Risk-reducing mastectomy.

Breast cancer is a malignant proliferation of epithelial cells lining the ducts or lobules of the breast. Excluding skin cancer, breast cancer is the most common cancer in women. Only lung cancer accounts for more cancer deaths in women. Breast cancer may exist for a long period either as an invasive or noninvasive disease, but not as a nonmetastatic disease. Consequently, timely diagnosis and appropriate management are lifesaving. Approximately 10% of human breast cancers are linked to germline mutations, such BRCA1 and BRCA2. Correct staging of breast cancer patients is critical. It permits an accurate diagnosis, as well as in many cases, therapeutic decisions based largely on the TNM classification. Staging provides the most important prognostic variable. Second opinions of the staging of breast cancer by pathologic examination of the tissue is recommended. There are some variables in which the association with disease-free survival and overall survival seem clear and include estrogen and progesterone receptor cells, S-phase analysis using flow cytometry, histologic classification, molecular changes in the tumor as well as neovasculature semi-quantitative scoring systems. There are four objectives to risk-reducing mastectomy. First, risk-reducing mastectomy should reduce the incidence of breast cancer in high-risk women, for example, BRCA1 or BRCA2 carriers. It should reduce mortality from breast cancer in high-risk women. Moreover, it should have psychological benefits in relieving anxiety about developing breast cancer. Finally, there must be a balance in the reduction in risk against cosmetic outcome, with subsequent quality of life issues. Women should be offered risk reduction mastectomy only on the basis of a strict selection and management plan, like that used in Manchester protocol. This protocol involves a minimum of two sessions with a geneticist/oncologist, a session with a psychiatrist and two sessions with a plastic and reconstructive surgeon with the support of a breast care nurse. The surgical technique should aim at removing substantially all at-risk breast tissue. However, there is an obvious balance between reduction of cancer risk and cosmetic outcome. The surgical technique involves several operations to include the risk-reducing mastectomy as well as breast reconstructive procedures. Skin-sparing mastectomy represents a new surgical approach that allows a mastectomy, whereas preserving the natural skin envelope of the breast. Breast reconstruction will involve several operations, especially if the nipple areola complex is resected and is subsequently reconstructed. The contraindications to risk-reducing mastectomy include the following. The status of the family history or Munchausen's syndrome has not been confirmed. The risk-reducing mastectomy is not the women's own choice. The patient has a current psychiatric disorder including clinical depression, cancer phobia or body dysmorphic syndrome. If the co-morbidity outweighs the clinical benefits, surgery should not be undertaken. Finally, the patient must not have unrealistic expectations of the benefits of surgery. She must understand the subsequent risk-reducing mastectomy may significantly reduce, but not eliminate the risk of subsequent breast cancer.

Advances in breast reconstruction after mastectomy.

Over the past 40 years, surgical reconstruction of the breast following mastectomy has become an important aspect of the cancer patient's rehabilitation process. While the surgical emphasis remains on a cure for the cancer, experience with breast reconstruction has not demonstrated any increased rate of cancer recurrence, even when reconstruction is performed immediately following tumor resection. Advances in surgical technique and biotechnology have made post-mastectomy reconstruction possible. The development of silicone gel and saline-filled implants as well as tissue expanders has revolutionized breast reconstruction. The elucidation of musculocutaneous flaps now provides the surgeon with the ability to transfer adequate quantities of vascularized tissue to reconstruct the surgical defects. The advent of microsurgical techniques has provided an additional reconstructive option, with free tissue transfer allowing the plastic surgeon to move musculocutaneous flaps from remote or distant sites to reconstruct the defect. The option of having the reconstruction immediately following the mastectomy procedure is now available to the patient. When reviewing the anatomy of the breast region, the surgeon must consider the mammary gland, its vascular supply, and its lymphatic system. The surgical techniques involved in reconstruction after mastectomy include the use of breast implants and tissue expansion, as well as reconstruction with autogenous tissues. Reconstruction with autogenous tissues includes the use of latissimus dorsi musculocutaneous flap, transverse rectus abdominus musculocutaneous flap, free flap transfer, as well as nipple-areola reconstruction. Breast reconstruction after mastectomy should be undertaken by a plastic and reconstructive surgeon with considerable training and experience with these diversified procedures.