Case 34 Breast Cancer Reconstruction

Victor A. King and Glyn E. Jones

Case 34 Breast Cancer Reconstruction

Case 34 A 55-year-old woman with history of left-sided ductal carcinoma in situ. She is planned for a left-sided mastectomy and seeks reconstructive options.

34.1 Description

  • A 55-year-old female with evidence of left-sided breast biopsy and large C-cup breasts

  • Image shows breast asymmetry with the left side higher than the right, suggestive of possible previous procedure versus baseline asymmetry

  • Notable laxity of the lower abdomen; reasonable candidate for autologous reconstruction

34.2 Work-Up

34.2.1 History

  • Breast cancer diagnosis: Ductal carcinoma, lobular carcinoma, and inflammatory breast carcinoma are most common

    • Noninvasive versus invasive

    • Location, tumor size, node, and metastasis (TNM) classification, and contralateral disease

  • Previous procedures or surgeries: Oncologic or aesthetic breast procedures, history of surgery, or radiation elsewhere in the body

  • Breast screening and diagnostic testing: Mammography, ultrasound, magnetic resonance imaging (MRI), computed tomography (CT) scan, pathology, and molecular and genetic testing

  • Age, pre- versus post-menopausal, pregnancy plans, and breastfeeding

  • Family history of breast and other cancers

  • History of smoking/tobacco use and comorbid conditions

  • Patient’s reconstructive desires, expectations, and desired timing

34.2.2 Physical Examination

  • Body habitus and body mass index (BMI): Weight (kg)/Height (m2)

  • Current breast characteristics (including contralateral breast)

    • Measurements (see Fig. 36.2, Table 36.2)

    • Breast masses and presence of lymphadenopathy

    • Quality and quantity of skin; presence and location of scars and deformities

  • Donor site availability and presence of scars: Abdomen, back, buttocks, and thighs

  • Lymphedema

34.2.3 Pertinent Imaging or Diagnostic Studies

  • Mammogram or other diagnostic imaging (especially if operating on unaffected breast)

  • Consider CT or MR angiography, if planning autologous free flap

34.3 Consultations

  • Surgical (breast) oncology, medical oncology, and radiation oncology (if needed)

  • Tumor board

34.4 Patient Counseling

  • Overall, 89.7% 5-year survival rate; 98.7% 5-year survival for localized breast cancer

  • BRCA mutations: Lifetime risk >50%, with increased risk of contralateral disease

  • Breast reconstruction often requires multiple operations

34.5 Treatment

  • The most important consideration is oncologic safety and prevention of recurrence

  • Surgery, chemotherapy, and radiation are mainstays of treatment

34.5.1 Preoperative and Surgical Considerations

  • Planned lumpectomy versus mastectomy

  • Immediate reconstruction: Psychosocial benefit, with reduced number of operations

  • Delayed reconstruction

    • Overall lower rate of complications

    • Preferred if medical comorbidities are significant, tissue quality is poor, oncologic safety of primary procedure is not certain, reconstruction risks are delaying adjuvant therapies, patient is not ready to make an informed decision, or breasts are large and ptotic

  • No reconstruction at all remains an option for treatment, especially in very sick patients

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Jul 17, 2021 | Posted by in General Surgery | Comments Off on Case 34 Breast Cancer Reconstruction
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