant/expander/tissue and healthy adjacent organs.(40) Patient receiving radiotherapy after immediate reconstruction has significantly increased risk for early or late complications (infection, seroma, hematoma or implant contracture) compared to patients receiving delayed reconstruction after radiotherapy.(41, 94, 95) Having in mind the above, many plastic surgeons will not address immediate reconstruction if radiotherapy is anticipating., despite its proven oncological safety in early stage cancer (77,96,98). Outcomes with two-stage reconstruction appear superior when implant is placed after radiotherapy, rather than immediately after mastectomy. On the other hand, autologous reconstruction has superior results over implant - based after radiotherapy due to utilization of non-irradiated tissue.(97) If otherwise chosen, any reconstruction should not delay the needed radiotherapy for 6 months, cause it reduces the survival rate.(42). However, an option for patients who will receive radiotherapy, but who wish an immediate implant based reconstruction, is a two –staged breast reconstruction: tissue expansion immediately after mastectomy, while on chemotherapy and permanent implant insertion several weeks after the last chemotherapy course but before radiotherapy. (8,96,97)
Patient related factors influencing reconstruction rate are age, socio-economic background, breast cancer awareness/health education and patient reconstruction preference, though other factors have been also addressed, such ethnic, race or geographical setting. (43) Despite the fact that age alone is not a contraindication for reconstruction, yet it is the most coherent factor that has negative impact on breast reconstruction rate. Crucial age seems to be greater than 50 years, mostly due to increased complication rates and coexisting comorbities in this population group. Recently, a study from Milanese European Oncology Institute presented great results treating elderly patients over 65 years with different techniques of immediate breast reconstruction(44). Surgeon’s bias in selecting candidates regarding their age shouldn’t be ignored. (35, 43) On contrary, reconstruction rates has significant positive correlation with the level of education, socio - economic status of the patient, as well as patients’ awareness and their health education. How does patient’s preference influences the reconstruction rate, it is unknown, but it is found that older patients are more likely to choose mastectomy alone than reconstruction. (45) If interested, patient‘s preference is determinative when making decision about the technique to be used. In a prospective Swizz study trying to evaluate this issues (46), it was found that 52% of the women do not know whether to decide in favor of primary (immediate) or secondary (delayed) reconstruction. Regarding the techniques, about 40% would have done autologous breast reconstruction, though 23% couldn’t make decision spontaneously. Furthermore, about 62% were highly concerned about the recurrence risk after reconstruction. This stresses out the necessity for wide information of women about the reconstructive options, and especially, the importance of surgeons and physicians in this role as some patients do not want prosthesis (avoidance of foreign body), some are not suitable for autologous reconstruction (skinny patients), some are not prepared for staged operations etc.(54) Finally, majority of them are overwhelmed by the cancer diagnosis and need help in decision making process.
Relative or absolute contraindications for surgery comprise another large clinical group of factors related to patient. Smoking is considered as relative contraindication as most surgeons ban smoking several weeks prior reconstruction. Many retrospective studies shows increased overall complication risk, especially for skin and flap necrosis in smokers.(47,48) Other clinical predictors contributing complication risk are chemotherapy, pre - reconstruction radiotherapy, post - reconstruction radiotherapy, hypertension, diabetes mellitus, abdominal scarring and obesity. In cases of absolute contraindications for surgery or previous failed reconstructions, there is the option of using fat grafting as a reconstructive technique.(78) Moreover, fat grafting is becoming more popular in the last years even as a solely reconstructive choice or as a modality for enhancing the results and correcting the defects of the previous reconstructive attempts.(79)