Breast Reconstruction in Women Under 30: A 10-Year Experience

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1 ORIGINAL ARTICLE Breast Reconstruction in Women Under 30: A 10-Year Experience Warren A. Ellsworth, MD,* Barbara L. Bass, MD, FACS, Roman J. Skoracki, MD, à and Lior Heller, MD* *Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Clinical Care Center, Houston, Texas; Department of Surgery, The Methodist Hospital, Weill Cornell Medical College, Houston, Texas; and à Department of Plastic Surgery, The University of Texas M.D. Anderson Cancer Center, Houston, Texas n Abstract: The number of women diagnosed with breast cancer at a young age ( 30 years) continues to rise. As young women present for breast cancer management with greater frequency, an accurate characterization of the differences in cancer treatments and reconstruction techniques is imperative to optimize care. Here, we sought to identify the reconstruction trends in this population of women 30 years at time of breast cancer diagnosis. We retrospectively reviewed the charts of women aged 30 years who underwent breast reconstruction at The University of Texas M.D. Anderson Cancer Center. We extracted data on the patients diagnosis, adjuvant therapy, reconstructive choice, reason for reconstructive choice, and decision for contralateral prophylactic mastectomy (CPM). Over a 10-year period, 54 patients aged 30 years underwent 77 breast reconstructions, including 30 microsurgical autologous tissue reconstructions and 34 tissue expanderbased reconstructions. Donor site limitations, including insufficient abdominal tissue, restricted the number of patients eligible for abdominal based reconstruction despite the patients interest in the latter. The rate of CPM was 43%, which was significantly higher than the national average of 8%, further complicating the possibility of total autologous reconstruction. Because of the high rate of bilateral mastectomy and innate donor tissue limitations, young, healthy women who are otherwise ideal candidates for free tissue transfer using the abdominal donor site undergo significantly more tissue expander reconstructions than expected. Implant-based reconstruction or donor sites other than the abdomen must be considered in this unique population. n Key Words: breast cancer, breast reconstruction, breast reconstruction in young women, young women with breast cancer While breast cancer is rare in women under 30 years of age, comprising <2% of all patients with the disease (1), it remains the leading type of cancer and cause of cancer death in women ages years (2). Young women have different physiologic and psychologic characteristics than older women necessitating different therapeutic approaches for management of the primary tumor and reconstructive strategies after mastectomy. Young women have a more youthful breast structure and are generally in better health than older women. Thus, young women may consider the full spectrum of reconstructive Address correspondence and reprint requests to: Lior Heller, MD, Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Clinical Care Center 6701 Fannin, CC Houston, TX 77030, USA, or lheller@bcm.edu. DOI: /j x Ó 2010 Wiley Periodicals, Inc., X/10 The Breast Journal, Volume 17 Number 1, options, including complex surgical procedures such as autologous reconstruction with free tissue transfer. However, various factors can influence a young woman s decision about reconstructive techniques, such as finding a life partner, planning a family, beginning a career, or having a highly active lifestyle. Similarly, young women are more informed by long-term lifetime risks of recurrent or metachronous development of breast cancer. Consequently, these women are often more willing to seek total mastectomy in lieu of breast-conserving therapy as a more definitive risk reduction strategy. These factors make surgical decision-making challenging for these patients. As young patients present for breast cancer management with greater frequency, an accurate characterization of the differences in the treatment and reconstructive options is critical to optimize care. The objective of our study was to review the trends in reconstruction of women below 30 years of age

2 Breast Reconstruction in Women Under 30: A 10-Year Experience 19 who underwent mastectomy followed by breast reconstruction. We were particularly interested in the type of reconstruction this population selected, whether autologous tissue or implant-based. In addition, we sought to identify the factors impacting their reconstructive choice and evaluate the relevance of these findings with respect to contemporary breast reconstruction in young women. METHODS The authors conducted a retrospective review of breast cancer patients who underwent surgery at The University of Texas M.D. Anderson Cancer Center (MDACC) from 1997 to Of all patients treated for breast cancer, 54 women were 30 years of age at diagnosis and underwent mastectomy followed by breast reconstruction. The charts of these identified patients were reviewed for demographic data including age and body mass index (BMI); cancer stage; adjuvant therapy; patient input into the reconstruction method selected; surgical reasoning behind the reconstruction choice; and details of reconstructive surgery. At the initial plastic surgery consultation, all patients had been questioned regarding preferred reconstructive modality, autologous or implant based, and we compared the ultimate reconstructive technique chosen with the patient s initial preference. Outcomes and complications were extracted from the patient s chart. RESULTS Patients From 1997 to 2007, 9,460 women underwent surgery for breast cancer at MDACC. Of these, 140 patients were aged 30 years at the time of diagnosis and were treated with either mastectomy or breast conservation therapy. Ultimately, 54 of these 140 women who were aged 30 years at diagnosis had undergone both mastectomy and breast reconstruction; the charts of these women were identified and reviewed. The patients ages ranged from 18 to 30 years, with a mean age of 28 years. The mean BMI of these women was Most women had either stage I or stage II disease (Table 1) and all patients were diagnosed with unilateral breast cancer. Unfortunately, genetic testing for susceptibility genes such as BRCA 1 and BRCA 2 was not consistently available and therefore was not considered. Twenty-three of the 54 patients (43%) Table 1. Breast Cancer Stage Disease stage Number of patients aged 30 years treated with mastectomy (%) Number of patients aged 30 years treated with BCT (%) 0 11 (20) 9 (10) I 9 (17) 23 (27) IIA 11 (20) 34 (40) IIB 15 (28) 0 IIIA 7 (13) 18 (21) IIIB 0 0 IIIC 1 (2) 0 IV 0 2 (2) chose to undergo contralateral prophylactic mastectomy (CPM), with a total of 77 breasts reconstructed. Reconstruction Techniques Twenty-four patients underwent 30 autologous microsurgical reconstructions (Table 2); the most commonly used free flap was the transverse rectus abdominus myocutaneous (TRAM) flap or one of its derivatives (muscle sparing TRAM, deep inferior epigastric artery perforator flap). The superior gluteal artery perforator flap (SGAP) was utilized in a single case. Three patients underwent three pedicled TRAM flap reconstructions, and seven patients underwent 10 pedicled latissimus dorsi (LD) myocutaneous flap reconstructions with implants. The remaining 22 patients underwent 34 tissue expander (TE)-based reconstructions. The choice of reconstructive technique was made in coordination with the patient desires and the attending surgeon assessment. Seventeen of the 22 women who underwent TE-based reconstruction (77%) initially expressed preference for autologous reconstruction Table 2. Reconstruction Methods Reconstruction technique Number of reconstructions Number of patients* All free TRAM flaps Free TRAM mstram 8 6 DIEP 4 4 Pedicle TRAM 3 3 Latissimus dorsi implant 10 7 Tissue expander implant SGAP 1 1 TRAM, transverse rectus abdominus myocutaneous flap; mstram, muscle-sparing transverse rectus abdominus myocutaneous flap; DIEP, deep inferior epigastric artery perforator flap; SGAP, superior gluteal artery perforator flap. *Total number of patients is 56 as two patients fall into two different categories. The total number of reconstructions remains 77.

3 20 ellsworth et al. using the abdomen. However, these women had BMIs that were considered too low for abdominally based reconstruction. The seven women treated with LD implant reconstruction uniformly were more interested in complete autologous reconstruction using the abdomen, but these women were also too thin and deemed inappropriate candidates for TRAM procedures by the attending surgeon due to the lack of abdominal tissue. Within the study population, the average BMI of patients who underwent autologous reconstruction was 26.8 compared to an average BMI of 20.9 for the women who underwent implant-based reconstruction (Table 3). A total of 4,215 women aged >30 years underwent breast reconstruction at MDACC during the 10-year period reviewed. For comparison, the reconstructive techniques were reviewed and found to be similar: 47% of women were reconstructed with autologous tissue using the abdomen, either pedicle or free TRAM; 45% of women were treated with TE-based reconstruction, and the remainder with LD or other flaps. The average BMI for this population, however, was significantly higher (29.4) compared to the women 30 years (25.2). An increasing trend toward abdominally based microvascular reconstruction was noted in the women >30 years of age as the 10-year period progressed. Of the women in our study group, 43 patients (80%) underwent immediate breast reconstruction and 11 patients (20%) underwent delayed breast reconstruction (Table 4). Nine of the 11 patients (82%) who underwent delayed breast reconstruction were delayed due to planned post-mastectomy radiation therapy (PMRT). All patients who underwent delayed reconstruction had autologous tissue reconstructions. Thirty-eight women (70%) were treated with chemotherapy either before or after reconstruction, and 15 patients (28%) underwent PMRT (Table 4). Table 3. Patient Selection Criteria Autologous reconstruction Implant-based reconstruction Average age Average BMI Average preoperative cup size* C B BMI, body mass index. *Calculated by assigning value of 1 through 5 for cup sizes A through DD, respectively, followed by averaging the data. This mean was the same as the median value for the groups. Table 4. Treatment Modalities Treatment Number of patients (%) Immediate reconstruction 43 (80) Chemotherapy (pre or postoperative) 28 Pre-reconstruction radiation therapy 0 Post-reconstruction radiation therapy 6 Delayed reconstruction 11 (20) Chemotherapy (pre or postoperative) 10 Pre-reconstruction radiation therapy 9 Post-reconstruction radiation therapy 0 Outcomes and Complications The complications included four seromas and four wound-healing complications, including superficial dehiscence, which were treated successfully with local wound care. Two complications were seen in patients who underwent PMRT prior to delayed reconstruction with autologous tissue, and no complications were seen in the patients who underwent immediate reconstruction followed by PMRT. During a mean followup of 62 months (range: months), no hernia or bulging from the abdominal wall was noted. Twentytwo patients underwent reconstruction revision procedures; most of these were to improve symmetry and contour. Four women ultimately died of disease progression. Five patients became pregnant and delivered six healthy children (one set of twins) by standard vaginal delivery; three of these patients had undergone TRAM reconstruction, and two had undergone TE-based reconstruction. DISCUSSION To our knowledge, this is the first report on breast reconstruction procedures in very young women with breast cancer. These women have different physical and psychosocial considerations compared to the typical patient cohort with breast cancer. Issues specific to treatment and reconstruction in this population have not been previously explored. Our review reveals interesting differences in regards to the reconstructive strategy and outcomes between young and older women. Forty-two percent of our patients chose to undergo CPM, subsequently requiring bilateral breast reconstruction. Despite the fact that the rate of CPM has risen from 3% in 1998 to 8% in 2003 (3), our rate is very informative. Women with a personal history of breast cancer have a threefold to fourfold increased risk of developing contralateral

4 Breast Reconstruction in Women Under 30: A 10-Year Experience 21 breast cancer, and CPM is gaining popularity in these patients deemed at high risk for developing contralateral disease (4). Gao et al. (5) studied the incidence of contralateral breast cancer using the Surveillance, Epidemiology, and End Results (SEER) data base and found the actuarial incidence of developing contralateral cancer at 5, 10, 15, and 20 years to be 3%, 6.1%, 9.1%, and 12%, respectively. The SEER data base notes the average age at diagnosis of breast cancer as 61 years old. Clearly our young cohort does not have significant evidence on which to base their personal decisions. The reasons these patients chose prophylactic contralateral mastectomy are not known, but it presumably reflects their personal view that optimal risk reduction is achieved with mastectomy in lieu of surveillance. Younger women typically prioritize their physical appearance and tend to avoid the use of a prosthesis after mastectomy (6). Given that they are comparatively healthier and more comfortable with the notion of plastic surgery, this group seems to retain fewer fears of complications from reconstructive surgery (6,7). In some series, the choice of reconstructive surgery is impacted by the need to return to work or child care concerns (6,7). Medical comorbidities in older women increase the risks associated with prolonged general anesthesia and lengthy procedures such as free tissue transfer. Given the satisfactory outcomes observed in our patient cohort, one may conclude that young women with breast cancer are good candidates for free flap reconstruction using the abdomen. Most of the patients in our study reported being aware of the autologous tissue reconstruction techniques available, and many specifically requested use of the abdomen as the donor site. However, due to minimal donor tissue, abdominally based reconstruction was not an option for many of the patient s in our study. In fact, 77% of the patients who had an implant-based reconstruction did so because the abdominal wall could not provide enough tissue to create an appropriately sized breast to match the contralateral side or two breasts in the case of bilateral mastectomy. The high rate of CPM made the idea of reconstruction of both breasts using the abdomen even less plausible. This is not surprising given the fact that the mean BMI in our study population was 25.2, compared to a mean BMI of 29.4 in the general female population undergoing breast reconstruction at MDACC. While TE-based reconstruction can be the ideal option for women who prefer a fast recovery, our study suggests that TE reconstruction was often the procedure of choice instead due to limitations in donor tissue from the abdominal wall. Despite expressing a desire for autologous reconstruction, many women, especially those requiring bilateral reconstruction, underwent TE-based reconstruction, which often allows for symmetric reconstruction in these slender patients. However, TE reconstruction requires weekly expansions and a second stage surgery, which can be inconvenient. In fact, seven women in our study underwent LD implant reconstruction because they had insufficient abdominal tissue for TRAM flaps and preferred to avoid the weekly expansions required by TE-based reconstruction. Several factors impact the choice and timing of breast reconstruction. Immediate breast reconstruction is reserved for patients with stage I or II disease who are at low risk of requiring PMRT. The aesthetic outcomes of immediate reconstruction are superior to those of delayed reconstruction due to retention of the natural breast skin envelope. However, when PMRT is planned, delayed reconstruction with total autologous tissue remains the authors preference. Indeed, nine of the 11 delayed reconstructions in this study were delayed owing to planned PMRT. Over the past 10 years, indications for PMRT in patients with early stage breast cancer have increased as a consequence of Danish and Canadian trials (8,9). The threshold for aggressive therapy is often lowered in very young patients, as well. Autologous tissue reconstruction allows for replacement of irradiated skin and a more natural appearing, ptotic breast. Tissue expander-based reconstruction is avoided after radiation therapy because of the high risk of wound healing problems and capsular contracture, with its associated pain and physical deformity (10). Recent review from the same institution has found that transferring normal, nonirradiated tissue to the breast, even if to cover an implant, reduces the complication rate and the rate of reconstruction failure (10). When autologous tissue from the abdomen is scant, as seen in our cohort, the authors instead have used and recommend LD implant reconstruction or gluteal based reconstruction as the patient s tissue supply permits. In an effort to save the natural skin envelope in patients with stage II breast cancer who may or may not require PMRT, the authors also often use a delayed-immediate or delayed-delayed approach, as described by Kronowitz et al (11). This report demonstrates that multiple options must be available to optimally match the goals of breast

5 22 ellsworth et al. reconstruction with each patient s disease-based needs and personal desires. While all options for breast reconstruction were presented to each patient, it is possible that microsurgical autologous reconstruction was emphasized since all plastic surgeons at MDACC are trained in microsurgical techniques. Advances in this field and the popularity of perforator-based reconstruction techniques have led some informed patients to request deep inferior epigastric artery perforator (DIEP) flap procedure. The DIEP flap relies on perforators that can be meticulously dissected through the rectus abdominus in order to spare the muscle from loss or damage during free flap transfer. Rectus function is maintained, and perhaps most importantly, the strength and integrity of the abdominal wall is minimally violated. However, slender women with minimal abdominal tissue, such as many in this study, are often too thin to provide adequate donor tissue. Another perforator-based breast reconstruction technique includes the gluteal artery perforator (GAP) flap, based on either the superior or inferior gluteal arteries. This reconstructive choice moves fat and fascia from the buttock area to the breast, sparing gluteus muscle, and the incision can often be hidden under the underwear line to limit visible deformities. This procedure is a useful second-line option for patients who are not candidates for abdominal based reconstruction. In our study, one woman who was considered too thin for TRAM flap had enough buttock tissue for reconstruction using the GAP flap, demonstrating the occasional value of this approach as a primary reconstruction option. Others have reported the use of the transverse musculocutaneous gracilis flap from the internal thigh area (12); however, we have no personal experience with this technique. Another factor that sets many younger breast cancer patients apart from older breast cancer patients is a desire to have children in the future. In our study, three of the five patients who became pregnant after reconstruction had undergone TRAM flap reconstruction. Vaginal deliveries without abdominal wall complications were accomplished in all births. While the literature is limited to case reports of pregnancy after TRAM reconstruction (13), some might suggest that the complication rate including development of hernia is higher in this group. In our early follow-up, the women in this study did not develop hernia or abnormal bulging after child birth; however, a larger series or study is warranted to better elucidate the safety and complication rates associated with vaginal delivery after TRAM reconstruction. CONCLUSIONS Women <30 years of age who are diagnosed with breast cancer represent an unusual population seeking breast reconstruction. These patients choose CPM at a higher rate than the general breast cancer population and the choice to pursue breast reconstruction remains proportionally higher in this group. The lack of available donor tissue in many younger women may require patients to reconsider reconstructive choices despite initial preferences for total autologous reconstruction using the abdomen as the donor site. Very young women have a lower BMI than the average patient with breast cancer, and therefore undergo TE and LD reconstruction at higher rates. Other autologous donor sites, including the buttock and thigh should be considered in the appropriate patient. Additional studies to define the impact of reconstruction on child bearing, patient satisfaction and other quality-of-life measures are warranted. DISCLOSURES All authors attest that this manuscript is not being considered for publication in any other journal and will not subsequently be submitted for potential publication in another journal until a decision has been made by The Breast Journal, nor has it been published previously in any media. Further, all authors have no personal conflicts of interest. There has been no financial support for this research, including funding, equipment and drugs. REFERENCES 1. Ries LAG, Eisner MP, Kosary CL, et al. SEER Cancer Statistics Review, Bethesda, MD: National Cancer Institute, Perkins CI, Cohen R, Morris CR, et al. Cancer in California: Sacramento, CA: California Department of Health Services, Cancer Surveillance Section, Tuttle TM, Habermann EB, Grund EH, et al. Increasing use of contralateral prophylactic mastectomy for breast cancer patients: a trend toward more aggressive surgical treatment. J Clin Oncol 2007;25: Kollias J, Ellis IO, Elston CW, et al. Clinical and histological predictors of contralateral breast cancer. Eur J Surg Oncol 1999;25: Gao X, Fisher SG, Emami B. Risk of second primary cancer in the contralateral breast in women treated for early-stage breast

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