Moving from a multilating surgery to Breast Reconstruction in advanced breast cancer : A shift to approach

Halsted proposed the concept of Radical mastectomy based on the idea that at first, breast cancer spread only locally or “centrifugally” by first invading contiguous tissue and then spreading though lymph ducts to close-by lymph nodes, where the cells were “trapped” for some time.

From Halstedian era of radical mastectomy to modified radical mastectomy(MRM) to breast conservation surgery(BCS) , as the surgical techniques have evolved since then it has always been observed in the researches that this evolution have contributed to functional and cosmetic outcome. Nonetheless it has changed psychological outcome too due to an improved psychosocial body image.

The breast being the symbol of :

1. Feminity
2. Beauty and
3. Motherhood, it further becomes important to pay attention to the diseases of the breast especially when the breast cancer is concerned.

An Onco-Surgeon’s perspective

To keep his / her oncosurgeon’s mind ‘ON’ while operating in order to ensure complete removal of cancer from a localized or locally advanced breast cancer (LABC) irrespective of the loss of volume of the breast tissue. This will certainly help us to offer her improved disease free survival as far as loco-regional control is concerned. We can always plan reconstruction in the same sitting (preferred) with proper preoperative planning in discussion with the patient.

Here, the combined approach by an onco-surgeon and a plastic surgeon plays a very important role in:

1. Counseling of the patient
2. On table-surgical planning and
3. Improved onco-surgical and cosmetic outcome. This approach builds up the patient’s confidence also.

Preoperative planning

The First and most important part of the surgical planning of the breast cancer patient is the proper:

1. Clinical examination
2. Comparison of both the breasts and their anthropometry measurement
3. Review of her medical records
4. Proper clinical staging at presentation

For locally-advanced inoperable breast cancer cases, neoadjuvant chemotherapy is recommended followed by interval or sequential surgical treatment. Decision to operate upon in such cases should be reviewed and discussed with the patient. All the surgical treatment options and their relevance should be briefly explained to the patient.

Available surgical options are :

1. MRM alone
2. BCS with or without flap reconstruction OR
3. MRM with DIEP free flap reconstruction in first sitting followed by nipple areola complex (NAC) reconstruction in second stage, which is usually preferred after the completion of adjuvant chemoradiation.

Options for autologous tissue reconstruction:

1. Pedicled flap (LD flap, TRAM flap)
2. Free flap (DIEP flap)

Should we offer free flap reconstruction option in LABC cases after MRM?

Yes, Schneiders in 1977 introduced the latissimus dorsi flap. Endoscopy can be used to mobilize latissimus dorsi flaps and minimize dorsal scarring preferred for reconstruction after BCS to fill the defect.

Holmstrom in 1979, proposed The DIEP flap, which makes large-volume transfer possible, with preservation of the abdominal muscle. This gives good, acceptable and comparable cosmetic outcome after MRM. However, the operating time is longer than for other breast reconstructions. But, this one of the most preferred choice by surgeon and patients when it comes to the resultant body image and cosmetic outcome without compromising oncological outcome.

Several types of expanders and prostheses have been used for breast reconstruction but they are not preferred for breast cancer cases.

The choice of breast reconstruction technique depends on the anatomical characteristics of the patient and the skill and experience of the plastic surgeon.

Conclusion

Post mastectomy autologous breast reconstruction, offers better cosmetic and psychological outcome. Studies have suggested that it doesn’t influence loco-regional recurrences and also doesn’t interfere with the detection of recurrences even if it happens. Imaging in follow-up period is widely available tool to monitor the oncological outcome.

Dr. Seema Singh
Consultant – Surgical Oncology
RGCIRC, Niti Bagh, South Delhi