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Breast Cancer Local Recurrence After Mastectomy and TRAM Flap Reconstruction: Incidence and Treatment Options
junct diagnostic tool in evaluating the donor site for abdominal-wall laxity or hernia, particularly in symptomatic patients for whom physical examination is not definitive. D. W. Chang, MD
Breast Reconstruction Using the Entire Transverse Abdominal Adipocutaneous Flap Based on Unilateral Superficial or Deep Inferior Epigastric Vessels Ulusal BG, Cheng MH, Wei FC, et al Plast Reconstr Surg 117:1395-1406, 2006 The advantages of superficial epigastric lower abdominal flaps for breast reconstruction were first reported by Grotting and colleagues at the University of Alabama in 1991.1 The present study was a clinical demonstration that a unilateral superficial epigastric inferior abdominal flap would nourish the entire flap. This is not surprising, as anatomical studies including dye injections have shown that the superficial epigastric vessels are located paramedially and travel cephalad, anastomosing freely and widely below the umbilicus with the contralateral superficial epigastric vessels. The superficial vessels also communicate with the perforators from the deep inferior epigastric vessels. The venous return is vast and unidirectional into the deep epigastric system. The advantages of the superficial epigastric flap are tempered by noted limitations, including unavailability of the superficial system in 48% of the authors’ cases and variation in the size of the vessels. It is clear from the authors’ experience, as well as from other reports, that the superficial epigastric artery flap should be attempted only for larger vessels—preferably those with diameters larger than 2 mm—and not at all for vessels with diameters of 1 mm or less. L. O. Vasconez, MD
Reference 1. Grotting JC: The free abdominoplasty flap for immediate breast reconstruction. Ann Plast Surg 27:351-354, 1991.
Breast Cancer Local Recurrence After Mastectomy and TRAM Flap Reconstruction: Incidence and Treatment Options Howard MA, Polo K, Pusic AL, et al Plast Reconstr Surg 117:1381-1386, 2006 Led by Halstead in the late 1800s, surgeons defined the radical mastectomy technique, which included removal of as much skin as possible with subsequent skin grafting. The Halstead mastectomy technique prevailed for the next 70 years until 1948, when Patey and Dyson pioneered the concept of the modified radical mastectomy and McWhirter proposed the simple mastectomy.1 In 1971, the National Surgical Adjuvant Breast and Bowel Project implemented the B-04 randomized trial, which demonstrated equal survival between the Halstead radical mastectomy and the simple mastectomy with radiation.2 This finding opened the door to preserving more native breast skin. At about the same time, breast reconstruction entered the scene and was compared to standard mastectomy without reconstruction. Having a breast reconstructed after a modified radical mastectomy did not increase the local recurrence rate, nor did it prolong survival.3 To improve cosmesis, Toth and Lappert introduced the concept of a skin-sparing mastectomy in 1984, and this technique has since gained wide acceptance.4 Several studies since then have shown that the local recurrence rate at short-term follow-
up is equivalent to that of standard mastectomy with or without reconstruction.5 Because the survival rates for breast cancer are getting better and better, longer follow-up results are needed to determine true equivalence. That is where the current study comes into play. The authors reviewed their extensive experience with breast reconstruction over a 15-year period. During that time, they performed 3,206 breast reconstructions, of which 419 were transverse rectus abdominis musculocutaneous (TRAM) flap reconstructions. From this huge cohort, they were able to demonstrate a 3.8% local recurrence rate, which is comparable with other published rates. More importantly, they were able to outline treatment strategies for these recurrences, which for most patients entailed wide local excision without removal of the TRAM flap. Although not mentioned in the paper, the survival rate quoted probably reflects synchronous or future development of distant metastatic disease and not local recurrence per se. I applaud the authors for the tremendous amount of work involved in performing all of these reconstructions and for having the data available to concisely and succinctly report their conclusions. Long-term follow-up data for this operative procedure were needed to secure its position as an oncologically sound alternative to mastectomy as the operative choice for breast cancer. We have come a long way since the Halstead radical mastectomy! C. Laronga, MD
References 1. Wagner F: History of breast disease and its treatment, in Bland KI, Copeland EM (eds): The Breast. Philadelphia, WB Saunders, 1991, pp 1-16. 2. Fisher B, Wolmark N, Redmond C, et al: Findings from NSABP protocol no. B-04: Comparison of radical mastectomy with alternative treatments. II. The clinical and biologic significance of medial-central breast cancers. Cancer 48:1863-1872, 1981. 3. Slavin S, Love S, Goldwyn R: Recurrent breast cancer following immediate reconstruction with myocutaneous flaps. Plast Reconstr Surg 93:1191-1204, 1994. 4. Toth B, Lappert P: Modified skin incisions for mastectomy: The need for plastic surgical input in preoperative planning. Plast Reconstr Surg 87:1048-1053, 1991. 5. Laronga C, Kemp B, Johnston D, et al: The incidence of occult nipple-areola complex involvement in breast cancer patients receiving a skin-sparing mastectomy. Ann Surg Oncol 6:609-613, 1999.
Postmastectomy Lymphedema: Long-Term Results Following Microsurgical Lymph Node Transplantation Becker C, Assouad J, Riquet M, et al Ann Surg 243:313-315, 2006 In this study, the authors retrospectively reviewed their experience with 24 women with postmastectomy lymphedema treated with microvascular transfer of inguinal lymphatic tissue to the axilla. This technique is interesting, but this report did not confirm its safety or efficacy. The surgical technique was imprecisely described, particularly the donor site dissection. The results were not thoroughly or convincingly reported. An explanation of the physiology was lacking. Despite the apparent success in some of the patients, this procedure needs further study before being recommended for general application. M. J. Miller, MD
®
Breast Diseases: A Year Book Quarterly Vol 17 No 4 2007
411 411
Breast Reconstruction Using the Entire Transverse Abdominal Adipocutaneous Flap Based on Unilateral Superficial or Deep Inferior Epigastric Vessels Ulusal BG, Cheng MH, Wei FC, et al Plast Reconstr Surg 117:1395-1406, 2006 The advantages of superficial epigastric lower abdominal flaps for breast reconstruction were first reported by Grotting and colleagues at the University of Alabama in 1991.1 The present study was a clinical demonstration that a unilateral superficial epigastric inferior abdominal flap would nourish the entire flap. This is not surprising, as anatomical studies including dye injections have shown that the superficial epigastric vessels are located paramedially and travel cephalad, anastomosing freely and widely below the umbilicus with the contralateral superficial epigastric vessels. The superficial vessels also communicate with the perforators from the deep inferior epigastric vessels. The venous return is vast and unidirectional into the deep epigastric system. The advantages of the superficial epigastric flap are tempered by noted limitations, including unavailability of the superficial system in 48% of the authors’ cases and variation in the size of the vessels. It is clear from the authors’ experience, as well as from other reports, that the superficial epigastric artery flap should be attempted only for larger vessels—preferably those with diameters larger than 2 mm—and not at all for vessels with diameters of 1 mm or less. L. O. Vasconez, MD
Reference 1. Grotting JC: The free abdominoplasty flap for immediate breast reconstruction. Ann Plast Surg 27:351-354, 1991.
Breast Cancer Local Recurrence After Mastectomy and TRAM Flap Reconstruction: Incidence and Treatment Options Howard MA, Polo K, Pusic AL, et al Plast Reconstr Surg 117:1381-1386, 2006 Led by Halstead in the late 1800s, surgeons defined the radical mastectomy technique, which included removal of as much skin as possible with subsequent skin grafting. The Halstead mastectomy technique prevailed for the next 70 years until 1948, when Patey and Dyson pioneered the concept of the modified radical mastectomy and McWhirter proposed the simple mastectomy.1 In 1971, the National Surgical Adjuvant Breast and Bowel Project implemented the B-04 randomized trial, which demonstrated equal survival between the Halstead radical mastectomy and the simple mastectomy with radiation.2 This finding opened the door to preserving more native breast skin. At about the same time, breast reconstruction entered the scene and was compared to standard mastectomy without reconstruction. Having a breast reconstructed after a modified radical mastectomy did not increase the local recurrence rate, nor did it prolong survival.3 To improve cosmesis, Toth and Lappert introduced the concept of a skin-sparing mastectomy in 1984, and this technique has since gained wide acceptance.4 Several studies since then have shown that the local recurrence rate at short-term follow-
up is equivalent to that of standard mastectomy with or without reconstruction.5 Because the survival rates for breast cancer are getting better and better, longer follow-up results are needed to determine true equivalence. That is where the current study comes into play. The authors reviewed their extensive experience with breast reconstruction over a 15-year period. During that time, they performed 3,206 breast reconstructions, of which 419 were transverse rectus abdominis musculocutaneous (TRAM) flap reconstructions. From this huge cohort, they were able to demonstrate a 3.8% local recurrence rate, which is comparable with other published rates. More importantly, they were able to outline treatment strategies for these recurrences, which for most patients entailed wide local excision without removal of the TRAM flap. Although not mentioned in the paper, the survival rate quoted probably reflects synchronous or future development of distant metastatic disease and not local recurrence per se. I applaud the authors for the tremendous amount of work involved in performing all of these reconstructions and for having the data available to concisely and succinctly report their conclusions. Long-term follow-up data for this operative procedure were needed to secure its position as an oncologically sound alternative to mastectomy as the operative choice for breast cancer. We have come a long way since the Halstead radical mastectomy! C. Laronga, MD
References 1. Wagner F: History of breast disease and its treatment, in Bland KI, Copeland EM (eds): The Breast. Philadelphia, WB Saunders, 1991, pp 1-16. 2. Fisher B, Wolmark N, Redmond C, et al: Findings from NSABP protocol no. B-04: Comparison of radical mastectomy with alternative treatments. II. The clinical and biologic significance of medial-central breast cancers. Cancer 48:1863-1872, 1981. 3. Slavin S, Love S, Goldwyn R: Recurrent breast cancer following immediate reconstruction with myocutaneous flaps. Plast Reconstr Surg 93:1191-1204, 1994. 4. Toth B, Lappert P: Modified skin incisions for mastectomy: The need for plastic surgical input in preoperative planning. Plast Reconstr Surg 87:1048-1053, 1991. 5. Laronga C, Kemp B, Johnston D, et al: The incidence of occult nipple-areola complex involvement in breast cancer patients receiving a skin-sparing mastectomy. Ann Surg Oncol 6:609-613, 1999.
Postmastectomy Lymphedema: Long-Term Results Following Microsurgical Lymph Node Transplantation Becker C, Assouad J, Riquet M, et al Ann Surg 243:313-315, 2006 In this study, the authors retrospectively reviewed their experience with 24 women with postmastectomy lymphedema treated with microvascular transfer of inguinal lymphatic tissue to the axilla. This technique is interesting, but this report did not confirm its safety or efficacy. The surgical technique was imprecisely described, particularly the donor site dissection. The results were not thoroughly or convincingly reported. An explanation of the physiology was lacking. Despite the apparent success in some of the patients, this procedure needs further study before being recommended for general application. M. J. Miller, MD
®
Breast Diseases: A Year Book Quarterly Vol 17 No 4 2007
411 411