Oncological Outcome & Patient Satisfaction with Skin-Sparing Mastectomy & Immediate Breast

Reconstruction at The LBI: A Prospective Observational Study

Prof. Kefah Mokbel MS, FRCS

The London Breast Institute

Introduction

• Most women with early breast cancer (BC) are managed with breast-conserving therapy (BCT)

• Approximately one-third undergo mastectomy– patient preference – BCT not oncologically adequate or aesthetically acceptable

• Lack of level-1 evidence regarding– optimal type of mastectomy – subsequent technique and timing of reconstruction– skin-sparing mastectomy (SSM) and immediate breast

reconstruction (IBR)

Current trends in IBR rates

IBR in the USA (1999-2003)

• Immediate breast reconstruction rate = 23.6% (range of 22.2% to 25.3%). IBR rate in the UK = 21%

• Independent predictors of immediate breast reconstruction after mastectomy include:

private insurance hospital in an urban location teaching hospital white race hospital region in the south age between the 3rd and 6th decades low number of comorbidities

0

10

20

30

40

50

60

70

80

IBR rate

USA 2003UK 2009LBI 2009/10

Skin-Sparing Mastectomy• En-bloc removal of all glandular tissue, nipple–areola complex

(NAC) and in some cases adjacent biopsy scars and skin overlying superficial tumours with maximal preservation of breast skin envelope and infra-mammary fold [1]

• Facilitates immediate breast reconstruction (IBR) with autologous tissue and/or prosthetic implants by utilising the native skin envelope to optimise contour, texture, colour and scarring of the reconstructed breast [1]

• Single-stage procedure– hospital admissions, return to employment and elimination of

post-mastectomy pre-reconstruction period

1. Cunnick GH, Mokbel K. Skin-sparing mastectomy. Am J Surg. 2004;188(1):78–84

Skin-Sparing Mastectomy• Aesthetic advantages tempered by concerns about oncological safety

• Complete excision of glandular tissue can be more demanding

• Perceived increase in risk of local recurrence (LR) attributed to preservation of skin envelope.

• Post-mastectomy radiotherapy (PMR) is recommended for those at high-risk.

• One-third of breast surgeons avoid SSM and IBR – concerns over oncological safety or uncertainty of the benefits or

indications [2]

2. Singletary SE, Robb GL. Oncologic safety of skin-sparing mastectomy. Ann Surg Oncol. 2003;10:95–97

Breast Reconstruction Following Mastectomy

• Implant only

• Conventional flap +/- implantLD flap

• Free flaps: DIEPGAP

Breast Reconstruction:Recent Advances

• Biological ImplantsStrattice: acellular dermal matrix

• Autologous Adipose-derived Stem Cells: formation of new subcutaneous tissue

Coleman fat transfer Cytorie technology• Stem cell reconstruction

Aims of Study

• Recently, several studies have supported the oncological adequacy of SSM in selected early-stage BC, excluding inflammatory BC and tumours with extensive skin involvement of the skin [1]

• In this study, the oncological outcome, post-operative morbidity and patients’ satisfaction with SSM and IBR using the latissimus dorsi (LD) myocutaneous flap and/or breast prosthesis is evaluated

1. Cunnick GH, Mokbel K. Skin-sparing mastectomy. Am J Surg. 2004;188(1):78–84

Patients & Methods

• Prospective cohort of 127 consecutive women with early-stage BC

• Selection criteria – pre-operative diagnosis (clinical examination, imaging and

needle biopsy) of Tis, T1 and T2 tumours without extensive skin involvement.

– 1 patient had T3 BC

• The principal indication for surgery was BC– 7 procedures were undertaken as risk-reducing prophylactic

mastectomies – 1 BRCA-1 gene carrier, 5 contra-lateral BC

Patients & Methods

• Pre-operatively counselling regarding ablative and reconstructive options available

• Surgical recommendations made case-by-case following discussion of tumour and patient factors within multidisciplinary team

• Surgical procedures were performed by the same surgeon, 2001 - 2008

• All 127 women underwent SSM and IBR – 117 unilateral and 10 bilateral procedures, total of 137 cases

• Nipple-preserving SSM (NP-SSM) & IBR undertaken in 10 cases (6 patients)

Patients & Methods

• IBR employed– LD pedicle-flap and implant (n = 86, including 1 bilateral case)– implant only (n = 51, including 9 bilateral cases)

• Initial implant was tissue expander, subsequently replaced with an anatomically profiled bio-dimensional cohesive silicon implant at the same time as nipple reconstruction or contra-lateral adjustment

• Nipple reconstruction was performed in 69 (54%) patients – trefoil local flap technique (n = 61), nipple sharing (n = 6), skin graft (n

= 1) and Monocryl mesh (n = 1)

Patients & Methods

• 30 (23.6%) patients underwent contra-lateral surgery for symmetry/cosmesis– 19 augmentations & 11 mastopexy/reduction mammoplasties

• Patients at high risk of requiring PMR – encouraged to opt for SSM and IBR using tissue expander alone– ‘immediate-delayed’ strategy in 11 cases.

• All patients underwent clinical examination on a 6 monthly basis and annual surveillance mammography.

• Satisfaction assessed using a linear visual analogue scale, 0 - 10– postal questionnaire or interview

Surgical Considerations

• SSM performed through peri-areolar incision – occasionally short horizontal incisions at the 3 and 9 o’clock positions

added– infra-mammary fold was preserved in all cases

• Intra-operative frozen section analysis of sub-areola tissue for NP-SSM

• Patients with clinically negative axillae underwent sentinel lymph node biopsy (SLNB)– axillary node clearance if intra-operative frozen section showed

malignancy

• Subsequent replacement of tissue expander with definitive implant prosthesis performed through short infra-mammary incisions– prosthesis placed in sub-muscular pocket

Results

• Median patients' age = 47 years (range = 27-72)

• Histopathological analysis of resection specimens – invasive carcinoma (+/- DCIS) in 105 cases– pure DCIS in 25 cases– BRCA-1 mutation - bilateral prophylactic mastectomies -

normal histology

• Median tumour size = 28mm (range 1mm - 100mm) – all superficial surgical margins were clear– 2 patients with extensive multi-centric disease, tumour focally

extended to the medial surgical margin, one received PMR

Results

• Lymph nodes involved in 45 patients– 41 macro-metastasis, 4 micro-metastatic spread

• Adjuvant chemotherapy required by 38 patients

• Prior RT had been received by 6 patients and 21 women underwent PMR – LD flap and implant reconstruction = 10, implant

only reconstruction = 11

Results

• No LR after median follow-up of 36 months (range = 6-101 months)

• Overall survival = 99.2%– 8 patients developed distant disease– 1 patient died of metastatic breast cancer, another died of lung cancer

• No cases of partial or total LD flap loss

• Morbidities– Infection - requiring implant removal in 2 (1.5%) cases – 1 patient (smoker) developed marginal ischemia of the skin envelope– Chemotherapy delayed by 2 weeks in 1 patient due to infection– Blood transfusion was required by 2 patients

Results

• All patients undergoing LD reconstruction developed donor site seromas– requiring percutaneous drainage as outpatient, median inpatient stay =

5 days

• Significant capsule formation in 87% of patients who had either prior RT or PMR vs. 13% without RT. – Capsulotomy performed when exchanging tissue expander for definitive

prosthesis– 1 patient required further capsulotomy several months after definitive

prosthesis

• 82/127 (64.6%) completed satisfaction survey – median score of 9 (range = 5-10)– IBR using LD + implant (mean = 9.3, median = 10)– implant only (mean = 9, median = 10)

SSM

SSM plus IBR

The LD Flap

SSM and LD Flap Recon.

SSM plus IBR

SSM plus IBR

Nipple Reconstruction

Nipple Reconstruction

NS-SSM plus IBR

Conclusions

• SSM and IBR is oncologically adequate in selected patients with Tis, T1 and T2 tumours in the absence of extensive skin involvement

• NAC preservation is possible, provided the tumour is not close to the nipple and a frozen section protocol is followed

• Radiotherapy is not a contra-indication for SSM & IBR

• SSM and IBR is associated with high levels of satisfaction and low morbidity

Thank You