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PubMed1997

The National Cancer Data Base report on the results of a large nonrandomized comparison of breast preservation and modified radical mastectomy.

BACKGROUND: Although the conclusions reached in the National Surgical Adjuvant Bowel and Breast Protocol B-06 trial and other clinical trials appear to remain intact, questions persist regarding the equivalency of breast preservation compared with modified radical mastectomy for patients with invasive carcinoma. Documentation and assessment of comparative survival rates in a large cohort of nonrandomized breast carcinoma patients was undertaken to understand better these outcome patterns. METHODS: Information gathered from the medical records of 96,030 women diagnosed with early stage carcinoma of the breast between 1985 and 1988 was reviewed to determine the age at diagnosis; tumor stage, grade, dimension; treatment; and disease status. RESULTS: Of these 96,030 Stage I and II (based on the American Joint Committee on Cancer staging system) patients, 8583 (8.9%) were treated with segmental mastectomy, axillary lymph node dissection, and radiotherapy without systemic treatment. Three thousand seven hundred and ninety-seven patients (4.0%) were treated with segmental mastectomy, axillary lymph node dissection, radiotherapy, and systemic therapy. Forty-four thousand two hundred and forty-nine patients (46.0%) were treated with modified radical mastectomy without systemic therapy, and 18,322 patients (19.1%) were treated with modified radical mastectomy with systemic therapy. Within each stage, reported survival was equal to or more favorable for patients managed with breast preservation compared with those treated with modified radical mastectomy. This comparability was observed in all subsets analyzed including those defined by age at diagnosis, histologic grade, and tumor dimension. CONCLUSIONS: These findings are consistent with the hypothesis that AJCC Stage I and II patients treated with breast preservation appear to have survival rates equivalent to those treated with modified radical mastectomy.

Adolescent↗
PubMed1995

Synchronous, bilateral mastectomy.

Sixty-four patients (mean age, 51 years) had mastectomies which were synchronous and bilateral. Sixty-one premastectomy biopsies (bilateral, 34 and unilateral, 27) demonstrated the following: invasive carcinoma, 17; noninvasive carcinoma, 24; combination of above, 10; and benign disease, 10. Twenty-two patients had bilateral mastectomy because of bilateral positive biopsy. Twenty-nine patients with unilateral carcinoma on biopsy had bilateral mastectomy. Thirteen patients had bilateral mastectomy despite benign disease only on biopsy (10) or no biopsy (3). Ten unexpected carcinomas (34%) were found in the contralateral breast in the 29 patients with carcinoma diagnosed on unilateral biopsy. The biopsy pathology of these 10 specimens was invasive ductal carcinoma in 1 and multifocal, noninvasive carcinoma (ductal, 3 and lobular, 6) in 9. An unexpected carcinoma may be found in the contralateral breast in a significant number of patients who are selected for bilateral mastectomy, particularly if the selection is on the basis of a noninvasive, lobular histology. Bilateral mastectomy may be appropriate for such patients, particularly when complicated by a strong family history and breasts which are difficult to assess by physical or mammographic examination.

Adult↗
PubMed2004

Immediate breast reconstruction after mastectomy increases wound complications: however, initiation of adjuvant chemotherapy is not delayed.

BACKGROUND: Immediate breast reconstruction is being increasingly used after mastectomy, although it may increase the incidence of wound complications. The indications for chemotherapy in breast cancer are expanding and wound complications following mastectomy may delay the initiation of adjuvant chemotherapy. HYPOTHESIS: Immediate breast reconstruction after mastectomy for breast cancer does not lead to an increased incidence of wound complications nor delay the initiation of systemic chemotherapy. DESIGN AND SETTING: Retrospective medical record review at a tertiary care center. PATIENTS: One hundred twenty-eight women treated with a mastectomy for breast cancer over an 8-year period (January 1, 1995, through December 31, 2002). MAIN OUTCOME MEASURES: Surgical site complications (infectious and noninfectious) and time to initiation of postoperative chemotherapy. RESULTS: One hundred forty-eight mastectomy procedures in 128 women with breast cancer were evaluated. We analyzed 4 subgroups according to whether or not immediate breast reconstruction was part of the surgical procedure (76 or 72 procedures, respectively) and whether or not postoperative adjuvant chemotherapy was administered (81 or 47 patients, respectively). There was an increased incidence of wound complications in patients who underwent immediate breast reconstruction compared with those who did not (6/72 [8.3%] vs 17/76 [22.3%]; P = .02). However, these complications did not delay initiation of postoperative chemotherapy. CONCLUSIONS: Although we observed an increased incidence of wound complications when immediate breast reconstruction was combined with mastectomy, there was no delay in the initiation of adjuvant therapy. Immediate breast reconstruction should remain an important treatment option after mastectomy even when postoperative chemotherapy is anticipated.

Adult↗
PubMed1983

A prospective analysis of nosocomial wound infection after mastectomy.

We evaluated the postoperative course of all patients who had mastectomies from 1978 through 1982 at City of Hope National Medical Center (Duarte, Calif). The overall clean mastectomy wound infection rate was 24/294 (8.2%). The incidence of mastectomy wound infection varied with the method of biopsy and was 3.2% after needle aspiration and 9.5% after open biopsy. Mastectomy immediately after open biopsy ("one step") had an infection rate of 5.3%, whereas mastectomy at a subsequent procedure ("two step") had a rate of 12.4%. The maximal infection rate (23.0%) occurred following the two-step procedure when the interval was four to seven days. The infection rates for patients hospitalized three or more days before mastectomy were elevated, but no significant correlation was observed between the infection rate and other demographic factors. We recommend that needle aspiration biopsy be used prior to open biopsy to minimize the need for a two-step approach to mastectomy.

Adult↗
PubMed1984

Prophylactic mastectomy: pros and cons.

Patients to be considered for prophylactic mastectomy fall into two groups. The first group comprises those who have already had a mastectomy and are either contemplating reconstructive surgery or are concerned about the development of cancer in their remaining breast. Since the patient who has had a mastectomy and is interested in reconstruction is already in a high-risk group, she has discussed at the initial interview, the possibility of prophylactic mastectomy and reconstruction. The second group of patients considering a prophylactic mastectomy also fall into the high-risk group. They have not yet had a mastectomy but find that they are emotionally disturbed-by the constant finding of new masses, and many have also had a number of biopsies. The patients in the second group are usually referred by a physician or surgeon who has followed them for a long period of time, or they have come on their own because of their mental anguish. It is the second group of patients, especially, who need time to have discussed with them in detail all our current knowledge concerning their high-risk status. However, both groups of patients must on their own, after counseling, make the final decision whether or not to have a prophylactic mastectomy.

Adult↗
PubMed1996

Skin-sparing mastectomy with immediate breast reconstruction: the M. D. Anderson Cancer Center experience.

BACKGROUND: Skin-sparing mastectomy with immediate reconstruction has become popular with patients because, compared with delayed reconstruction, it improves the cosmetic result, reduces cost and anesthetic risk, and in one stage completes most of the surgical treatment that the patient will ever require for treatment of her breast cancer. In the past, reconstruction was often delayed because of an unwarranted fear of locoregional recurrence or because the patient, having to live for some time with a flat chest wall, would be more appreciative of her reconstruction. This concept is now considered unacceptable, and many women regard this attitude as evidence of a lack of concern for the psychological impact of mastectomy. METHOD: Provided that the breast skin is not involved with or close to the tumor, we prefer to perform the mastectomy with removal of only the nipple-areolar complex and the tumor biopsy scar. The mastectomy is otherwise the same as a standard modified radical mastectomy with removal of all breast tissue and a level I-II axillary node dissection. Our preference is to use the transverse rectus abdominis myocutaneous flap with a microvascular anastomosis because it provides a better blood supply, reduces abdominal wall muscle sacrifice, and eliminates the bulge from tunneling required by a pedicled flap. RESULT: Using the skin-sparing technique with immediate reconstruction in 545 patients with early-stage breast cancer, our overall incidence of regional recurrence was 2.6%. Of 95 patients who were followed for > four years, the recurrence rate was 4.2%. CONCLUSIONS: Regional recurrence after skin-sparing mastectomy is a function of the biology of the tumor and the stage of the disease and is not affected by the use of immediate reconstruction or skin-preservation mastectomy.

Female↗
PubMed1988

Influence of mastectomy technique on sex steroid receptor analysis.

Accurate analysis of hormone receptors in breast carcinoma is critical from prognostic and therapeutic standpoints. Controversy exists over whether there is receptor decay when specimens are obtained upon completion of, rather than prior to, mastectomy. In addition, the effect of mastectomy technique on receptor concentration has not been addressed. Twenty patients with breast carcinoma had biopsy specimens taken prior to and upon completion of modified radical mastectomy. Ten had axillary dissection followed by mastectomy (Group A). The others had mobilization of the breast before axillary dissection (Group B). The estrogen receptor concentration was higher in 14 of 20 premastectomy specimens. All 10 patients in Group B had positive receptors before mastectomy; 5 were negative after mastectomy. All seven patients in Group A with positive premastectomy receptors remained so postmastectomy. We concluded that if a tumor specimen for receptor analysis is not obtained prior to modified radical mastectomy, axillary dissection should precede breast mobilization.

Axilla↗
PubMed2000

Prophylactic mastectomy; evolving perspectives.

It is not at all uncommon for surgeons dealing with breast disease to be confronted with the issue of prophylactic mastectomy. Recent advances in understanding the genetic basis of susceptibility to breast cancer and a better identification of the histological factors affecting a woman's lifetime risk of developing breast cancer have contributed to placing prophylactic mastectomy in a proper clinical perspective. Existing data suggest that prophylactic total mastectomy significantly reduces, but does not totally eliminate, the risk of subsequent development of cancer. However, the benefit of prophylactic mastectomy over alternative strategies (surveillance and chemoprevention) remains to be proven. Currently, prophylactic mastectomy may be considered in a few, carefully selected patients. The decision to perform a prophylactic mastectomy should be a multidisciplinary one. Detailed patient' counselling is very important; the patient should understand the limitations of prophylactic mastectomy and the need for postoperative follow-up. Furthermore, she should be well informed about the alternative strategies.

Antineoplastic Agents↗
PubMed2004

Prophylactic bilateral mastectomy for breast cancer prevention.

Prophylactic bilateral mastectomy, or preventive removal of the breasts, is an option for women who are at increased risk of developing breast cancer. Among the highest risk groups are those women with a significant family history of breast cancer and those with a known genetic predisposition to the disease. There are many issues surrounding prophylactic mastectomy. Recent research has demonstrated that prophylactic mastectomy may be effective in preventing breast cancer in high-risk women, as well as those with a known BRCA1/2 mutation. The limited research that has been done on the psychosocial implications of the preventive surgery suggests that prophylactic mastectomy may be effective in reducing distress levels in high-risk women and that most women who have had the surgery do not experience psychosocial difficulties. Overall, women who have had prophylactic mastectomy are satisfied with their decision to have the preventive surgery. However, women who choose prophylactic mastectomy may differ compared with those who do not. The results may not be generalizable to all high-risk women. Counseling of high-risk women, specifically those with a BRCA1 or BRCA2 mutation, should include a discussion of prophylactic mastectomy, including the medical and psychosocial risks and benefits.

Attitude to Health↗
PubMed2001

Efficacy of bilateral prophylactic mastectomy in BRCA1 and BRCA2 gene mutation carriers.

BACKGROUND: In women with a family history of breast cancer, bilateral prophylactic mastectomy is associated with a decreased risk of subsequent breast cancer of approximately 90%. We examined the association between bilateral prophylactic mastectomy and breast cancer risk in women at high risk for breast cancer who also had mutations in BRCA1 and BRCA2 genes. METHODS: We obtained blood samples from 176 of the 214 high-risk women who participated in our previous retrospective cohort study of bilateral prophylactic mastectomy. We used conformation-sensitive gel electrophoresis and direct sequence analysis of the blood specimens to identify women with mutations in BRCA1 and BRCA2. The carriers' probabilities of developing breast cancer were estimated from two different penetrance models. RESULTS: We identified 26 women with an alteration in BRCA1 or BRCA2. Eighteen of the mutations were considered to be deleterious and eight to be of uncertain clinical significance. None of the 26 women has developed breast cancer after a median of 13.4 years of follow-up (range, 5.8-28.5 years). Three of the 214 women are known to have developed a breast cancer after prophylactic mastectomy. For two of these women, BRCA1 and BRCA2 screening was negative, and no blood specimen was available for the third. Estimations of the effectiveness of prophylactic mastectomy were performed, considering this woman as both a mutation carrier and a noncarrier. These calculations predicted that six to nine breast cancers should have developed among the mutation carriers, which translates into a risk reduction, after bilateral prophylactic mastectomy, of 89.5%-100% (95% confidence interval = 41.4% to 100%). CONCLUSIONS: Prophylactic mastectomy is associated with a substantial reduction in the incidence of subsequent breast cancer not only in women identified as being at high risk on the basis of a family history of breast cancer but also in known BRCA1 or BRCA2 mutation carriers.

Breast Neoplasms↗
PubMed1975

Is modified radical mastectomy adequate for axillary lymph node dissection?

The effectiveness of axillary dissection by modified radical mastectomy was assessed by a comparison of the total axillary nodes removed by this operation to that by radical mastectomy. In a series of 121 consecutive radical mastectomies performed during the period of 1964 to 1969, we found that the number of axillary nodes removed ranged from 3 to 63 with a median of 22 and a mean of 23.4 per patient. In a subsequent series of 111 consecutive modified radical mastectomies performed between 1969 and 1973, the total axillary nodes removed ranged from 6 to 77 with a median of 24 and mean of 25.7 nodes in each mastectomy specimen. These results strongly suggest that axillary dissection in modified radical mastectomy is as complete as that in the Halsted radical mastectomy.

Axilla↗
PubMed1991

Mastectomy following preoperative chemotherapy. Strict operative criteria control operative morbidity.

The surgical morbidity associated with aggressive preoperative chemotherapy in 106 patients with advanced primary breast cancer who had chemotherapy followed by mastectomy was examined. These patients were compared with a group of 91 consecutive patients who had mastectomy without preoperative chemotherapy. Strict operative criteria were used to determine the timing of mastectomy following chemotherapy. Wound infection rates were no different in the preoperative chemotherapy group compared to the mastectomy-alone groups (7% versus 4%; p = 0.62). The incidence of wound necrosis was similar (11% versus 6%; p = 0.29). Seroma formation was decreased significantly in the preoperative chemotherapy group compared to the mastectomy-alone group (15% versus 28%; p = 0.04). Intensive preoperative chemotherapy did not delay the reinstitution of postoperative treatment (30% versus 20%; p = 0.27). However, when delay in instituting postoperative chemotherapy was more than 30 days, there was a significant decrease in overall survival rate (p = 0.04). This study provides evidence that intensive preoperative chemotherapy and mastectomy can be performed without increased morbidity. Furthermore it is important to institute systemic chemotherapy within 30 days of mastectomy to achieve maximum survival.

Adult↗
PubMed1997

Skin-sparing mastectomy. Oncologic and reconstructive considerations.

OBJECTIVE: The authors compared skin-sparing mastectomy and traditional mastectomy both followed by immediate reconstruction in the treatment of breast cancer. SUMMARY BACKGROUND DATA: Skin-sparing mastectomy is used increasingly in the treatment of breast cancer to improve the aesthetic results of immediate reconstruction. The oncologic and reconstructive outcomes of this procedure have never been analyzed closely. METHODS: Institutional experience with 435 consecutive patients who underwent total mastectomy and immediate reconstruction from January 1989 through December 1994 was examined. Mastectomies were stratified into skin-sparing (SSM) and non-skin-sparing (non-SSM) types. RESULTS: Three hundred twenty-seven SSMs and 188 non-SSMs were performed. The mean follow-up was 41.3 months (SSM, 37.5 months, non-SSM, 48.2 months). Local recurrences from invasive cancer occurred after 4.8% of SSMs versus 9.5% of non-SSMs. Sixty-five percent of patients who underwent SSMs had nothing performed on the opposite breast versus 45% in the group of patients who underwent non-SSM (p = 0.0002). Native skin flap necrosis occurred in 10.7% of patients who underwent SSMs versus 11.2% of patients who underwent non-SSMs. CONCLUSIONS: Skin-sparing mastectomy facilitates immediate breast reconstruction by reducing remedial surgery on the opposite breast. Native skin flap necrosis is not increased over that seen with non-SSM. Skin-sparing mastectomies can be used in the treatment of invasive cancer without compromising local control.

Adolescent↗
PubMed2005

Quality of life and affective distress in women seeking immediate versus delayed breast reconstruction after mastectomy for breast cancer.

BACKGROUND: This study compared the presurgical psychosocial and functional status of 238 women seeking breast reconstruction, either at the time of their mastectomy (immediate) (n = 151) or after prior mastectomy (delayed) (n = 87). Delayed subjects were further categorized in groups of time-since-mastectomy to examine the effects of time on postmastectomy psychosocial adjustment. METHODS: Presurgical measures of quality of life, psychological distress, and somatic anxiety were obtained. RESULTS: The results revealed relative impairment of quality of life and psychosocial functioning for immediate compared with delayed subjects. Immediate subjects reported greater disturbance in general mental health functioning, more severe impairment in emotional well being related to their cancer diagnosis, and higher levels of anxiety. Immediate subjects also reported a trend toward greater disturbance in work and daily activities, more frequent interference in social activities, and less vitality. Similarly, it was noted that the immediate group reported greater impairment in physical and functional well being related to their cancer adjustment. On psychological assessment, immediate subjects were more likely to report higher levels of affective distress, depressive symptoms, and obsessive-compulsive traits. For the delayed group, no statistically significant differences in the dependent measures were obtained when comparing subjects at 1 year, 2 years, and more than 2 years after mastectomy. CONCLUSIONS: Women seeking immediate reconstruction at the time of mastectomy show a relatively higher incidence of psychosocial impairment and functional disability. Women who undergo mastectomy demonstrate early restoration of psychosocial health within the first year after surgery. Patient preoperative psychosocial distress may have important implications for clinical decision-making and surgical outcome for women seeking combined mastectomy and breast reconstruction.

Breast Neoplasms↗
PubMed2003

Impact of immediate reconstruction on the local recurrence of breast cancer after mastectomy.

The incidence of local recurrence of breast cancer in women who underwent mastectomy with or without reconstruction was examined. All female mastectomy patients were followed-up in a 10-year retrospective review. Groups consisted of patients who had mastectomy, mastectomy with immediate reconstruction, or delayed reconstruction. Reconstruction was performed using prostheses, latissimus dorsi musculocutaneous flaps with or without implants, or transverse rectus abdominis musculocutaneous flaps. Charts were reviewed for local breast cancer recurrence. Statistical analysis was performed using Pearson's chi-square and analysis of variance. Of the 1,444 mastectomies performed from 1988 to 1997, 1,262 breasts (87%) were not reconstructed, 182 (13%) were reconstructed, 158 (87%) were immediately reconstructed, and 24 (13%) were reconstructed later. There were no recurrences in the delayed reconstruction group, two recurrences (1.3%) in the immediate reconstruction group, and nine recurrences (0.7%) in the mastectomy without reconstruction group (p=0.746). Analyses of an additional time period from 1992 to 2000 yielded similar results. There is little relationship between local recurrence of breast cancer after mastectomy and reconstruction.

Adult↗
PubMed1983

Considerations of cost and effectiveness in the choice of mastectomy.

Operable breast cancer may be managed equally well by a number of different regimens of mastectomy and/or radiotherapy. This paper examines the financial and morbidity costs, together with the node sampling efficacy, of three commonly employed techniques: simple mastectomy; total mastectomy with node biopsy or limited node excision; and modified radical mastectomy. Adjuvant radiotherapy (and/or chemotherapy) can only be applied rationally if node sampling is effective. Simple mastectomy cannot achieve this. Total mastectomy, providing that a node sample is obtained, is effective, and is probably the cheapest option. Total axillary clearance runs the risk of increased morbidity (and financial cost), while not necessarily guaranteeing more effective node sampling. Much of the cost and morbidity of mastectomy may be reduced by a limited but rational radiation policy.

Breast Neoplasms↗
PubMed2006

Management of skin-sparing mastectomy: results of a survey of German hospitals.

BACKGROUND: The aim of this study was to evaluate the current management of skin-sparing mastectomy in German hospitals and to determine its oncologic safety. For this purpose, 100 surgeons were surveyed regarding their use of skin-sparing mastectomy. RESULTS: Almost all surveyed hospitals performed skin-sparing mastectomy. Most of them believe that the recurrence rate is equal to that of conventional mastectomy. 95% regard inflammatory cancer as a contraindication to skin-sparing surgery. Most of the hospitals thin out the skin without leaving any macroscopic glandular tissue behind, and 73% leave the nipple-areola complex (NAC) on the basis of frozen sections. Volume replacement is most commonly done with latissimus dorsi muscle flaps and pedicled TRAM flaps. In 76% of the surveyed hospitals, reconstruction after mastectomy is performed by the gynecological department. CONCLUSION: Skin-sparing mastectomy is considered to be the best cosmetic option for breast reconstruction in selected breast cancer patients. At present, statistical proof of its oncologic safety is lacking. The surgical techniques used for skin-sparing mastectomy have not yet been standardized. In order to achieve standardization, careful discussion-making and evaluation remain important.

Breast Neoplasms↗
PubMed2000

Intention to undergo prophylactic bilateral mastectomy in women at increased risk of developing hereditary breast cancer.

PURPOSE: To assess intention to undergo prophylactic bilateral mastectomy and psychologic determinants in unaffected women at increased risk of developing hereditary breast cancer. PATIENTS AND METHODS: Three hundred thirty-three women who were awaiting their initial appointments for risk assessment, advice about surveillance, and prophylactic options at one of 14 familial cancer clinics participated in a cross-sectional, questionnaire-based survey. RESULTS: Nineteen percent of women would consider and 47% would not consider a prophylactic mastectomy, should genetic testing identify a mutation in a breast cancer-predisposing gene, whereas 34% were unsure and 1% had already undergone a prophylactic mastectomy. In a bivariate analysis, women at a moderately increased risk of developing breast cancer had the highest proportion of subjects reporting that they would consider a prophylactic mastectomy (25%), compared with women at high risk (16%) (chi(2) = 7.79; P =.051). In multivariate analyses, consideration of prophylactic mastectomy strongly correlated with high levels of breast cancer anxiety (odds ratio [OR] = 17.4; 95% confidence interval [CI], 4.35 to 69.71; P =. 0001) and overestimation of one's breast cancer risk (OR = 3.01; 95% CI, 1.43 to 6.32; P =.0036), whereas there was no association with objective breast cancer risk (P =.60). CONCLUSION: A significant proportion of women at increased risk of developing hereditary breast cancer would consider prophylactic mastectomy. Although prophylactic mastectomy may be appropriate in women at high risk of developing breast cancer, it is perhaps less so in those who have a moderately increased risk. Such moderate-risk women are likely to benefit from interventions aimed at reducing breast cancer anxiety and correcting exaggerated breast cancer risk perceptions.

Adult↗