Risk-Reducing Mastectomy and Breast Reconstruction

Factors influencing prophylactic surgical intervention in women with genetic predisposition for breast cancer

INTRODUCTION

In the United States, 5%-10% of breast cancer cases are due to genetic predisposition. Among this population, prophylactic mastectomy is viable risk-reducing option.

OBJECTIVE

The objective of this study is to understand the timing to prophylactic mastectomy in patients with genetic predisposition to breast cancer and uncover factors influencing this decision.

METHODS

This study is a retrospective review of patients diagnosed with genetic predisposition for breast cancer from 2010 to 2020.

RESULTS

In a cohort of 506 patients with genetic predisposition for breast cancer, 154 (30.4%) underwent prophylactic mastectomy, the remainder opted for surveillance alone. The median time from diagnosis to mastectomy was 1.1 years (IQR, 0.5-3.1 years). During the surveillance period, 118 patients (33.5%) underwent breast biopsy. Of the patients with benign or atypical findings, 35 (36.8%) pursued prophylactic mastectomy, a median of 0.5 years (IQR, 0.2-1.6 years) after their gene diagnosis. The most common factor impacting the decision to undergo prophylactic mastectomy was having a family member with cancer (54.7%) followed by a personal diagnosis of other cancer(s) (27.5%).

CONCLUSION

Understanding the factors influencing the decision to undergo prophylactic surgery will allow for more effective shared decision-making for primary care providers, breast surgeons, and reconstructive surgeons.

A Long-term Evaluation of Acellular Dermal Matrix for Immediate Implant-based Breast Reconstruction following Risk-reducing Mastectomy

Background

Acellular dermal matrices (ADMs) are sometimes used in implant-based breast reconstructions (IBR), but long-term ADM-related evaluations are scarce. In this study, we evaluated early and late complications and patient-related outcomes (PROs) over an 8-year postoperative period in women who had undergone immediate IBR following risk-reducing mastectomy with bovine ADM (SurgiMend).

Methods

This prospective observational single-center analysis involved 34 women at high risk for breast carcinoma. Complications were prospectively recorded during the first year, followed by 4 years of postoperative retrospective chart reviews. Long-term evaluations were done using a questionnaire. Preoperative, 1 year, and 5- to 8-year postoperative PRO assessments were obtained based on results from the BREAST-Q questionnaire.

Results

In 56 breasts, complications after a mean of 12.4 months follow-up included implant loss (7.1%), implant change (1.8%), hematoma (7.1%), breast redness (41.1%), and seroma (8.9%). Most breasts (80.3%) were graded Baker I/II, which indicated a low capsular contracture incidence. After a mean of 6.9 years, the total implant explantation rate was 33.9%, and the revision surgery rate was 21.4%. Two cases of breast cancer were reported during the long-term evaluation. BREAST-Q results indicated significantly decreased satisfaction with outcome (P = 0.024). A positive trend regarding psychosocial well-being and declining trend regarding satisfaction with both breast physical- and sexual well-being parameters were reported.

Conclusions

The observed complication rates agree with previous findings concerning ADM-assisted IBR. A high demand for revision surgery exists, and PROs remain relatively stable over time.

Implant-Based Breast Reconstruction after Risk-Reducing Mastectomy in BRCA Mutation Carriers: A Single-Center Retrospective Study

Women with BRCA gene mutations have a higher lifetime risk of developing breast cancer. Furthermore, cancer is usually diagnosed at a younger age compared to the wild-type counterpart. Strategies for risk management include intensive surveillance or risk-reducing mastectomy. The latter provides a significant reduction of the risk of developing breast cancer, simultaneously ensuring a natural breast appearance due to the preservation of the skin envelope and the nipple-areola complex. Implant-based breast reconstruction is the most common technique after risk-reducing surgery and can be achieved with either a submuscular or a prepectoral approach, in one or multiple stages. This study analyzes the outcomes of the different reconstructive techniques through a retrospective review on 46 breasts of a consecutive, single-center case series. Data analysis was carried out with EpiInfo version 7.2. Results of this study show no significant differences in postoperative complications between two-stage tissue expander/implant reconstruction and direct-to-implant (DTI) reconstruction, with DTI having superior aesthetic outcomes, especially in the prepectoral subgroup. In our experience, the DTI prepectoral approach has proven to be a safe and less time-consuming alternative to the submuscular two-stage technique, providing a pleasant reconstructed breast and overcoming the drawbacks of subpectoral implant placement.

Cost analysis of pre-pectoral implant-based breast reconstruction

With improvement in mastectomy skin flap viability and increasing recognition of animation deformity following sub-pectoral implant placement, there has been a transition toward pre-pectoral breast reconstruction. While studies have explored the cost effectiveness of implant-based breast reconstruction, few investigations have evaluated cost with respect to pre-pectoral versus sub-pectoral breast reconstruction. A retrospective review of 548 patients who underwent mastectomy and implant-based breast reconstruction was performed from 2017 to 2020. The demographic and surgical characteristics of the pre-pectoral and sub-pectoral cohorts were well matched, except for reconstructive staging, as patients who underwent pre-pectoral reconstruction were more likely to undergo single-stage instead of two-stage reconstruction. Comparison of institutional cost ratios by reconstructive technique revealed that the sub-pectoral approach was more costly (1.70 ± 0.44 vs 1.58 ± 0.31, p < 0.01). However, further stratification by laterality and reconstructive staging failed to demonstrate difference in cost by reconstructive technique. These results were confirmed by multivariable linear regression, which did not reveal reconstructive technique to be an independent variable for cost. This study suggests that pre-pectoral breast reconstruction is a cost-effective alternative to sub-pectoral breast reconstruction and may confer cost benefit, as it is more strongly associated with direct-to-implant breast reconstruction.

Prepectoral breast reconstruction: an ideal approach to bilateral risk-reducing mastectomy

Background

Bilateral risk-reducing mastectomy (BRRM) has increased its popularity in the last years because of its aim to minimise the chances of developing breast cancer in high-risk patients. Women undergoing this procedure must be considered highly demanding patients given the need to combine aesthetical, functional and preventive desires. This study aims to present the authors' experience in performing BRRM followed by single-stage prepectoral reconstruction (PPBR) with implant completely covered by acellular dermal matrix (ADM) and to report indications, surgical techniques, functional and aesthetic results.

Methods

A single-centre prospective data collection was carried out from January 2017 to January 2021 of patients at high risk of developing breast cancer undergoing BRRM and immediate PPBR with ADM. Patients were subdivided into two groups according to the breast shape: Group A had small and medium size breasts and Group B had large and ptotic breasts. Oncological and surgical outcomes were collected. Satisfaction with reconstruction and related quality of life were evaluated through the BREAST-Q questionnaire.

Results

A total of twenty-three patients met the inclusion criteria. Seventeen patients were included in group A and six patients in group B. Average follow-up was 18.4 months. Minor complications occurred in four breasts: one seroma, one hematoma and two cases of wound dehiscence. Capsular contracture was not observed. All patients were satisfied with the final result according to the post-operative BREAST-Q questionnaire.

Conclusions

Immediate prepectoral breast reconstruction could represent the ideal reconstruction option after BRRM and should be offered to all women that fulfil the inclusion criteria.

Risk-reducing mastectomy: a case series of 124 procedures in Brazilian patients

PURPOSE

Women with mutations in breast cancer predisposition genes have a significantly higher lifetime risk of developing breast cancer and can opt for risk-reducing mastectomy. Women with positive family history of cancer can also opt for prophylactic surgery as a preventive method in selected cases. Current studies showed reduced risk of developing breast cancer after prophylactic nipple-sparing mastectomy, however, despite the good clinical outcomes, one of the main concerns regarding nipple-sparing mastectomy (NSM) is the oncological safety of nipple-areola complex preservation. In this study, we aimed to evaluate the indications, complication rates, and unfavorable events of 62 Brazilian patients that underwent risk-reducing NSM from 2004 to 2018.

METHODS

Patient data were reviewed retrospectively and descriptive statistics were utilized to summarize the findings.

RESULTS

The mean patients age was 43.8 years. The main indication for risk-reducing NSM was the presence of pathogenic mutation (53.3%), followed by atypia or lobular carcinoma in situ (25.8), and family history of breast cancer and/or ovarian cancer (20.9%). There were four (3.2%) incidental diagnosis of ductal carcinoma in situ and one invasive ductal carcinoma (0.8%). From the 124 prophylactic NSM performed, two (1.6%) complications had occurred: one (0.8%) infection and one (0.8%) partial nipple necrosis. In a mean follow-up of 50 months, there was one (1.6%) newly diagnosed breast cancer in the 62 patients undergoing prophylactic NSM.

CONCLUSIONS

Our findings demonstrated efficacy and safety to perform NSM as prophylactic surgery with good oncological outcomes and low complication rates in a case series of Brazilian patients.