ReviewOncological safety and patient satisfaction with skin-sparing mastectomy and immediate breast reconstruction
Section snippets
Introduction and background
The primary aim of surgical intervention in breast cancer is to achieve local control of disease. Secondarily, surgery to the breast and axilla provides material that can used to facilitate the planning of adjuvant local and systemic therapy. Over the last two decades a third objective has emerged, namely patient satisfaction, both with the process and end-result of surgical intervention. Historically, this has been seen as a competing interest, with the aspirations of the patient conflicting
Patients and methods
All procedures were performed by the same surgeon (K.M.), between 2001 and 2007, in one of three independent sector healthcare centres in London. The medical records of 83 consecutive women were reviewed. Each member of the case series underwent SSM and IBR and 10 patients had bilateral SSM and IBR (five had bilateral cancer, four had contra-lateral prophylactic surgery and one BRCA-1 gene carrier had bilateral prophylactic SSM and IBR). In total, there were 93 SSMs with IBR and the standard
Surgical considerations
We differentiated between two types of SSM: standard SSM where the whole skin envelope of the breast was preserved except for the NAC and NP-SSM where the whole skin envelope of the breast was preserved. The standard SSM was performed through a peri-areolar incision and the infra-mammary fold was preserved in all cases. The peri-areolar incision was adequate to remove all breast tissue in most cases. Patients with clinically negative axillae underwent sentinel node biopsy (SNB) using blue dye
Results
The median patients’ age was 47 years (range=27–72). Histological analysis of resection specimens showed pure DCIS in 15 patients and invasive carcinoma (+/− DCIS) in 72 patients. One patient carrying BRCA-1 gene mutation had bilateral prophylactic mastectomy with normal histology and another patient had a malignant phyllodes tumour. The histological findings in SSM specimens are shown in Table 1, classified according to the TNM system. The median tumour size was 28 mm (range 1–100 mm) and in all
Discussion
Despite numerous studies demonstrating the oncological adequacy of SSM and IBR, concerns still remain about the safety of this procedure, particularly with regard to LR within the preserved skin envelope. Ho et al. [4] performed histological examination of the 30 NSSM specimens and found the skin flaps (excluding the NAC) to be involved with cancerous cells in 23%. In two women, the skin involved was not directly over the tumour, implying spread via the dermal lymphatics. Overall, 12% of
Conclusion
SSM and IBR are oncologically safe in appropriately selected patients with Tis, T1 and T2 tumours in the absence of extensive skin involvement. Utility for higher stage tumours remains controversial. NAC preservation is possible for remote tumours, providing a frozen section protocol is followed. The technique is aesthetically superior to NSSM with delayed reconstruction and is associated with high levels of patient satisfaction and a low morbidity. Randomised controlled trials are required to
Conflict of Interest Statement
None.
References (35)
- et al.
Skin-sparing mastectomy
American Journal of Surgery
(2004) - et al.
Skin-sparing mastectomy
Surgical Clinics of North America
(2003) - et al.
A 7-year experience with immediate breast reconstruction after skin sparing mastectomy for cancer
European Journal of Surgical Oncology
(2007) - et al.
Patterns of local breast cancer recurrence after skin-sparing mastectomy and immediate breast reconstruction
American Journal of Surgery
(2007) - et al.
Local recurrence of stage 1 and 2 breast cancer after skin-sparing mastectomy and immediate breast reconstruction in a 15-year series
European Journal of Surgical Oncology
(2007) Towards optimal management of ductal carcinoma in situ of the breast
European Journal of Surgical Oncology
(2003)- et al.
Evidence-based indications for postmastectomy irradiation
Surgical Clinics of North America
(2003) - et al.
The influence of radiotherapy on skin circulation of the breast after subcutaneous mastectomy and immediate reconstruction
British Journal of Plastic Surgery
(1999) - et al.
Prediction of nipple and areola involvement in breast cancer
European Journal of Surgical Oncology
(1998) - et al.
Nipple-sparing mastectomy in breast cancer: a viable option?
European Journal of Surgical Oncology
(2001)
Oncologic safety of skin-sparing mastectomy
Annals of Surgical Oncology
Skin involvement in invasive breast carcinoma: safety of skin-sparing mastectomy
Annals of Surgical Oncology
Fifteen-year series of skin-sparing mastectomy for stage 0 to 2 breast cancer
American Journal of Surgery
Late results of skin-sparing mastectomy followed by immediate breast reconstruction
British Journal of Surgery
Skin-sparing mastectomy and immediate breast reconstruction: a prospective cohort study for the treatment of advanced stages of breast carcinoma
Annals of Surgical Oncology
Factors associated with local recurrence after skin-sparing mastectomy and immediate breast reconstruction for invasive breast cancer
Annals of Surgery
Cited by (66)
The Impact of Postoperative Wound Complications on Oncological Outcomes Following Immediate Breast Reconstruction for Breast Cancer: A Meta-analysis
2021, Clinical Breast CancerCitation Excerpt :The reasons for this are multifactorial and include increasing patient awareness, the apparent positive impact on psychosocial well-being, and the involvement of oncological multidisciplinary meetings. It has also been shown to be safe, without an increase in postoperative complications when compared with delayed reconstruction.18 Despite this, challenges in the use of IBR persist owing to concerns regarding the increased risk of local recurrence and the possible delays in the delivery of adjuvant therapies as a result of postoperative complications.6,7,19
General principles of mastectomy: Evaluation and therapeutic options
2018, The Breast: Comprehensive Management of Benign and Malignant DiseasesNeoadjuvant Chemotherapy for Breast Cancer Treatment and the Evidence-Based Interaction with Immediate Autologous and Implant-Based Breast Reconstruction
2018, Clinics in Plastic SurgeryCitation Excerpt :Although approximately 30% of oncologists think that breast reconstruction may interfere with the oncological treatment of breast cancer,1,2 there is currently sufficient scientific evidence to demonstrate that immediate breast reconstruction is a safe procedure from the oncological perspective because it does not modify the patient's overall disease-free survival rate or interfere with subsequent oncological controls.3,4
Breast reconstruction modality and outcomes after mastectomy
2016, Formosan Journal of SurgeryCitation Excerpt :Breast cancer is one of the most common cancers among women worldwide.1 Postmastectomy breast reconstruction is currently widely used for oncological safety2–4 and because of its higher psychosocial satisfaction.5 Breast cancer is generally treated using multimodalities, including surgical resection, hormone therapy, chemotherapy, and radiation.
Skin-sparing mastectomy for the treatment of breast cancer
2023, Cochrane Database of Systematic Reviews