Contralateral Prophylactic Mastectomy with Immediate Reconstruction: Added Benefits, Added Risks Grant W. Carlson Wadley R. Glenn Professor of Surgery Divisions of Plastic Surgery & Surgical Oncology Emory University School of Medicine
Disclosures: None
Outline Predictors of contralateral prophylactic mastectomy () Potential benefits of Oncological Reconstructive Patient satisfaction Morbidity
Analysis of Prophylactic Mastectomy Immediate Reconstruction Variable n=174 (%) No n=272 (%) p value Age 50.4 56.8 <0.001 Body mass index 26.1 27.4 0.04 White Race 151 (86.8) 200 (73.8) 0.004 Family history 90 (52) 90 (33.3) <0.001 Personal history 18 (10.3) 37 (13.6) 0.31 Preoperative MRI 98 (56.3) 106 (39) <0.001 BCT attempted 12 (6.9) 43 (15.8) 0.004 Pinell-White et al. Ann Plastic Surg 2014
Analysis of Prophylactic Mastectomy Variable n=174 (%) No n=272 (%) p value Histology DCIS 39 (22.4) 66 (24.3) 0.653 Ductal 107 (61.5) 171 (62.9) 0.770 Lobular 24 (13.8) 32 (11.8) 0.528 Stage 0 36 (20.7) 64 (23.5) 0.483 I 54 (31) 62 (22.8) 0.053 III 30 (17.2) 56 (20.6) 0.382
Contralateral Prophylactic Mastectomy Variable Odds ratio Confidence Interval P value Age 0.95 0.93-0.97 <0.001 Race White 1.00 Reference Black 0.35 0.19-0.65 0.001 Other 0.36 0.11-1.21 0.097 Pinell-White et al. Ann Plastic Surg 2014
Contralateral Prophylactic Mastectomy Variable Family history Odds ratio Confidence Interval P value First degree relative 2.96 1.72-5.10 <0.001 Second degree relative 1.80 1.06-3.06 0.03 Preoperative MRI 1.89 1.23-2.91 0.004 BCT attempted 0.35 0.17-0.74 0.006 Pinell-White et al. Ann Plastic Surg 2014
Contralateral Prophylactic Mastectomy Potential Oncological Benefits does not eliminate the risk of contralateral breast cancer and does not markedly improve survival rates In young women (less 49 years) with early stage ERtumors only a small survival benefit Fear of recurrence and avoidance of radiation are cited as major reasons choosing TM and May alleviate patient s anxiety and limit future diagnostic imaging / biopsies
Contralateral Prophylactic Mastectomy Pathological Findings Benign 82.2% Incidental contralateral breast cancer 7 (4%) DCIS 4 Invasive ductal cancer 3 High risk pathology 24 (13.9%) Lobular carcinoma in situ 4 Atypical ductal hyperplasia 11 Atypical lobular hyperplasia 9
Contralateral Prophylactic Mastectomy 70% 60% 50% 40% 30% 20% 10% 0% 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Pinell-White et al. Ann Plastic Surg 2014
Reconstructive Methods 80% 70% 60% 50% 40% 30% Expander/Implant Latissimus TRAM 20% 10% 0% 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Pinell-White et al. Ann Plastic Surg 2014
Reconstructive Methods 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 7.5% 7.7% 15.5% 38.6% 60.9% * 17.3% 36.4% 16.1% No Latissimus dorsi TRAM Expander/Implant No reconstruction * p<0.001 Pinell-White et al. Ann Plastic Surg 2014
Aesthetic Satisfaction Impact of Time From Reconstruction Appearance Shape Softness Size Projection Breast Q 110 109 Hu et al. Plast Reconstr Surg 124: 1, 2009
Impact of on Patient Satisfaction MSKCC study 294 patients undergoing immediate implant based reconstruction No 182 112 Breast Q questionnaire administered mean of 52 months from surgery Koslow et al. Ann Surg Oncol 20: 3422-3429,2013
Patient Reported Satisfaction and Implant Reconstruction Breast-Q Mean score P-value Satisfaction with Breasts <0.001 64.4 No 54.9 Satisfaction with Outcome 0.007 74.8 No 67.7 Multivariate analysis: strongest predictor of Satisfaction with Breasts (p=0.005) Koslow et al. Ann Surg Oncol 2013; 20: 3422-3429
Distribution of Complications and Immediate Reconstruction TM 26% None 50% Both 8% 16% Pinell-White et al. Ann Plastic Surg 2014
Complications Unilateral vs Bilateral Reconstruction 120 100 80 60 40 None Minor Major 20 * 0 UM/implant n=44 /implant n=106 UM/TRAM n=95 /TRAM n=26 *P=0.006 Pinell-White et al. Ann Plastic Surg 2014
Predictors of Complications Multivariate Analysis Factor Odds ratio Confidence Interval P value 2.11 1.28-3.49 0.004 Breast reconstruction None 1.00 Referent Expander/implant 24.89 7.46-83.05 <0.001 Latissimus flap 26.72 6.99-102.12 <0.001 TRAM flap 24.09 7.23-80.33 <0.001
Conclusions Women who choose are more often young, white, and have a family history of breast cancer Preoperative breast MRI and failed breast conservation are contributing factors The increase in is mirrored by an increase use of implant reconstruction significantly increases the complication rate of immediate breast reconstruction
Contralateral Prophylactic Mastectomy with Immediate Reconstruction: Added Benefits, Added Risks Grant W. Carlson Divisions of Plastic Surgery & Surgical Oncology Emory University School of Medicine