Breast Reconstruction in a Changing Breast Cancer Treatment Paradigm


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Excerpt

Current trends in the treatment of breast cancer reveal a progressively higher value being placed on the conservation of breast tissue. In the shift from the radical mastectomies of Halsted to breast-conserving therapies, there has been a greater realization of the possibility and the benefits of providing less invasive procedures with decreased tissue volume resections as procedures are increasingly tailored to specific tumor characteristics. This move toward smaller procedures and more individualized therapies achieves multiple advances in improving care and outcomes for women undergoing breast cancer treatment.The goal of recent developments in breast conservation therapy, including sentinel lymph node biopsy and partial breast irradiation techniques, is to decrease morbidity and complications for women. In addition to improving functional results for women, these new advances allow breast surgeons and plastic surgeons to truly maximize aesthetic and reconstructive outcomes. The use of bilateral reduction mammaplasty as a strategy for avoiding breast contour defects after large-volume partial mastectomy has shown excellent results in optimizing breast symmetry and appearance. When mastectomy is indicated, breast surgeons are preserving an increasing amount of skin envelope through skin-sparing and nipple-sparing mastectomy techniques, providing plastic surgeons with an improved aesthetic pocket in which to place implants or autologous tissue flaps and a virtually intact nipple-areola complex that requires little, if any, further reconstruction. Refinement of the deep inferior epigastric perforator (DIEP) flap and other perforator flaps has continued to improve outcomes after autologous tissue reconstructions.In this article, the authors review the recent development of new tools, techniques, and strategies for the management of breast cancer. The paradigm shift shaping the surgical treatment of breast cancer makes the current options and environment in the field of breast reconstruction ever evolving and increasingly rewarding.BREAST CONSERVATION THERAPYThe possibility of providing adequate oncologic safety while minimizing the morbidity of mastectomy began to be systematically studied over 30 years ago with the National Surgical Adjuvant Breast and Bowel Project B-06 trial comparing lumpectomy with or without radiation therapy to mastectomy in women with invasive breast cancer. Results after 20 years of follow-up1 and results from a similar large Italian trial by Veronesi et al.2 showed no significant differences among groups for disease-free survival, distant disease-free survival, or overall survival, although improved local control was seen with the addition of radiation therapy in the lumpectomy arms. The emphasis on margins free of invasive cancer and ductal carcinoma in situ also rose to significance at the time of publication of these results, particularly given the significant locoregional recurrence rates seen in patients undergoing breast conserving therapy in whom negative tumor margins had not been ensured.3–6For most patients, partial mastectomy and postoperative radiation therapy is the standard of care for the surgical management of early stage breast cancer. Mastectomy is reserved for women with multicentric breast cancer, a history of ipsilateral breast cancer treated with a partial mastectomy and radiation therapy, or a history of chest wall radiation therapy; and for women diagnosed in early stage pregnancy who wish to continue the pregnancy.7 However, standard external beam radiotherapy, the modality used in these trials and commonly used in breast cancer management, also carries its own set of associated morbidities and toxicities to the patient. In addition, radiation doses in the earlier studies had significant negative effects on breast appearance and cosmesis. Over the past 20 years, new techniques in radiation therapy have been developed to improve patient outcomes and maximize oncologic benefit.

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