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Division of Plastic Surgery, Department of Surgery, University of California San Diego, CA, USA
Department of Plastic and Hand Surgery, Plastic Surgery Unit, Romailah Hospital, Hamad Medical Corporation, Doha, Qatar
a r t i c l e i n f o
a b s t r a c t
Article history:
Received 13 April 2012
Received in revised form
22 July 2012
Accepted 22 July 2012
Available online 27 July 2012
The overview of current diagnostic and therapeutic advances and controversies in the management of
breast cancer is presented. Specic topics and their impact on breast reconstruction surgeons practicing
in culturally different areas and with variable access to breast education and health care are discussed.
The following approaches to the most common types of problems are presented: prophylactic mastectomy for women at high risk of breast cancer, size and location of the primary tumor and feasibility of
breast conserving surgery and oncoplastic approach, management of the axilla, post-mastectomy radiation and chemotherapy, emerging breast reconstructive techniques (fat transfer, stem cells) and cancer
risk, oncological follow up and imaging of the reconstructed breast, including illustrative cases. This
material should help oncological and plastic surgeon specialists to understand each others considerations for the best possible outcome of the breast cancer treatment.
2012 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.
Keywords:
Cancer breast
TRAM ap
Cultural concepts
1. Introduction
In the 1980s the indications for breast reconstruction were
liberalized as a result of increasing experience with the various
procedures, including microsurgery, development of implants and
tissue expanders designed for breast reconstruction, recognition of
the benecial psychological effects of immediate breast reconstruction, and most importantly, due to the clinical evidence that
reconstructive procedures did not negatively impact the results of
a mastectomy (at that time the mainstay of the primary breast
cancer treatment).1,2
However, the natural evolution of breast cancer development
risk assessment, diagnostic and surveillance methods, development of breast conservation strategies, and changes in the design of
comprehensive breast cancer management, necessitate ongoing
evaluation of reconstructive approaches to ensure that reconstructive approaches do not hinder cancer detection or treatment
as those modalities may be changing. Issues controversial yesterday
are not controversial today and new questions are emerging. The
question to reconstruct or not to reconstruct? itself was
a controversy yesterday.2 Notably, practice guidelines for the
treatment of the breast cancer do not include details of reconstructive recommendations.3,4 Reconstructive approaches vary
* Corresponding author.
E-mail address: hamdya24@yahoo.com (H. El-Khatib).
from surgeon to surgeon, from center to center, and from one sociocultural region to another, etc. In general, patient impact on
management decisions has increased. The level of self-education on
relevant issues (e.g., through Internet sources) is high among breast
cancer patients, however, the perception and application of this
information varies depending on socio-economic and cultural
patient background.5e7 This overview is an attempt to update the
discussion of current diagnostic and therapeutic advances and to
discuss old and new controversies and their impact on reconstructive approaches while considering management determinants
resulting from the diversity of global cultures.1,2,5
2. Prophylactic mastectomy for women at high risk of breast
cancer
A woman is considered to be at high genetic risk for the
development of breast cancer if she has a BRCA1 or BRCA2 mutation
or her family history suggests an autosomal dominant pattern of
inheritance.8 A woman with a breast malignancy who presents at
a young age, or has relatives affected by breast cancer, should
consider testing for BRCA1/2 mutations. Breast cancer prevention
measures for these women include ovarian ablation, Tamoxifen
administration, bilateral prophylactic mastectomy, and a variety of
new agents entering clinical trial.9 It is a difcult decision whether
or not to undergo a prophylactic bilateral mastectomy to reduce the
risk of breast cancer in general, and it is equally as difcult to decide
to undergo a contralateral mastectomy in an effort to decrease the
1743-9191/$ e see front matter 2012 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.ijsu.2012.07.008
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Fig. 2. A proactive patient, an opposite to the patient depicted on Fig. 1: 23 year old
female, BRCA2 positive, with mother and grandmother who had prophylactic
mastectomies because of the family history, with 32 year old maternal aunt who
passed away because of the breast cancer, and with 28 year old maternal cousin just
diagnosed. Her options included; careful observation (with serial mammograms,
however, quality of mammograms for dense, young breast is not reliable), possibly
repeated ductal lavage, oophorectomy (systemic consequences unknown at such
young age), Tamoxifen (long term benets and systemic effects also unknown for
young age patients). Patient choice: bilateral prophylactic mastectomy including
nipples-areolas and reconstruction with tissue expanders and implants followed by
nipple/areola reconstruction.
Fig. 1. A 45 year old California woman with access to modern Western medicine who
did not want mastectomy at all because she believed in homeopathic, herbal medicine
and allowed her breast cancer to grow for ten years until the cancerous growth
virtually destroyed both breast and anterior chest wall.
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M.K. Dobke et al. / International Journal of Surgery 10 (2012) 429e435
Fig. 3. a. 43 year old patient with history of multiple lumpectomies and radiation to
the left breast for lobular breast carcinoma prepared for reconstruction utilizing TRAM
ap. The patient should consider prophylactic mastectomy on the right side and
undergo simultaneous reconstruction on both sides! b. Five years later the same
patient developed right breast cancer (also lobular) and underwent mastectomy with
reconstruction utilizing latissimus dorsi myocutaneous unit. Poor esthetic result of
reconstruction utilizing different types of aps on each side.
431
Fig. 4. a. A patient who underwent subcutaneous mastectomy, in which the nippleareola complex is preserved. b. Same patient, postoperatively, the defect was treated
with TRAM ap. 4-month follow-up.
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Author contribution
All authors are sharing equally in data collection, data analysis,
and writing.
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Conicts of interest
No nancial interest.
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