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3.
Breast Cancer Res Treat ; 179(2): 255-265, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31605310

RESUMO

INTRODUCTION: There has been a sharp rise in the rate of contralateral prophylactic mastectomy over the last decade, despite the low incidence of new primary cancers predicted for the contralateral breast. This study compares the postoperative complication rates between the diseased breast treated with mastectomy and the contralateral breast that underwent prophylactic mastectomy, followed by immediate bilateral breast implant reconstruction. We hypothesized that there will be no difference in postoperative outcomes between prophylactic and diseased groups, as the surgical approach would be comparable. METHODS: After IRB approval, a retrospective chart review identified consecutive unilateral breast cancer patients who underwent bilateral mastectomy and immediate breast reconstruction between May 2008 and May 2018 at a tertiary academic medical center. A paired sample t-test and a penalized logic regression model were constructed to identify relationships between breast laterality and outcomes. RESULTS: A total of 1117 patients with unilateral breast cancer who underwent bilateral mastectomy and immediate breast implant reconstruction were identified. Rates of capsular contracture and infection were significantly greater in the diseased breast, while rates of revision were significantly greater in the contralateral prophylactic breast. There were no statistically significant differences between breasts in rates of explant, skin flap necrosis or hematoma. When adjusted for confounding variables, a higher infection rate was observed in the diseased breast. CONCLUSION: This study detected significant differences in postoperative complication rates between the diseased and prophylactic breasts following bilateral mastectomy and immediate breast implant reconstruction. Postoperative complications occurred more frequently in the diseased breast compared with low rates of complications in the contralateral prophylactic breast. This information is helpful for preoperative decision making, as surgeons and patients carefully weigh the additional risks of contralateral prophylactic procedure.


Assuntos
Implante Mamário/efeitos adversos , Neoplasias da Mama/cirurgia , Mamoplastia/efeitos adversos , Complicações Pós-Operatórias/etiologia , Mastectomia Profilática/efeitos adversos , Adulto , Implante Mamário/métodos , Neoplasias da Mama/complicações , Neoplasias da Mama/diagnóstico , Terapia Combinada , Feminino , Humanos , Mamoplastia/métodos , Pessoa de Meia-Idade , Gradação de Tumores , Estadiamento de Neoplasias , Mastectomia Profilática/métodos , Medição de Risco , Resultado do Tratamento
4.
Breast Cancer ; 27(1): 70-76, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31292927

RESUMO

BACKGROUND: Breast reconstruction is a favorable option for women with BRCA1 or BRCA2 mutations (BRCA1/2Mut+) who undergo risk-reducing mastectomy (RRM). We assessed characteristics of patients who underwent RRM, with or without breast reconstruction. METHODS: We included 46 patients with BRCA1/2Mut+ who underwent RRM from July 2011 to December 2017. RESULTS: Among the 46 patients who underwent RRM, 3 had not been diagnosed with breast cancer (BC) and 43 had cancer in a single breast; 33 patients (71.7%) underwent breast reconstruction with RRM; and 13 patients (28.3%) did not undergo breast reconstruction. All of 3 patients who had not been diagnosed with BC underwent bilateral RRM with breast reconstruction. There was no significant difference of clinical characteristic between patients undergoing RRM with and without breast reconstruction. However, patients who decided to undergo RRM with the current diagnosis of BC had significantly higher rates of RRM with breast reconstruction than that of patients with a past history of BC (P = 0.043). The rate of nipple-sparing mastectomy (NSM) in patients with breast reconstruction was significantly higher (28 of the 37 breasts, 75.7%) than that in patients without reconstruction (3 of the 14 breasts, 21.4%) (P < 0.001). Two patients who had complications underwent RRM with breast reconstruction, and one of them had a history of irradiation after lumpectomy. CONCLUSIONS: For BRCA1/2Mut+ patients, the decision of taking RRM with the diagnosis of current BC might affect whether they undergo immediate breast reconstruction with RRM. These patients who undergo RRM with breast reconstruction preferred NSM to skin-sparing mastectomies.


Assuntos
Neoplasias da Mama/genética , Neoplasias da Mama/cirurgia , Mamoplastia , Mastectomia Profilática , Adulto , Neoplasias da Mama/diagnóstico , Neoplasias da Mama/patologia , Feminino , Genes BRCA1 , Genes BRCA2 , Humanos , Mamoplastia/estatística & dados numéricos , Pessoa de Meia-Idade , Mutação , Mastectomia Profilática/métodos , Mastectomia Profilática/estatística & dados numéricos
5.
Eur J Surg Oncol ; 46(4 Pt A): 511-515, 2020 04.
Artigo em Inglês | MEDLINE | ID: mdl-31706716

RESUMO

PURPOSE: Acellular dermal matrices (ADM) are increasingly used in implant-based breast reconstruction (IBR). Uncertainty remains with regard to their efficacy and complications. The aim of this study was to evaluate the outcomes and complication rates associated with the use of ADMs in IBR. METHODS: Retrospective cohort study of patients undergoing ADM-assisted IBR between 2008 and 2013. Cases were identified from a prospectively collected database. Simple descriptive statistics and logistic regression analysis were performed. RESULTS: A total of 110 patients (175 mastectomies) were included in the analysis. The median age was 46 (19-75) years and the median BMI was 22.2 (16.2-41.5). Seventy nine mastectomies were performed for therapeutic purposes. The median mastectomy weight was 244 (185-335) gr. The majority of reconstructions were performed with fixed volume (n = 115, 66%) or permanent expandable implants (n = 53, 30%) as one-stage procedures. Forty mastectomies were associated with at least one complication. The infection rate was 2.3% (n = 4). Post-operative haematoma developed in 5 cases (2.9%), but only 2 required surgical interventions. Three mastectomies were complicated by nipple necrosis (3.6%), 3 with skin necrosis (1.7%) and 9 with wound dehiscence (5.1%). The capsule formation rate was 2.3% (n = 4). Reconstruction failure with implant loss occurred in 3 cases (1.7%). CONCLUSIONS: The complication rates following ADM-assisted IBR can be very low with appropriate patient selection and meticulous surgical technique. This supports the safety of using ADM in carefully selected patients. Further research is warranted to assess the health economics of ADM use in IBR.


Assuntos
Derme Acelular , Implante Mamário/métodos , Neoplasias da Mama/cirurgia , Carcinoma Ductal de Mama/cirurgia , Carcinoma Intraductal não Infiltrante/cirurgia , Carcinoma Lobular/cirurgia , Mastectomia/métodos , Complicações Pós-Operatórias/epidemiologia , Adulto , Idoso , Neoplasias da Mama/prevenção & controle , Estudos de Coortes , Feminino , Humanos , Contratura Capsular em Implantes/epidemiologia , Tempo de Internação , Excisão de Linfonodo , Mamoplastia , Pessoa de Meia-Idade , Necrose , Mamilos , Tratamentos com Preservação do Órgão , Complicações Pós-Operatórias/terapia , Mastectomia Profilática/métodos , Estudos Retrospectivos , Biópsia de Linfonodo Sentinela , Seroma/epidemiologia , Seroma/terapia , Pele , Deiscência da Ferida Operatória/epidemiologia , Deiscência da Ferida Operatória/terapia , Infecção da Ferida Cirúrgica/epidemiologia , Infecção da Ferida Cirúrgica/terapia , Falha de Tratamento , Adulto Jovem
6.
Ann Surg Oncol ; 27(3): 743-749, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-31732944

RESUMO

BACKGROUND: Neoadjuvant chemotherapy (NAC) for breast cancer increases breast-conserving surgery (BCS) rates, but many women opt for mastectomy with contralateral prophylactic mastectomy (CPM). Here we evaluate factors associated with CPM use in women undergoing mastectomy post-NAC. METHODS: A retrospective institutional NAC database review identified women with clinical stage I-III, unilateral invasive breast cancer undergoing unilateral mastectomy (UM) or CPM mastectomy from 9/2013 to 12/2017. Clinical/pathologic characteristics, imaging, and presence of contraindications to BCS post-NAC were compared, with subset analysis of BCS candidates. The multivariable analysis was adjusted for potential confounders. RESULTS: Five hundred sixty-nine women underwent mastectomy after NAC, 297 (52%) UM and 272 (48%) CPM. On univariable analysis, younger age, BRCA+, lower pre-NAC clinical stage, pathologic complete response, and axillary surgery extent were associated with CPM (all p < 0.01). Favorable post-NAC clinical factors of no residual palpable disease, clinically negative nodes, complete response on breast imaging, and no post-NAC contraindication to BCS were also associated with CPM (all p < 0.01). On multivariable analysis, young age (odds ratio [OR] 0.93, 95% confidence interval [CI] 0.91-0.95), lower pre-NAC stage (OR 0.51, 95% CI 0.34-0.77), and no contraindication to BCS (OR 3.12, 95% CI 2.02-4.82) were significantly associated with CPM. Among the 203 (35%) women who had no contraindications to BCS post-NAC, 145 (71%) underwent CPM. BRCA+ and family history were reasons more frequently cited for mastectomy among CPM than UM (p < 0.001). CONCLUSIONS: CPM was performed in 48% of women undergoing mastectomy after NAC; younger women with earlier-stage cancers were more likely to undergo CPM. While increased use of CPM in women with more favorable disease is medically appropriate, our findings indicate a lost opportunity for use of BCS.


Assuntos
Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Neoplasias da Mama/cirurgia , Terapia Neoadjuvante/métodos , Mastectomia Profilática/métodos , Neoplasias da Mama/tratamento farmacológico , Neoplasias da Mama/patologia , Feminino , Seguimentos , Humanos , Pessoa de Meia-Idade , Prognóstico , Estudos Retrospectivos
7.
Am J Case Rep ; 20: 1812-1816, 2019 Dec 05.
Artigo em Inglês | MEDLINE | ID: mdl-31801936

RESUMO

BACKGROUND Technical innovations allow endoscopic nipple-sparing mastectomy (NSM), which is well tolerated and associated with greater patient satisfaction. Endoscopic technique did not have wide diffusion; many centers have abandoned this technique because of technical challenges. Implant-based reconstruction (IBR) remains the most common form of breast reconstruction. Current techniques involve partial or total coverage of the implant with pectoralis major muscle to prevent exposure or infection. Muscle dissection has functional and cosmetic consequences. CASE REPORT We present a case of 45-year-old patient presenting with personal history of right breast cancer. The patient requested left prophylactic mastectomy. We used a 4 cm-long single hidden scar on axillary line. Endoscopic nipple-sparing mastectomy was done using a single port with 3 sleeves. Immediate breast reconstruction was performed by inserting a silicon implant in prepectoral plane without Acellular Dermal Matrix (ADM). At 6 months postoperatively, no complication had been reported. The patient was satisfied with the result and no further correction was necessary. CONCLUSIONS Endoscopic surgery is a valuable option for nipple-sparing mastectomy. This method is a less expensive alternative technique to robotic approach. It could enable safe prepectoral IBR without placement of ADM and with lower risk of complications.


Assuntos
Implantes de Mama , Endoscopia , Mamoplastia , Mamilos/cirurgia , Mastectomia Profilática/métodos , Neoplasias da Mama/cirurgia , Feminino , Humanos , Pessoa de Meia-Idade , Tratamentos com Preservação do Órgão
9.
Curr Oncol ; 26(4): e439-e457, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-31548812

RESUMO

Background: Contralateral prophylactic mastectomy (cpm) in women with known unilateral breast cancer (bca) has been increasing despite the lack of supportive evidence. The purpose of the present study was to identify the determinants of cpm in women with unilateral bca. Methods: This qualitative descriptive study used semi-structured interviews informed by the Theoretical Domains Framework. We interviewed 74 key informants (surgical oncologists, plastic surgeons, medical oncologists, radiation oncologists, nurses, women with bca) across Canada. Interviews were analyzed using thematic analysis and an analysis for shared and discipline-specific beliefs. Results: In total, 58 factors influencing the use of cpm were identified: 26 factors shared by various health care professional groups, 15 discipline-specific factors (identified by a single health care professional group), and 17 factors shared by women with unilateral bca. Health care professionals identified more factors discouraging the use of cpm (n = 26) than encouraging its use (n = 15); women with bca identified more factors encouraging use of cpm (n = 12) than discouraging its use (n = 5). The factor most commonly identified by health care professionals that encouraged cpm was lack of awareness of existing evidence or guidelines for the appropriate use of cpm (n = 44, 75%). For women with bca, the factor most likely influencing their decision for cpm was wanting a better esthetic outcome (n = 14, 93%). Conclusions: Multiple factors discouraging and encouraging the use of cpm in unilateral bca were identified. Those factors identify potential individual, team, organization, and system targets for behaviour change interventions to reduce cpm.


Assuntos
Neoplasias da Mama/cirurgia , Segunda Neoplasia Primária/prevenção & controle , Mastectomia Profilática/métodos , Adulto , Canadá , Tomada de Decisão Clínica , Feminino , Conhecimentos, Atitudes e Prática em Saúde , Humanos , Entrevistas como Assunto , Pessoa de Meia-Idade , Guias de Prática Clínica como Assunto , Pesquisa Qualitativa , Medição de Risco
10.
Breast Cancer Res Treat ; 177(3): 723-733, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31302855

RESUMO

BACKGROUND: In healthy BRCA1/2 mutation carriers, bilateral risk-reducing mastectomy (BRRM) strongly reduces the risk of developing breast cancer (BC); however, no clear survival benefit of BRRM over BC surveillance has been reported yet. METHODS: In this Dutch multicenter cohort study, we used multivariable Cox models with BRRM as a time-dependent covariable to estimate the associations between BRRM and the overall and BC-specific mortality rates, separately for BRCA1 and BRCA2 mutation carriers. RESULTS: During a mean follow-up of 10.3 years, 722 out of 1712 BRCA1 (42%) and 406 out of 1145 BRCA2 (35%) mutation carriers underwent BRRM. For BRCA1 mutation carriers, we observed 52 deaths (20 from BC) in the surveillance group, and 10 deaths (one from BC) after BRRM. The hazard ratios were 0.40 (95% CI 0.20-0.90) for overall mortality and 0.06 (95% CI 0.01-0.46) for BC-specific mortality. BC-specific survival at age 65 was 93% for surveillance and 99.7% for BRRM. For BRCA2 mutation carriers, we observed 29 deaths (7 from BC) in the surveillance group, and 4 deaths (no BC) after BRRM. The hazard ratio for overall mortality was 0.45 (95% CI 0.15-1.36). BC-specific survival at age 65 was 98% for surveillance and 100% for BRRM. CONCLUSION: BRRM was associated with lower mortality than surveillance for BRCA1 mutation carriers, but for BRCA2 mutation carriers, BRRM may lead to similar BC-specific survival as surveillance. Our findings support a more individualized counseling based on BRCA mutation type.


Assuntos
Proteína BRCA1/genética , Proteína BRCA2/genética , Neoplasias da Mama/etiologia , Neoplasias da Mama/prevenção & controle , Heterozigoto , Mutação , Mastectomia Profilática , Neoplasias da Mama/mortalidade , Neoplasias da Mama/cirurgia , Feminino , Mutação em Linhagem Germinativa , Humanos , Mortalidade , Países Baixos/epidemiologia , Prognóstico , Mastectomia Profilática/métodos , Vigilância em Saúde Pública , Comportamento de Redução do Risco
12.
Rev. senol. patol. mamar. (Ed. impr.) ; 32(2): 41-47, abr.-jun. 2019. tab, graf
Artigo em Espanhol | IBECS | ID: ibc-187034

RESUMO

Objetivos: El propósito de este trabajo fue evaluar la evolución de la mastectomía bilateral con reconstrucción inmediata (MBRI) como tratamiento del cáncer unilateral o como profilaxis en pacientes de alto riesgo. También, analizar la variación en las técnicas quirúrgicas de reconstrucción y las complicaciones en diferentes periodos de tiempo. Métodos: Análisis retrospectivo de pacientes con MBRI como tratamiento y profilaxis de cáncer de mama. Periodos de estudio: 2001-2006, 2007-2011 y 2012-2016. Resultados: En total, se realizaron 332 MBRI: 110 (33,1%) en el primer periodo, 82 (24,7%) en el segundo y 140 (42,2%) en el tercero. En el primer periodo la indicación más frecuente en pacientes con cáncer unilateral fue la elección de la paciente (12 casos [10,9%]), y en el segundo y tercero, la multifocalidad o la multicentricidad, con 20 (24,4%) y 34 casos (24,3%), respectivamente. La mastectomía bilateral profiláctica se practicó por riesgo histológico en 10 (9,1%), 6 (7,3%) y 0 casos; por riesgo familiar sin mutación en 4 (3,6%), 3 (3,7%) y 5 casos (3,6%); y por mutación en los genes BRCA1/2 en 3 (2,7%), 2 (2,4%) y 14 casos (10%). Las técnicas más empleadas fueron Spira (39,1,39,6 y 41,4%) e incisión lateral externa (32,7, 25,6 y 38,9%). Las tasas de complicaciones son similares (25%) y la causa más frecuente de reintervención por secuelas es la contractura capsular en los 3 grupos: 17/110 (15,5%), 10/82 (12,2%) y 14/140 (10%). Conclusiones: Las pacientes con cáncer unilateral siguen demandando la mastectomía contralateral profiláctica, mientras las indicaciones de mastectomía bilateral profiláctica o reductora de riesgo han variado notablemente


Objectives: The aim of this study was to analyse changes in bilateral mastectomy with immediate reconstruction (BMIR) in the treatment of unilateral cancer or as prophylaxis in high-risk patients. We also analysed variation in surgical reconstruction techniques and complications in different time periods. Methods: Retrospective analysis of patients with BMIR in the treatment and prophylaxis of breast cancer. The study periods were 2001-2006, 2007-2011 and 2012-2016. Results: In total, 332 BMIR interventions were performed: 110 (33.1%) in the first period, 82 (24.7%) in the second and 140 (42.2%) in the third. The most frequent indication in unilateral cancer was patient choice in the first period (12 cases [10.9%]), and multifocality and/or multicentricity in the second and third periods; 20 cases (24.4%) and 34 cases (24.3%). BMIR was performed due to histological risk in 10 (9.1%), 6 (7.3%) and 0 patients; family risk without mutation in 4 (3.6%), 3 (3.7%) and 5 patients (3.6%); and mutation in BRCA1/2 genes in 3 (2.7%), 2 (2.4%) and 14 cases (10%) in the different periods, respectively. The most commonly used techniques were Spira (39.1, 39.6, 41.4%) and external lateral incision (32.7, 25.6, 38.9%). Complication rates were similar (25%) and the main cause of reoperation due to sequels was capsular contracture in the 3 groups (17/110 [15.5%], 10/82 [12.2%] and 14/140 [10%]). Conclusions: Patients with unilateral cancer continue to request prophylactic contralateral mastectomy, while the indications for prophylactic bilateral mastectomy have varied markedly


Assuntos
Humanos , Feminino , Neoplasias da Mama/cirurgia , Mastectomia Profilática/métodos , Mastectomia/métodos , Mamoplastia/métodos , Neoplasias da Mama/prevenção & controle , Estudos Retrospectivos , Mutação/genética , Genes BRCA1 , Genes BRCA2 , Procedimentos Cirúrgicos Eletivos/métodos , Recidiva Local de Neoplasia/cirurgia , Metástase Neoplásica/terapia
13.
Breast Cancer Res Treat ; 177(1): 175-183, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31140081

RESUMO

PURPOSE: Previous studies have reported increased rates of contralateral prophylactic mastectomy (CPM) in the United States among women with unilateral breast cancer. These trends have primarily focused on younger breast cancer patients. Given the growing aging population in the United States, we sought to determine whether CPM use is also increasing in elderly patients. METHODS: This population-based study identified patients in the surveillance epidemiology and end results (SEER) data. We determined the rate of CPM as a proportion of all surgically treated patients and as a proportion of all mastectomies. We compared the unadjusted CPM rates over the study period using the Cochrane-Armitage test for trend. We used a logistic regression model to test for the factors associated with CPM utilization. RESULTS: We identified 261,281 patients ≥ 65 years who underwent surgical treatment for breast cancer. For all patients treated with surgery for invasive breast cancer, the use of CPM increased from 1 in 2004 to 3% in 2014 (200% increase). Among mastectomy patients, the use of CPM increased from 3 in 2004 to 7% in 2014 (133% increase). Young age, non-Hispanic white race, lobular histology, higher grade, increased stage, negative lymph node status, and recent year of diagnosis were significantly associated with increased CPM rates. CONCLUSIONS: For elderly patients the use of CPM has continued to increase in the United States. These observations warrant concern in light of increasing evidence that CPM does not improve oncological outcomes and is associated with increased morbidity in older patients.


Assuntos
Neoplasias da Mama/epidemiologia , Neoplasias da Mama/prevenção & controle , Mastectomia Profilática , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Neoplasias da Mama/patologia , Feminino , Pesquisas sobre Serviços de Saúde , Humanos , Vigilância da População , Mastectomia Profilática/métodos , Mastectomia Profilática/estatística & dados numéricos , Mastectomia Profilática/tendências , Fatores de Risco , Programa de SEER , Neoplasias Unilaterais da Mama/diagnóstico , Neoplasias Unilaterais da Mama/epidemiologia , Neoplasias Unilaterais da Mama/cirurgia , Estados Unidos/epidemiologia
14.
Breast J ; 25(4): 612-618, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-31087467

RESUMO

BACKGROUND: There is a tendency to avoid nipple-sparing mastectomy (NSM) when a tumor-nipple distance (TND) is <2 cm due to the risk of occult nipple involvement. The purpose of the study was to determine whether the patients who undergo NSM with immediate reconstruction are oncologically safe when TND is <2 cm. METHODS: Patients who underwent NSM followed by immediate reconstruction for breast cancer were retrospectively analyzed. Patients who are negative for nipple-base in either frozen-section or paraffin histopathology were included. MRI was used to obtain TNDs to compare local-recurrence-free and disease-free survival in group I (TND <2 cm) and group II (TND ≥2 cm). Disease-free survival rates were determined to assess the outcome. RESULTS: Of the 214 cases with malignancy on MRI, 21 cases diagnosed with pure ductal carcinoma in situ were excluded. Among the 193 NSM cases diagnosed with invasive cancer, TND was <2.0 cm in 59 (30.56%) cases and ≥2.0 cm in 134 (69.43%) cases. No significant differences were found between groups in regards to ER, PR, HER2-neu status, and nodal involvement (P = 0.34, P = 0.41, P = 0.54, and P = 0.12 respectively). In a median follow-up time of 62 months (range; 13-114), patients in group I had four local recurrences, whereas group II was found to have five local and three distant metastases. No significant differences were observed between groups concerning disease-free survival (10-year DFS 93.2% vs 96.3%; P = 0.368 respectively). CONCLUSIONS: Patients who have invasive cancer diagnosis with a TND <2 cm are eligible to undergo therapeutic NSM with immediate reconstruction.


Assuntos
Neoplasias da Mama/patologia , Neoplasias da Mama/cirurgia , Mastectomia/métodos , Mamilos/cirurgia , Adulto , Neoplasias da Mama/diagnóstico por imagem , Neoplasias da Mama/mortalidade , Carcinoma Ductal de Mama/diagnóstico por imagem , Carcinoma Ductal de Mama/mortalidade , Carcinoma Ductal de Mama/patologia , Carcinoma Ductal de Mama/cirurgia , Carcinoma Intraductal não Infiltrante/diagnóstico por imagem , Carcinoma Intraductal não Infiltrante/mortalidade , Carcinoma Intraductal não Infiltrante/patologia , Carcinoma Intraductal não Infiltrante/cirurgia , Intervalo Livre de Doença , Feminino , Humanos , Imagem por Ressonância Magnética , Mamoplastia , Mastectomia/efeitos adversos , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/patologia , Mamilos/anatomia & histologia , Tratamentos com Preservação do Órgão , Complicações Pós-Operatórias/etiologia , Mastectomia Profilática/métodos , Taxa de Sobrevida
15.
Breast ; 46: 48-51, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31082761

RESUMO

The last twenty years have seen a complete change in society's attitude to the strategy of risk reduction of breast cancer in high-risk individuals by means of proactive mastectomy. Once termed 'prophylactic mastectomy', risk reducing mastectomy (RRM) was considered two decades ago not only extreme, but in some quarters almost unethical. RRM is now commonly undertaken in specialist breast units for women at high individual breast cancer risk, by virtue of an inherited breast cancer related gene mutation or from calculated high statistical risk from family history data, and the efficacy of RRM in reducing subsequent incident diagnoses of breast cancer has been published from a number of centres. RRM is offered routinely in conjunction with total breast reconstruction, using the whole range of reconstructive surgical techniques. The public announcement by the actor Angelina Jolie in 2013 that she had inherited and harboured a BRCA1 gene mutation, and was undergoing RRM and breast reconstruction to lower her intrinsic breast cancer risk, had a significant effect on public attitudes and perception. Whilst there are other means of lowering breast cancer risk by means of selective oestrogen receptor modulators, such as tamoxifen and raloxifene, their lowering effect on risk of breast cancer remains substantially less than that afforded by surgical removal of 'at risk' breast tissue. The progressive development and increasing sophistication of techniques of breast reconstructive surgery has paralleled the trend for more RRM surgery, and the substantial majority of women who opt for RRM choose immediate breast reconstruction.


Assuntos
Neoplasias da Mama/prevenção & controle , Conhecimentos, Atitudes e Prática em Saúde , Mastectomia Profilática/psicologia , Adulto , Neoplasias da Mama/psicologia , Feminino , Genes BRCA1 , Genes BRCA2 , Humanos , Mastectomia Profilática/métodos , Comportamento de Redução do Risco , Resultado do Tratamento
18.
BJS Open ; 3(2): 169-173, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30957063

RESUMO

Background: Bilateral nipple-sparing mastectomy (NSM) is a technically feasible operation and is associated with excellent cosmetic outcomes. The aim of this study was to evaluate trends in patient characteristics, indications for surgery and long-term outcomes of bilateral NSM for breast cancer risk reduction over time. Methods: A review of a single-centre experience with bilateral NSM performed between 2001 and 2017 for breast cancer risk reduction in patients without breast cancer was performed. Trends in patient characteristics and indications for surgery were evaluated over four time intervals: 2001-2005, 2006-2009, 2010-2013 and 2014-2017. Statistical analysis was performed using χ2 tests. Results: Over the study period, 272 NSMs were performed in 136 patients; their median age was 41 years. The number of bilateral NSMs performed increased over time. The most common indication was a mutation in breast cancer-associated genes (104 patients, 76·5 per cent), which included BRCA1 (62 patients), BRCA2 (35), PTEN (2), TP53 (3) and ATM (2). Other indications were family history of breast cancer (19 patients, 14·0 per cent), lobular carcinoma in situ (10, 7·4 per cent) and a history of mantle irradiation (3, 2·2 per cent). The proportion of patients having a bilateral NSM for mutation in a breast cancer-associated gene increased over time (2001-2005: 2 of 12; 2006-2009: 9 of 17; 2010-2013: 34 of 41; 2014-2017: 61 of 66; P < 0·001). Mean follow-up was 53 months; no breast cancers were found during follow-up. Conclusion: The use of bilateral NSM for breast cancer risk reduction is increasing and the indications have evolved over the past 16 years. These excellent long-term oncological results suggest that bilateral NSM is a good option for surgical breast cancer risk reduction.


Assuntos
Biomarcadores Tumorais/genética , Neoplasias da Mama Masculina/cirurgia , Neoplasias da Mama/cirurgia , Mastectomia Subcutânea/métodos , Tratamentos com Preservação do Órgão/métodos , Mastectomia Profilática/métodos , Adulto , Idoso , Neoplasias da Mama/genética , Neoplasias da Mama Masculina/genética , Feminino , Seguimentos , Mutação em Linhagem Germinativa , Humanos , Masculino , Mastectomia Subcutânea/efeitos adversos , Anamnese , Pessoa de Meia-Idade , Mamilos/cirurgia , Tratamentos com Preservação do Órgão/efeitos adversos , Seleção de Pacientes , Mastectomia Profilática/efeitos adversos , Estudos Retrospectivos , Resultado do Tratamento , Adulto Jovem
19.
Ann Ital Chir ; 90: 1-2, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30872561

RESUMO

Aim of this paper is to allows to analyze a topic of great relevance and media interest such as the role of prophylactic mastectomy in healthy women with BRCA mutation proposing to the surgeons some useful informations for decision-making. Less than 15% of all breast cancers are associated with germline genetic mutations. The majority of hereditary breast tumors are due to mutations in BRCA1 and BRCA2 genes that are responsible for only one third of hereditary cases. The risk estimates are extremely heterogeneous with a mean cumulative lifetime breast cancer risk of approximately 72% in BRCA1 and 69% in BRCA2 by age 80. The breast cancer is often bilateral and multicentric in BRCA mutation carriers. BRCA1 carriers have earlier-onset disease, particularly before age 50 and are more likely to develop aggressive triple-negative breast cancer than BRCA2 carriers or those who are BRCA mutation negative 1. Multiple strategies are effective in managing the risk of breast cancer in these women, including surveillance, chemoprevention, bilateral salpingo-oophorectomy and risk-reducing mastectomy. More intensive surveillance, including annual mammography and breast magnetic resonance imaging screening (commonly alternated every six months) beginning at age 25 or individualized based upon the earliest age of onset in the family, have significantly improved early detection of breast cancer among patients with deleterious BRCA mutations 1. The risk-reducing benefit of chemoprevention is not as well defined; chemopreventive strategies to reduce the risk of breast cancer have focused exclusively on prevention in high-risk women and involve the use of selective estrogen receptor modulators (SERMs) and aromatase inhibitors for breast cancer prevention. Only limited data are available regarding the preventive benefit of tamoxifene in BRCA mutations carriers 1. Risk-reducing bilateral salpingo-oophorectomy is recommended for BRCA mutation carriers by 35 to 40 or when childbearing is completed, or individualized based on age of onset of ovarian cancer in the family; bilateral salpingo-oophorectomy decreases the risk of both breast cancer and ovarian cancer in BRCA1 and BRCA2 mutation carriers and has also been associated with reduced all cause, breast cancer-specific, and ovarian cancer- specific mortality; risk-reducing bilateral salpingooophorectomy seems to offer an approximate 50% relative reduction in breast cancer risk 1. Prophylactic mastectomy provides the greatest reduction in risk of breast cancer development. In both retrospective and prospective observational studies, bilateral prophylactic mastectomy decreases the incidence of breast cancer by 90 percent or more in patients with BRCA mutation; it also is able to determine a variable gain in life expectancy compared to radiological surveillance; besides risk-reducing mastectomy allows to contain the strong anxiety and the fear of getting sick that often compromise the quality of life of BRCA mutation carriers 2. Prophylactic mastectomy could be technically performed in different ways. However, regarding the surgical technique, on the basis of current evidence, the gold standard seems to be represented by nipple-sparing mastectomy which, thanks to the preservation of the skin envelope and the nipple-areola complex, is able to optimize the oncological and aesthetic results. Nipple-sparing mastectomy provides superior cosmetic results. This procedure is usually performed through an inframmamary or radial or axillary incision where the skin is carefully dissected off the breast until all anatomic boundaries of the breast are reached and the gland in its entirety is excised. This technique does not seem to compromise the oncological/preventive efficacy compared to other types of mastectomy. In a multi-institution review of prophylactic 346 BRCA carriers undergoing either bilateral mastectomy or contralateral mastectomy with nipple- areola sparing there were no cases of breast cancer, whereas, based on models, 22 would have been expected 3. However nipple-sparing mastectomy must be carried out with technical skill and maximum attention not to leave macroscopic residues of mammary gland in particular in the axillary extension, peripheral extremities of the gland and the nipple-areola complex; it is necessary to perform an accurate dissection and a meticulous preparation of the skin flaps and of the areola-nipple complex which must be reasonably thin without however compromising its vitality. Whenever the patients opt to proceed with bilateral prophylactic mastectomy, an accurate preoperative radiological study should always be performed with mammography, ultrasound and magnetic resonance imaging to rule out the presence of suspicious breast lesions and minimize the risk of occult carcinomas by definitive histological examination. In the absence of contraindications, all patients should be candidates for breast reconstruction in order to minimize the negative physical and psychological impact of the mastectomy; the breast reconstruction should preferably be immediate, performed at the same time of the prophylactic mastectomy, by a team of dedicated plastic surgeons, or with permanent prosthesis or autologous tissues; the choice of the most appropriate reconstructive technique depends on various factors such as the physical/anatomical structure of the woman, the morphology/ degree of breast ptosis, the comorbidities but also the patient's wishes and preferences 1. However, in the discussion on the possibility of carrying out a prophylactic mastectomy, it is always necessary to consider a series of issues related to this procedure: - the possible oncological failure because risk-reducing mastectomy does not completely eliminate the risk of developing breast cancer; there is always a residual risk of about 5% to be related to the possible presence of residual glandular tissue or ectopic breast tissue 2; - the surgical morbidity with overall complication rates of 15-20% such as ischemia of the skin and/or of the areola-nipple complex, haematomas, infections, implant failure, partial/total autologous flap loss; in a considerable percentage of cases there is also the need to resort after the prophylactic mastectomy to further aesthetic/ plastic procedures to correct some imperfections or repair surgical complications 3-5; - the presence of sequelae such as the loss of sensitivity of the areola-nipple complex, possible paresthesias, painful sensations and the need for re-adaptation to a different body image 2; - the possible body image issues due to many factors, such as self-consciousness, feeling less sexually attractive and dissatisfaction with the scars 2,3. In addition to these issues we must add that most of the studies that show a gain in life expectancy thanks to prophylactic mastectomy, are based only on mathematical models and that the few prospective cohort studies often do not show a statistically significant improvement in terms of survival among women undergoing MP and intensive radiological surveillance 1,2. Therefore in consideration of the benefits but also of the problems that the prophylactic mastectomy involves, all the international guidelines highlight that this procedure must be considered, must be discussed with healthy BRCA women, however without giving an absolute recommendation to perform it 1. This discussion must take place, case by case, in specialized breast centers with a dedicated risk team. A personalized multidisciplinary path should guarantee an accurate genetic and clinical counselling, adequate psychological support and detailed information about all alternative risk management strategies. Clinical decision-making about strategies to pursue for breast cancer risk reduction should involve a tradeoff between life expectancy and quality of life. However if the patient and the medical team opt to proceed with prophylactic surgery, the cumulative evidence to date supports nipple sparing mastectomy with immediate reconstruction as an appropriate risk-reducing procedure to optimize the oncological and aesthetic results and improve quality of life.


Assuntos
Neoplasias da Mama/genética , Neoplasias da Mama/prevenção & controle , Cirurgia Geral , Genes BRCA2 , Heterozigoto , Mutação , Mastectomia Profilática , Feminino , Humanos , Mastectomia Profilática/métodos
20.
BJOG ; 126(6): 686-689, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30770625

RESUMO

BRCA1/BRCA2 genes were discovered in early 1990s and clinical testing for these has been available since the mid-1990s. National Institute of Health and Care Excellence (NICE) and other international guidelines recommend genetic-testing at a ~10% probability threshold of carrying a BRCA-mutation. A detailed three generation family-history (FH) of cancer is used within complex mathematical models (e.g. BOADICEA, BRCAPRO, Manchester-Scoring-System) or through standardized clinical-criteria to identify individuals who fulfil this probability threshold and can be offered genetic-testing. Identification of unaffected carriers is important given the high risk of cancer in these women and the effective options available for clinical management which can reduce cancer risk, improve outcomes and minimise burden of disease. This article is protected by copyright. All rights reserved.


Assuntos
Intervenção Médica Precoce/métodos , Genes BRCA1 , Genes BRCA2 , Testes Genéticos , Acesso aos Serviços de Saúde/normas , Síndrome Hereditária de Câncer de Mama e Ovário , Quimioprevenção/métodos , Anticoncepção/métodos , Análise Custo-Benefício , Feminino , Testes Genéticos/economia , Testes Genéticos/métodos , Testes Genéticos/estatística & dados numéricos , Genética Populacional/métodos , Síndrome Hereditária de Câncer de Mama e Ovário/etnologia , Síndrome Hereditária de Câncer de Mama e Ovário/genética , Síndrome Hereditária de Câncer de Mama e Ovário/prevenção & controle , Humanos , Mutação , Determinação de Necessidades de Cuidados de Saúde , Mastectomia Profilática/métodos , Melhoria de Qualidade , Medição de Risco
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