Sentinel lymph node biopsy for risk-reducing mastectomy.

Risk-reducing mastectomy (RRM) confers 90-95% decreased risk of breast cancer, and may reduce mortality, especially in high-risk groups such as BRCA carriers. Risk of occult disease in RRM specimen is ~5%. This demands axillary staging: sentinel lymph node (SLN) biopsy is no longer possible, axillary clearance confers significant risks and may prove negative. Contemporaneous SLN biopsy allows axillary staging with minimal further dissection. Women undergoing RRM and SLN biopsy between June 2005 and July 2010 were reviewed retrospectively from our prospectively maintained database of 1,522 SLN procedures in 1,498 patients. SLN(s) localized using routine tracer methods. SLNs and mastectomy specimens underwent routine histologic examination. Eighty-three RRMs with SLN biopsy were performed in 71 patients (12 bilateral). Indications for RRM: contralateral invasive (55), in situ (5) disease, BRCA 1/2 mutation (12), and strong family history (10). Mean number of SLNs: 1.35. Occult disease was detected in four cases (4.8%), with one case of occult invasive lobular carcinoma (1.2%). Remaining occult disease was lobular in situ neoplasia (LISN). SLNs were negative in all cases. Our findings are comparable to those in the literature: 4.8% rate of occult disease overall, 1.2% invasive. The significant risk with SLN biopsy is lymphoedema, quoted around 7%. We have had no reports of symptomatic lymphoedema in patients undergoing RRM and SLN biopsy. We propose that SLN at the time of mastectomy requires only limited further dissection, and confers minimal risk compared with secondary axillary surgery.

Treatment of recurrent breast cancer following breast conserving surgery.

Patients with isolated ipsilateral breast cancer recurrence face completion mastectomy in the majority of cases. Selected patients may derive good outcomes from repeat breast conservation surgery and indeed repeat irradiation may be employed using one of many different modalities. Tumor biology rather than salvage surgery method is likely to influence outcome. Patients with isolated breast tumor recurrence are treated in the majority of cases with completion mastectomy, when for selected patients there exists little evidence that more radical surgery provides better outcomes in terms of further recurrence and overall survival, than repeated breast conserving surgery. Literature search identifying articles addressing the issue of repeat breast conserving surgery for ipsilateral breast tumor recurrence, and repeat radiotherapy(search terms include: repeat breast conserving surgery, salvage mastectomy, salvage breast conserving surgery,salvage radiotherapy, reirradiation). Thirty-five articles discussed the outcomes of repeat breast conserving surgery versus salvage mastectomy, methods of repeat breast irradiation, repeat sentinel lymph node biopsy and related factors. Repeat breast conserving surgery may represent a safe and feasible treatment method for isolated ipsilateral breast tumor recurrence.

Oncological advantages of oncoplastic breast-conserving surgery in treatment of early breast cancer.

The standard approach to breast-conserving surgery is wide local excision of the tumor and radiotherapy. However, a significant number of patients require further surgery to obtain oncologically clear margins, and may obtain a poor cosmetic result following adjuvant radiotherapy. Oncoplastic techniques may result in improved cosmesis, but few studies have investigated the oncological advantage of this approach. The aim of this retrospective study was to compare tumor clearance and the need for further margin excision following standard wide local excision (group A, 121 patients), and oncoplastic breast-conserving surgery (group B, 37 patients). These techniques included therapeutic mammoplasty, sub-axillary fat pad rotation mammoplasty, thoraco-epigastric flap, and central flap. Compared to standard surgery (group A), oncoplastic techniques (group B) can be employed for significantly larger tumors (17.6 mm versus 23.9 mm, p = 0.002). Oncoplastic breast-conserving surgery results in higher mean specimen weights (58.1 g versus 231.1 g, p < 0.0001), higher specimen volumes (112.3 cm(3) versus 484.5 cm(3) , p < 0.0001), and wider clear margins (6.1 mm versus 14.3 mm, p < 0.0001), resulting in lower rates of further surgery (28.9% versus 5.4%, p = 0.002). There was no statistical increase in complication rates following oncoplastic surgery. Oncoplastic breast-conserving surgery is more successful than standard wide local excision in treating larger tumors and obtaining wider radial margins, thus reducing the need for further margin excision, which delays adjuvant therapy. There was no increase in postoperative complication rate using an oncoplastic approach.

Avoiding back wound dehiscence in extended latissimus dorsi flap reconstruction.

BACKGROUND: The latissimus dorsi breast reconstruction flap has a number of advantages, but despite the advances in surgical techniques, it has remained vulnerable to skin dehiscence or necrosis at the donor site. We describe a novel surgical technique to prevent this. METHODS: Patients treated with extended latissimus dorsi flap reconstruction between January 2005 and January 2010 were studied prospectively. RESULTS: Eighteen patients were reviewed (12 immediate and 6 delayed). Two patients were smokers. The mean age was 54.4 (range: 42-64) years and the mean body mass index was 31.6 (range: 22.3-38). The mean weight of the mastectomy specimen was 551 g (range: 280-980 g). Six patients developed back seroma which required aspiration, and one patient developed a haematoma of the reconstructed breast. All wounds healed primarily. CONCLUSION: The new technique is safe, simple and effective in avoiding wound dehiscence at the donor site after extended latissimus dorsi flap reconstruction.