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Bilateral reduction mammoplasty in combination with lumpectomy for treatment of breast cancer in patients with macromastia
The American Journal of Surgery 187 (2004) 647– 651
Scientific paper
Bilateral reduction mammoplasty in combination with lumpectomy for treatment of breast cancer in patients with macromastia Eugene Chang, M.D.b, Nathalie Johnson, M.D.a,c,*, Bruce Webber, M.D.c, James Booth, M.D.c, Dina Rahhal, M.D.b, David Gannett, M.D.c, William Johnson, M.D.a,c, Daisy Franzini, M.D.a, Henry Zegzula, M.D.a a
Legacy Cancer Services, Portland, OR, USA Oregon Health and Science University, Portland, OR, USA c Providence St. Vincent’s Medical Center, Portland, OR, USA b
Manuscript received December 11, 2003; revised manuscript January 18, 2004 Presented at the 90th Annual Meeting of the North Pacific Surgical Association, Portland, Oregon, November 14 –15, 2003
Abstract Background: Bilateral reduction mammoplasty has been described as a surgical option for treatment of breast cancer in women with large, pendulous breasts. Using this technique can provide unique surgical oncologic challenges. Methods: Retrospective chart review. Results: Thirty-seven patients were identified. The average weight of tissue removed was 653 g. Tumor size ranged from 0.6 to 5.2 cm. One patient had microscopically positive surgical margins on final pathology. The tumor bed was not marked, and completion mastectomy was required. Two patients had unexpected malignancy in the contralateral breast. One patient required completion mastectomy for positive nonoriented margins. In another patient, tissue from the contralateral side was oriented, and mastectomy was avoided. Conclusions: Bilateral reduction mammoplasty with lumpectomy is an ideal option in women with macromastia. We recommend marking the tumor bed on the flaps and pedicle as well as orienting tissue removed from the contralateral side as maneuvers that will decrease need for completion mastectomy. © 2004 Excerpta Medica, Inc. All rights reserved. Keywords: Breast cancer; Macromastia; Reduction mammoplasty
Therapeutic management of breast malignancy in women with large, pendulous breasts poses a significant challenge for both surgeons and radiation oncologists. The conventional options of mastectomy or breast-conservation therapy each have drawbacks in women with macromastia. A unilateral mastectomy in a woman with very large breasts produces unacceptable and uncomfortable asymmetry. Reconstruction is onerous and often requires a reduction mammoplasty on the contralateral side to achieve symmetry. Although patients with large breasts tolerate partial mastectomy with minimal impact in symmetry, such breasts pose difficulties for the radiation oncologist [1,2]. Radiation treatment is as efficacious in large breasts as it is in small
breasts, but dose-homogeneity is far more difficult to achieve in large breasts [3]. It is quite common to have “hot spots” or areas in the breast that receive 10% to 15% more dose. Radiation fibrosis, chronic pain, and poor cosmesis often result [4]. Reduction mammoplasty can play a significant role in this special subgroup. Reduction offers a way to perform lumpectomy and get smaller, symmetrical breasts that more easily tolerate radiation. We have learned that applying this procedure in the realm of oncology can lead to occasional challenges. We review our experience here.
* Corresponding author. Tel.: ⫹1-503-229-7339; fax: ⫹1-503-2297938. E-mail address: [email protected]
A retrospective review of the charts and pathology of patients treated by bilateral reduction mammoplasty (BRM) and lumpectomy in community surgical practices between
Methods
0002-9610/04/$ – see front matter © 2004 Excerpta Medica, Inc. All rights reserved. doi:10.1016/j.amjsurg.2004.01.002
648
E. Chang et al. / The American Journal of Surgery 187 (2004) 647– 651
1998 and 2003 was performed. Standard criteria were maintained in selecting patients for breast-conservation therapy. For nonpalpable lesions, needle localization and dye injection was carried out before surgery. Patients undergoing sentinel lymph node biopsy received a preoperative injection of radionuclide tracer and an intraoperative injection of lymphazurin blue dye. Initial exposure and flap development was made through a Wise-pattern incision performed by the plastic surgeon, and the tumor was removed as part of the reduction mammoplasty specimen. This portion of the procedure was performed in combination by both the general surgeon and the plastic surgeon. Treatment of axillary lymph nodes was carried out through the mammoplasty incision or through a separate axillary incision. Specimens were submitted for gross review intraoperatively and, subsequently, permanent histology. A secondary pathologic review was performed to confirm margins for the purpose of this report. In all except 1 patient, both breasts underwent reduction mammoplasty in a single operation. Separate instruments were used when operating on the contralateral breast. All patients underwent postoperative radiation therapy. Adjuvant chemotherapy was given as appropriate for stage of disease. Patients were followed-up clinically and surveyed regarding their satisfaction with results.
was found in the “unaffected” breast specimen. However, in this case the tissue had been oriented. This made it possible to identify the region where the tumor was located. She underwent a re-excision of the flap and pedicle in the area of the tumor. Residual tumor was removed with clear margins. Despite removal of additional tissue from both the flap and pedicle, we were able to maintain a cosmetically pleasing breast. On follow-up, 6 patients developed fat necrosis. These firm areas were excised or underwent core-needle biopsy to rule out recurrence. One patient developed lymphedema of the ipsilateral side. One patient required a revision for “dogears” involving the incision. Twenty of 37 patients responded to the satisfaction survey. Fourteen of 20 rated their cosmetic result as excellent (rating 5 on a scale of 5) even though 55% (11 of 20) said there was a change in the cosmetic result after radiation therapy. Patients expressed a high degree of satisfaction with the functional and cosmetic result of the reduction mammoplasty. All 20 (100%) stated that they would choose BRM over mastectomy or lumpectomy if they had to make this decision again. To date, no recurrences have been detected.
Comments Results Thirty-seven patients underwent partial mastectomy and BRM. Age ranged from 34 to 77 years (average 52). Seventeen women had palpable lesions. The types of tumors included infiltrating ductal carcinoma (n ⫽ 29), infiltrating lobular carcinoma (n ⫽ 2), ductal carcinoma in-situ (n ⫽ 2), and colloid carcinoma (n ⫽ 2).Tumor size ranged from 0.6 to 5.2 cm. Weight of tissue removed ranged from 144 to 1924 g (average 653 g/breast). One patient had a positive margin. The remainder of margins ranged from 0.25 mm to 5.0 cm. All lumpectomy specimens were marked for margins, and immediate gross examination was performed. Unexpected malignancy was encountered in the contralateral breast in 2 patients. Two patients required completion mastectomies. One patient was found to have positive margins on microscopic review of the lumpectomy/reduction mammoplasty specimen. This patient had a 2.5-cm infiltrating ductal carcinoma with extensive ductal carcinoma in situ. The tumor bed on the flap and pedicle had not been marked. She required a completion mastectomy. The mastectomy specimen showed no residual tumor. In the second patient, unexpected malignancy was discovered in the contralateral breast. As is customary, the tissue from the “unaffected side” was unmarked and unoriented. Margins were unclear, and she underwent completion mastectomy. No residual tumor was found in the mastectomy specimen. In another patient, unexpected contralateral malignancy
Breast-conservation therapy with BRM is an ideal option for the treatment of breast cancer in women with macromastia (Fig. 1). The procedure results in symmetric breast with a high degree of satisfaction. Newman et al [5,6] described the successful use of this procedure in 28 patients with large breasts. Spear et al [7]reported on their series of 11 patients with macromastia in whom reduction mammoplasty after partial mastectomy was performed for breast cancer. They experienced good treatment outcomes and high patient satisfaction. We also found this procedure to be quite advantageous. However, in reviewing our experience we learned that there are some clinical caveats to using reduction mammoplasty in the setting of cancer management. Persistent attention to detail and cooperation between the plastic and general surgeon will lead to better outcomes and decrease the risk of need for completion mastectomy. Standard indications and contraindications for lumpectomy should be maintained. Multicentric tumors, significant multifocal disease, and extensive ductal carcinoma in situ are relative contraindications. Any one of these findings is more likely to result in failure to clear margins, which may result in need for completion mastectomy. Similar to our experience, 1 patient in the study by Newman et al [5] required completion mastectomy for positive margins. Breast magnetic resonance imaging can often help to elucidate the extent of disease in this setting and may be helpful in treatment planning and patient counseling. If appropriate, neoadjuvant chemotherapy may be used to attempt breast conservation as we do for the normal-sized breast.
E. Chang et al. / The American Journal of Surgery 187 (2004) 647– 651
649
Fig. 1. (A) Wise pattern for reduction mammoplasty. (B) Needle localization of tumor. (C) Reduction mammoplasty specimen. (D) Postoperative results.
Traditionally, when performing lumpectomy we mark and orient the specimen to delineate margins. When combining lumpectomy with reduction mammoplasty we recommend not only orienting the lumpectomy specimen but also leaving clips or other marking suture at the tumor bed on both the flap and the pedicle (Fig. 2). Placing these markers allows the surgeon to reopen the flaps and re-excise the tumor bed for clear margins if indicated. If marks are not
placed, then it is difficult to later reconstruct the tumor bed and confidently remove tissue for clear margins. An unmarked tumor bed may commit the patient to a completion mastectomy or repeat excision of a wide area resulting in asymmetry. This is emotionally difficult for the patient because most are very happy with the reduction result. The incidence of synchronous tumors in our series was low at 5.5%. The incidence of invasive malignancy found in
Fig. 2. (A) Location of a tumor in relation to Wise pattern for reduction mammoplasty. (B) Surgical clips to be placed on pedicle and flap at points closest to tumor. (C) Final position of surgical clips marking tumor bed.
650
E. Chang et al. / The American Journal of Surgery 187 (2004) 647– 651
tissue from contralateral prophylactic mastectomy specimens is reported at 5% in the literature [8]. In situ disease, most often lobular carcinoma in situ, was noted in 8% to 51% of contralateral prophylactic mastectomy specimens [9]. Unfortunately, unexpected cancer in the contralateral breast resulted in need for completion mastectomy in 1 patient in our series. After this occurred, we began to orient the tissue removed from the unaffected side. This allows the pathologist to give information on tumor location and more accurate margin determination. The surgeon can then reopen the flaps and excise the flap and pedicle on the side from which tumor was located. We were successfully able to do that in 1 case and avoided completion mastectomy. We re-excised the entire medial portion of the flap and pedicle, and fortunately this did not affect the cosmetic outcome. These patients still require adjuvant radiation therapy. They are not candidates for the newer brachytherapy options and should undergo 6 weeks of traditional externalbeam therapy. After reduction mammoplasty, the new, smaller breast receives a more homogeneous radiation treatment. There is then far less incidence of radiation fibrosis or acute skin toxicity for these women than had they not undergone reduction mammoplasty. Although traditionally a boost is given to the tumor bed, it is not necessary in this setting. The tumor bed margins may not be opposing when the flaps are closed. There is also no cavity or seroma to localize as is the case with standard lumpectomy. On survey, ⬎50% of respondents had some change in cosmetic result after radiation therapy, but this did not negatively impact their satisfaction with their overall result. One of the complications noted with this technique was development of fat necrosis. At follow-up it can be difficult to discern between fat necrosis and tumor recurrence. Six of our patients (16%) developed this complication. Two had surgical removal of the area. One underwent core-needle biopsy to confirm a diagnosis of fat necrosis. If an area of fat necrosis is noted before radiation therapy is initiated, we would recommend excising it before proceeding with radiotherapy. For patients with significant macromastia, reduction mammoplasty may offer the best treatment outcome and superior quality of life. It should be strongly considered in this subgroup of patients. Again, standard indications for breast-conservation therapy should be maintained. Although it requires more presurgical planning and intraoperative mapping, reduction mammoplasty leads to better overall results and satisfaction in patients with extremely large breasts.
References [1] Edlund T, Gannett D. A single isocenter technique using CT based planning in the treatment of breast cancer. Med Dosim 1999;24:239 – 245.
[2] Cross MA, Elson HR, Aron BS. Breast conservation radiation therapy technique for women with large breasts. Int J Radiat Oncol Biol Phys 1989;17:199 –203. [3] Moody AM, Mayles WPM, Bliss JM, et al. The influence of breast size on late radiation effects and association with radiotherapy dose inhomogeneity. Radiother Oncol 1994;33:106 –112. [4] Bouvet M, Singletary SE, Ames F, et al. Combined breast conserving surgery and bilateral reduction mammoplasty facilitates postoperative radiotherapy and improves cosmesis in patients with early stage breast cancer and large pendulous breast. Breast Dis 1996;7:236 – 8. [5] Newman LA, Kuerer HM, McNeese MD, et al. Reduction mammoplasty improves breast conservation therapy in patients with macromastia. Am J Surg 2001;181:215–220. [6] Newman LA, Washington TA. New trends in breast conservation therapy. Surg Clin North Am 2003;83:841– 83. [7] Spear SL, Pelletiere CV, Wolfe AJ, et al. Experience with reduction mammoplasty combined with breast conservation therapy in the treatment of breast cancer. Plast Reconstr Surg 2003;111:1102–1109. [8] Beller FK, Nienhaus H, Niedner W, et al. Bilateral breast cancer: the frequency of undiagnosed cancers. Am J Obstet Gynecol 1986;155: 247–255. [9] Hoffman E. The contralateral breast in ipsilateral breast carcinoma. South Med J 1990;83:1009 –1015.
Commentary Emilia Dauway-Williams, M.D. (Seattle, WA): Treatment planning for breast carcinoma has become more challenging, and breast conservation is the preferred treatment for early-stage breast cancers. Several factors—including breast size, tumor size, tumor location, and the role for adjuvant therapy—are considered when evaluating a patient for surgical options. This study reviews factors specific for women with macromastia. Although breast conservation can be easily achieved with negative margins in this population of women, several studies have demonstrated an increased risk of radiation fibrosis thought to be secondary to dose-inhomogeneity. Bilateral reduction mammoplasty (BRM) and concurrent lumpectomy, also known as “oncoplastic surgery,” would be an optimal treatment option for this subgroup of patients. In a retrospective chart review involving 37 patients, these investigators discuss their experience with BRM and concurrent lumpectomy. In 1959, Snyderman and Lizardo (Plast Reconstr Surg 1960;25:253– 6.), in the largest study to date, examined the incidence of occult malignancy identified from reduction mammoplasty. They reported an incidence of 0.38%, and a more recent review by Jansen et al (Plast Reconst Surg 1998;110:361– 4) reported 0.16%. The incidence of occult malignancy in prophylactic mastectomy is approximately 5%. The present study had 1 of 7 patients with occult malignancy identified in the contralateral breast. Did this patient require nodal evaluation, and—if so—was sentinel lymph node biopsy or axillary node dissection performed? Did the investigators believe that reduction mammoplasty dissection could potentially alter lymphatic drainage patterns, thereby making lymphatic mapping and sentinel node biopsy difficult and possibly inaccurate? Furthermore, 2 of the 37 patients required completion
E. Chang et al. / The American Journal of Surgery 187 (2004) 647– 651
mastectomy because there was no orientation of the specimen or placement of markers. The incidence of occult malignancy detected with reduction mammoplasty is low, but it increases in patients with breast cancer. Because it is customary not to orient the specimen or to place markers in the unaffected breast, would the investigators now recommend that all surgeons performing reduction mammoplasty
651
for patients with a known breast cancer or a history of breast cancer perform tissue orientation and place markers? Last, this study mentions breast magnetic resonance imaging as a method of determining extent of disease. What criteria are used to select patients for breast magnetic resonance imaging before reduction mammoplasty with lumpectomy in the unaffected breast is undertaken?
Scientific paper
Bilateral reduction mammoplasty in combination with lumpectomy for treatment of breast cancer in patients with macromastia Eugene Chang, M.D.b, Nathalie Johnson, M.D.a,c,*, Bruce Webber, M.D.c, James Booth, M.D.c, Dina Rahhal, M.D.b, David Gannett, M.D.c, William Johnson, M.D.a,c, Daisy Franzini, M.D.a, Henry Zegzula, M.D.a a
Legacy Cancer Services, Portland, OR, USA Oregon Health and Science University, Portland, OR, USA c Providence St. Vincent’s Medical Center, Portland, OR, USA b
Manuscript received December 11, 2003; revised manuscript January 18, 2004 Presented at the 90th Annual Meeting of the North Pacific Surgical Association, Portland, Oregon, November 14 –15, 2003
Abstract Background: Bilateral reduction mammoplasty has been described as a surgical option for treatment of breast cancer in women with large, pendulous breasts. Using this technique can provide unique surgical oncologic challenges. Methods: Retrospective chart review. Results: Thirty-seven patients were identified. The average weight of tissue removed was 653 g. Tumor size ranged from 0.6 to 5.2 cm. One patient had microscopically positive surgical margins on final pathology. The tumor bed was not marked, and completion mastectomy was required. Two patients had unexpected malignancy in the contralateral breast. One patient required completion mastectomy for positive nonoriented margins. In another patient, tissue from the contralateral side was oriented, and mastectomy was avoided. Conclusions: Bilateral reduction mammoplasty with lumpectomy is an ideal option in women with macromastia. We recommend marking the tumor bed on the flaps and pedicle as well as orienting tissue removed from the contralateral side as maneuvers that will decrease need for completion mastectomy. © 2004 Excerpta Medica, Inc. All rights reserved. Keywords: Breast cancer; Macromastia; Reduction mammoplasty
Therapeutic management of breast malignancy in women with large, pendulous breasts poses a significant challenge for both surgeons and radiation oncologists. The conventional options of mastectomy or breast-conservation therapy each have drawbacks in women with macromastia. A unilateral mastectomy in a woman with very large breasts produces unacceptable and uncomfortable asymmetry. Reconstruction is onerous and often requires a reduction mammoplasty on the contralateral side to achieve symmetry. Although patients with large breasts tolerate partial mastectomy with minimal impact in symmetry, such breasts pose difficulties for the radiation oncologist [1,2]. Radiation treatment is as efficacious in large breasts as it is in small
breasts, but dose-homogeneity is far more difficult to achieve in large breasts [3]. It is quite common to have “hot spots” or areas in the breast that receive 10% to 15% more dose. Radiation fibrosis, chronic pain, and poor cosmesis often result [4]. Reduction mammoplasty can play a significant role in this special subgroup. Reduction offers a way to perform lumpectomy and get smaller, symmetrical breasts that more easily tolerate radiation. We have learned that applying this procedure in the realm of oncology can lead to occasional challenges. We review our experience here.
* Corresponding author. Tel.: ⫹1-503-229-7339; fax: ⫹1-503-2297938. E-mail address: [email protected]
A retrospective review of the charts and pathology of patients treated by bilateral reduction mammoplasty (BRM) and lumpectomy in community surgical practices between
Methods
0002-9610/04/$ – see front matter © 2004 Excerpta Medica, Inc. All rights reserved. doi:10.1016/j.amjsurg.2004.01.002
648
E. Chang et al. / The American Journal of Surgery 187 (2004) 647– 651
1998 and 2003 was performed. Standard criteria were maintained in selecting patients for breast-conservation therapy. For nonpalpable lesions, needle localization and dye injection was carried out before surgery. Patients undergoing sentinel lymph node biopsy received a preoperative injection of radionuclide tracer and an intraoperative injection of lymphazurin blue dye. Initial exposure and flap development was made through a Wise-pattern incision performed by the plastic surgeon, and the tumor was removed as part of the reduction mammoplasty specimen. This portion of the procedure was performed in combination by both the general surgeon and the plastic surgeon. Treatment of axillary lymph nodes was carried out through the mammoplasty incision or through a separate axillary incision. Specimens were submitted for gross review intraoperatively and, subsequently, permanent histology. A secondary pathologic review was performed to confirm margins for the purpose of this report. In all except 1 patient, both breasts underwent reduction mammoplasty in a single operation. Separate instruments were used when operating on the contralateral breast. All patients underwent postoperative radiation therapy. Adjuvant chemotherapy was given as appropriate for stage of disease. Patients were followed-up clinically and surveyed regarding their satisfaction with results.
was found in the “unaffected” breast specimen. However, in this case the tissue had been oriented. This made it possible to identify the region where the tumor was located. She underwent a re-excision of the flap and pedicle in the area of the tumor. Residual tumor was removed with clear margins. Despite removal of additional tissue from both the flap and pedicle, we were able to maintain a cosmetically pleasing breast. On follow-up, 6 patients developed fat necrosis. These firm areas were excised or underwent core-needle biopsy to rule out recurrence. One patient developed lymphedema of the ipsilateral side. One patient required a revision for “dogears” involving the incision. Twenty of 37 patients responded to the satisfaction survey. Fourteen of 20 rated their cosmetic result as excellent (rating 5 on a scale of 5) even though 55% (11 of 20) said there was a change in the cosmetic result after radiation therapy. Patients expressed a high degree of satisfaction with the functional and cosmetic result of the reduction mammoplasty. All 20 (100%) stated that they would choose BRM over mastectomy or lumpectomy if they had to make this decision again. To date, no recurrences have been detected.
Comments Results Thirty-seven patients underwent partial mastectomy and BRM. Age ranged from 34 to 77 years (average 52). Seventeen women had palpable lesions. The types of tumors included infiltrating ductal carcinoma (n ⫽ 29), infiltrating lobular carcinoma (n ⫽ 2), ductal carcinoma in-situ (n ⫽ 2), and colloid carcinoma (n ⫽ 2).Tumor size ranged from 0.6 to 5.2 cm. Weight of tissue removed ranged from 144 to 1924 g (average 653 g/breast). One patient had a positive margin. The remainder of margins ranged from 0.25 mm to 5.0 cm. All lumpectomy specimens were marked for margins, and immediate gross examination was performed. Unexpected malignancy was encountered in the contralateral breast in 2 patients. Two patients required completion mastectomies. One patient was found to have positive margins on microscopic review of the lumpectomy/reduction mammoplasty specimen. This patient had a 2.5-cm infiltrating ductal carcinoma with extensive ductal carcinoma in situ. The tumor bed on the flap and pedicle had not been marked. She required a completion mastectomy. The mastectomy specimen showed no residual tumor. In the second patient, unexpected malignancy was discovered in the contralateral breast. As is customary, the tissue from the “unaffected side” was unmarked and unoriented. Margins were unclear, and she underwent completion mastectomy. No residual tumor was found in the mastectomy specimen. In another patient, unexpected contralateral malignancy
Breast-conservation therapy with BRM is an ideal option for the treatment of breast cancer in women with macromastia (Fig. 1). The procedure results in symmetric breast with a high degree of satisfaction. Newman et al [5,6] described the successful use of this procedure in 28 patients with large breasts. Spear et al [7]reported on their series of 11 patients with macromastia in whom reduction mammoplasty after partial mastectomy was performed for breast cancer. They experienced good treatment outcomes and high patient satisfaction. We also found this procedure to be quite advantageous. However, in reviewing our experience we learned that there are some clinical caveats to using reduction mammoplasty in the setting of cancer management. Persistent attention to detail and cooperation between the plastic and general surgeon will lead to better outcomes and decrease the risk of need for completion mastectomy. Standard indications and contraindications for lumpectomy should be maintained. Multicentric tumors, significant multifocal disease, and extensive ductal carcinoma in situ are relative contraindications. Any one of these findings is more likely to result in failure to clear margins, which may result in need for completion mastectomy. Similar to our experience, 1 patient in the study by Newman et al [5] required completion mastectomy for positive margins. Breast magnetic resonance imaging can often help to elucidate the extent of disease in this setting and may be helpful in treatment planning and patient counseling. If appropriate, neoadjuvant chemotherapy may be used to attempt breast conservation as we do for the normal-sized breast.
E. Chang et al. / The American Journal of Surgery 187 (2004) 647– 651
649
Fig. 1. (A) Wise pattern for reduction mammoplasty. (B) Needle localization of tumor. (C) Reduction mammoplasty specimen. (D) Postoperative results.
Traditionally, when performing lumpectomy we mark and orient the specimen to delineate margins. When combining lumpectomy with reduction mammoplasty we recommend not only orienting the lumpectomy specimen but also leaving clips or other marking suture at the tumor bed on both the flap and the pedicle (Fig. 2). Placing these markers allows the surgeon to reopen the flaps and re-excise the tumor bed for clear margins if indicated. If marks are not
placed, then it is difficult to later reconstruct the tumor bed and confidently remove tissue for clear margins. An unmarked tumor bed may commit the patient to a completion mastectomy or repeat excision of a wide area resulting in asymmetry. This is emotionally difficult for the patient because most are very happy with the reduction result. The incidence of synchronous tumors in our series was low at 5.5%. The incidence of invasive malignancy found in
Fig. 2. (A) Location of a tumor in relation to Wise pattern for reduction mammoplasty. (B) Surgical clips to be placed on pedicle and flap at points closest to tumor. (C) Final position of surgical clips marking tumor bed.
650
E. Chang et al. / The American Journal of Surgery 187 (2004) 647– 651
tissue from contralateral prophylactic mastectomy specimens is reported at 5% in the literature [8]. In situ disease, most often lobular carcinoma in situ, was noted in 8% to 51% of contralateral prophylactic mastectomy specimens [9]. Unfortunately, unexpected cancer in the contralateral breast resulted in need for completion mastectomy in 1 patient in our series. After this occurred, we began to orient the tissue removed from the unaffected side. This allows the pathologist to give information on tumor location and more accurate margin determination. The surgeon can then reopen the flaps and excise the flap and pedicle on the side from which tumor was located. We were successfully able to do that in 1 case and avoided completion mastectomy. We re-excised the entire medial portion of the flap and pedicle, and fortunately this did not affect the cosmetic outcome. These patients still require adjuvant radiation therapy. They are not candidates for the newer brachytherapy options and should undergo 6 weeks of traditional externalbeam therapy. After reduction mammoplasty, the new, smaller breast receives a more homogeneous radiation treatment. There is then far less incidence of radiation fibrosis or acute skin toxicity for these women than had they not undergone reduction mammoplasty. Although traditionally a boost is given to the tumor bed, it is not necessary in this setting. The tumor bed margins may not be opposing when the flaps are closed. There is also no cavity or seroma to localize as is the case with standard lumpectomy. On survey, ⬎50% of respondents had some change in cosmetic result after radiation therapy, but this did not negatively impact their satisfaction with their overall result. One of the complications noted with this technique was development of fat necrosis. At follow-up it can be difficult to discern between fat necrosis and tumor recurrence. Six of our patients (16%) developed this complication. Two had surgical removal of the area. One underwent core-needle biopsy to confirm a diagnosis of fat necrosis. If an area of fat necrosis is noted before radiation therapy is initiated, we would recommend excising it before proceeding with radiotherapy. For patients with significant macromastia, reduction mammoplasty may offer the best treatment outcome and superior quality of life. It should be strongly considered in this subgroup of patients. Again, standard indications for breast-conservation therapy should be maintained. Although it requires more presurgical planning and intraoperative mapping, reduction mammoplasty leads to better overall results and satisfaction in patients with extremely large breasts.
References [1] Edlund T, Gannett D. A single isocenter technique using CT based planning in the treatment of breast cancer. Med Dosim 1999;24:239 – 245.
[2] Cross MA, Elson HR, Aron BS. Breast conservation radiation therapy technique for women with large breasts. Int J Radiat Oncol Biol Phys 1989;17:199 –203. [3] Moody AM, Mayles WPM, Bliss JM, et al. The influence of breast size on late radiation effects and association with radiotherapy dose inhomogeneity. Radiother Oncol 1994;33:106 –112. [4] Bouvet M, Singletary SE, Ames F, et al. Combined breast conserving surgery and bilateral reduction mammoplasty facilitates postoperative radiotherapy and improves cosmesis in patients with early stage breast cancer and large pendulous breast. Breast Dis 1996;7:236 – 8. [5] Newman LA, Kuerer HM, McNeese MD, et al. Reduction mammoplasty improves breast conservation therapy in patients with macromastia. Am J Surg 2001;181:215–220. [6] Newman LA, Washington TA. New trends in breast conservation therapy. Surg Clin North Am 2003;83:841– 83. [7] Spear SL, Pelletiere CV, Wolfe AJ, et al. Experience with reduction mammoplasty combined with breast conservation therapy in the treatment of breast cancer. Plast Reconstr Surg 2003;111:1102–1109. [8] Beller FK, Nienhaus H, Niedner W, et al. Bilateral breast cancer: the frequency of undiagnosed cancers. Am J Obstet Gynecol 1986;155: 247–255. [9] Hoffman E. The contralateral breast in ipsilateral breast carcinoma. South Med J 1990;83:1009 –1015.
Commentary Emilia Dauway-Williams, M.D. (Seattle, WA): Treatment planning for breast carcinoma has become more challenging, and breast conservation is the preferred treatment for early-stage breast cancers. Several factors—including breast size, tumor size, tumor location, and the role for adjuvant therapy—are considered when evaluating a patient for surgical options. This study reviews factors specific for women with macromastia. Although breast conservation can be easily achieved with negative margins in this population of women, several studies have demonstrated an increased risk of radiation fibrosis thought to be secondary to dose-inhomogeneity. Bilateral reduction mammoplasty (BRM) and concurrent lumpectomy, also known as “oncoplastic surgery,” would be an optimal treatment option for this subgroup of patients. In a retrospective chart review involving 37 patients, these investigators discuss their experience with BRM and concurrent lumpectomy. In 1959, Snyderman and Lizardo (Plast Reconstr Surg 1960;25:253– 6.), in the largest study to date, examined the incidence of occult malignancy identified from reduction mammoplasty. They reported an incidence of 0.38%, and a more recent review by Jansen et al (Plast Reconst Surg 1998;110:361– 4) reported 0.16%. The incidence of occult malignancy in prophylactic mastectomy is approximately 5%. The present study had 1 of 7 patients with occult malignancy identified in the contralateral breast. Did this patient require nodal evaluation, and—if so—was sentinel lymph node biopsy or axillary node dissection performed? Did the investigators believe that reduction mammoplasty dissection could potentially alter lymphatic drainage patterns, thereby making lymphatic mapping and sentinel node biopsy difficult and possibly inaccurate? Furthermore, 2 of the 37 patients required completion
E. Chang et al. / The American Journal of Surgery 187 (2004) 647– 651
mastectomy because there was no orientation of the specimen or placement of markers. The incidence of occult malignancy detected with reduction mammoplasty is low, but it increases in patients with breast cancer. Because it is customary not to orient the specimen or to place markers in the unaffected breast, would the investigators now recommend that all surgeons performing reduction mammoplasty
651
for patients with a known breast cancer or a history of breast cancer perform tissue orientation and place markers? Last, this study mentions breast magnetic resonance imaging as a method of determining extent of disease. What criteria are used to select patients for breast magnetic resonance imaging before reduction mammoplasty with lumpectomy in the unaffected breast is undertaken?