Perioperative Care of the Cancer Patient: Breast Procedures





Background


In the United States breast cancer is the most commonly diagnosed cancer in women and accounts for over 260,000 new cases each year. A woman living in the United States has a 12% lifetime risk of being diagnosed with breast cancer. Although mortality rates have been declining, it is the second most common cause of death in women and responsible for over 40,000 deaths.


Risk Factors


Multiple risk factors are associated with breast cancer development. Increased exposure to estrogen is associated with an elevated risk of developing breast cancer, whereas reducing exposure is thought to be protective. Correspondingly, factors that increase the number of menstrual cycles such as early menarche, nulliparity, older age at first pregnancy, and late menopause are associated with increased risk. Additionally, obesity is associated with long-term heightened exposure to estrogen. Nonhormonal risk factors include older age, family history, genetic predisposition, and radiation exposure (particularly mantle radiation during adolescence). Seventy-five percent of breast cancer cases occur in patients aged >50 years. A family history of breast cancer, particularly in a first-degree relative, incre­ases the risk twofold in the case of one affected relative, and up to fourfold in the case of more than one affected relative compared to women without a family history.


Five to ten percent of breast cancers are caused by inheritance of germline mutations in genes such as BRCA1 and BRCA2. Compared to women in the general population, BRCA1 and BRCA2 mutation carriers are estimated to have as high as 70% risk of developing breast cancer by the age of 80 years. Other inherited conditions associated with an increase in breast cancer risk include Li-Fraumeni and Cowden syndromes. , Lobular carcinoma in situ (LCIS) is characterized by abnormal cell growth within and expanding the terminal duct lobular units. Women with LCIS are 7 to 12 times more likely to develop invasive cancer in either breast compared to women without LCIS, with 65% of those being ductal in origin. As such, LCIS is generally not thought to be a precursor for invasive cancer but regarded as a strong marker of increased risk.


Screening


The American Cancer Society (ACS) recommendations for the early detection of breast cancer vary depending on a woman’s age and underlying risk factors. Screening modalities include mammography and magnetic resonance imaging (MRI) for women who are at high risk. For women at average risk of developing breast cancer, the ACS recommends that women 40 to 44 years of age have the option to begin annual mammography, those aged 45 to 54 years should undergo annual mammography, and those aged 55 years and older may transition to biennial mammography or continue to have the option of annual mammograms. Furthermore, women should continue breast cancer screening as long as their overall health is good, and they have a life expectancy of 10 years or more. For women with a high lifetime risk (∼20%–25%) of breast cancer, recommendations include an annual screening MRI in addition to mammography beginning at 30 years of age.


Staging


All patients diagnosed with breast cancer should be assigned a clinical stage based on the involvement of the breast and/or nodal regions. Staging allows for efficient identification/guidance of local and systemic therapy options and provides baseline prognostic information for patients and providers. TNM is an internationally accepted system used to determine the disease stage. The TNM classification uses information on tumor size and local spread (T), the extent of spread to nearby lymph nodes (N), the presence or absence of distant metastases (M), and additional biological factors. , A breast cancer stage of 0–IV is assigned, ranging from locally contained disease to advanced disease.


Types of Breast Cancers


Breast cancer cells are considered to be in situ or invasive depending on whether they invade the basement membrane. Ductal carcinoma in situ (DCIS) is characterized by abnormal proliferation of the epithelium that lines the milk ducts. Approximately 20% of breast cancer cases diagnosed in the United States are DCIS. There is a significant risk (nearly fivefold) of invasive breast cancer in women with DCIS. Invasive cancer is usually observed in the ipsilateral breast, suggesting that DCIS is an anatomic precursor for more invasive diseases.


Although invasive breast cancer is generally referred to as a single disease, there are several distinct histologic subtypes and at least four different molecular subtypes that differ in terms of risk factors, presentation, response to treatment, and outcomes. , Invasive ductal carcinoma accounts for approximately 70%–80% of invasive lesions. This type of carcinoma presents with macroscopic or microscopic axillary lymph node metastases in up to 25% of screen-detected cases and 60% of symptomatic cases. Invasive lobular carcinoma accounts for approximately 8% of all breast cancers. The histopathologic features of this cancer include small cells that infiltrate the mammary stroma and adipose tissue individually and in a single-file pattern. Mixed histology, comprising both ductal and lobular characteristics, occurs in approximately 7% of invasive cancers. Other histologic subtypes include mixed, medullary, papillary, tubular, and mucinous, which account for less than 5% of invasive breast cancers.


Routine identification of the presence or absence of specific hormones or growth factor receptors is utilized in gene profiling. Hormone (estrogen [ER] or progesterone [PR]) receptors, excess levels of human epidermal growth factor receptor 2 (HER2), and/or extra copies of the HER2 gene (HER2+/HER2−) are routinely identified in invasive cancers. Molecular subtypes are identified based on these analyses. The main types include luminal, HER2-enriched, and basal.


Prognosis


The prognosis of patients depends on the stage of the tumor at the time of diagnosis. Influencing factors include tumor size, histologic grade, axillary lymph node status, and hormone receptor status. The majority of breast cancer recurrences occur within the first 5 years of diagnosis, particularly with hormone receptor-negative disease. The overall 5-year relative survival rate is 99% for localized disease, 85% for regional disease, and 27% for distant-stage disease.


Future Aims in the Approach to Breast Cancer


Up to 50% of women in the United States will consult a surgeon about breast disease at some point in their lives. Twenty-five percent of women will undergo breast biopsy for the diagnosis of an abnormality, and 12% will develop some variant of breast cancer. Considerable progress has been made in the integration of surgery, radiation therapy, and systemic therapy to control local-regional disease, enhance survival, and improve the quality of life (QoL) of breast cancer survivors. Potential areas for further research and improvement in breast cancer include: (1) increasing patient access to education regarding breast cancer treatment options with the goal of improving decision-making, (2) health-related quality of life (HR-QoL) outcomes research, (3) prompt dissemination and adoption of new treatment options, and (4) strategies to curb the rising costs of health care for patients. ,


In the next section we present an overview of the medical and surgical management of the breast cancer patient.


Management of the Breast Cancer Patient


Nonsurgical Management of Breast Cancer


Systemic Treatment


Systemic therapy refers to the medical treatment of breast cancer using endocrine therapy, chemotherapy, and/or biologic therapy prior to or following definitive local treatment. To determine the risk of recurrence and the effectiveness of systemic therapy, one must assess factors, such as age, life expectancy, comorbidities, pathologic findings in the breast and axilla, and biological behavior of the tumor. Systemic therapy may be offered based on primary tumor characteristics, such as tumor size, grade, number of involved lymph nodes, status of ER and PR receptors, and expression of HER2 receptor.


Neoadjuvant Chemotherapy


Neoadjuvant chemotherapy is utilized in cases of locally advanced and potentially inoperable breast cancer to render the disease amenable to resection. Clinical criteria for inoperability include inflammatory carcinoma, tumors that are fixed to the bony chest wall (e.g., ribs and sternum), extensive skin involvement with ulceration or satellite skin nodules, fixed or matted axillary lymphadenopathy, involvement of neurovascular structures of the axilla, or lymphedema of the ipsilateral arm. In these cases, systemic therapy may be administered as an initial treatment to reduce tumor burden and will subsequently improve the rate of operability to 80%. Neoadjuvant chemotherapy is also used in cases of operable tumors to downstage disease in the breast and axilla. This may facilitate breast conservation surgery (BCS), improve cosmetic outcome, and in some instances allow patients to avoid axillary lymph node dissection (ALND) and the associated morbidity with this procedure. Last, neoadjuvant therapy may be utilized in women who may have a temporary contraindication to surgery such as women diagnosed with breast cancer during pregnancy.


Chemotherapy remains the standard neoadjuvant approach in most patients, including those with hormone receptor-positive disease; however, endocrine therapy may be used in a certain subset of these patients. For patients with HER2-positive breast cancer, a HER2-directed agent (i.e., trastuzumab with or without pertuzumab) is typically administered in addition to the chemotherapy regimen. For patients with hormone receptor-negative and HER2-negative disease, neoadjuvant therapy consists of chemotherapy alone. Overall, in selected patients, neoadjuvant therapy reduces the rate of axillary lymph node metastases, increases the rate of breast conservation, and has comparable long-term disease-free survival and overall survival compared to patients undergoing primary surgery followed by adjuvant systemic therapy. ,


Adjuvant Chemotherapy


Generally, adjuvant chemotherapy is indicated for patients with triple-negative breast cancer and either a tumor size >0.5 cm or pathologically involved lymph nodes (regardless of tumor size). Common regimens utilized for HER2-negative disease include anthracycline-based regimens such as doxorubicin and cyclophosphamide. These are typically administered for four cycles of dose-dense treatment (every 2 weeks) followed by paclitaxel administered either weekly for 12 weeks or every 2 weeks for four cycles. With the use of an anthracycline-containing regimen compared with no treatment, there is a reduction in the risk of recurrence from 47% to 39%. Furthermore, breast cancer mortality also decreases from 36% to 29% and overall mortality from 40% to 35%, respectively.


Meta-analyses have demonstrated the benefits of adjuvant chemotherapy in reducing recurrence and breast cancer mortality. There is a greater magnitude of benefit in those with HR-negative disease (21%–25% relative risk reduction) compared to those with HR-positive disease (8%–12%). , For patients with HR-positive and node-negative breast cancer, Oncotype DX provides an estimate of chemotherapy benefit. Patients with high Oncotype recurrence scores (≥31) have a large reduction in risk of recurrence with chemotherapy, while those with low scores derive minimal if any benefit from chemotherapy. Chemotherapy for patients in this group may consist of either anthracycline-containing or anthracycline-sparing regimens. In patients with low Oncotype recurrence scores, endocrine therapy alone is sufficient, as these patients have a favorable outcome with a 5-year overall survival of 98% with endocrine therapy alone.


HER2-Directed Therapy


Approximately 20% of patients with early breast cancer have tumors that exhibit overexpression, amplification, or a combination of these characteristics of the HER2 receptor or oncogene. Adjuvant HER2-targeted therapy (trastuzumab and/or pertuzumab) is now the standard of care for these patients. Several large trials have demonstrated that a year of adjuvant trastuzumab after chemotherapy reduces recurrence (about 50%) and increases 10-year disease-free survival (9%) in patients with this type of early breast cancer.


Endocrine Therapy


Hormone receptor-positive breast cancer represents the vast majority of breast cancers around the world; approximately 60%–75% of women with invasive breast cancer are ER-positive and 65% are PR-positive. Endocrine therapy is recommended for most patients with hormone-positive disease. Patients may be treated with endocrine therapy for 5–10 years and possibly longer, as a longer duration of therapy may confer additional benefits. If women are pre- or perimenopausal or if menopausal status is unknown, they should be offered tamoxifen for a total duration of 10 years. Aromatase inhibitors (anastrozole, letrozole, and exemestane) are used in postmenopausal women but may also be prescribed sequentially with tamoxifen. Adjuvant tamoxifen reduces the risk of recurrence by nearly 50% during years 0–4 with continued risk reduction of over 30% in years 5–9. , Furthermore, after 5 years of tamoxifen treatment, an additional 5 years of aromatase inhibitors provides an additional 40% relative risk reduction in recurrence.


Surgical Management of Breast Cancer


Breast-conserving Therapy


Successful breast-conserving therapy (BCT) entails complete, cosmetically acceptable surgical removal of the tumor (lumpectomy with negative surgical margins defined as no ink on tumor) followed by radiotherapy (RT) to eradicate any residual disease. Among women with operable breast cancer, randomized trials have demonstrated equivalent disease-free and overall survival between mastectomy and BCT. Advances in neoadjuvant therapy, surgical and radiation therapy techniques, and pathologic assessment of the tumor have increased patient eligibility for this approach. Inability to obtain adequate surgical margins or patient intolerance of adjuvant RT may preclude BCT. Additional contraindications include inflammatory breast cancer, multicentric disease, diffuse malignant microcalcifications on mammography, prior history of chest RT, pregnancy, and connective tissue disease (i.e., scleroderma or lupus erythematosus). ,


Radiotherapy in Breast-Conserving Therapy


In patients opting for BCT, it is important to determine preoperatively whether the patient is a candidate for adjuvant radiation. For the majority of women treated with lumpectomy, including those who have received neoadjuvant therapy with a complete response to treatment, whole-breast radiation therapy (WBRT) is recommended.


WBRT following BCT reduces the locoregional recurrence rate and risk of breast cancer death. The benefits were demonstrated in a meta-analysis performed by the Early Breast Cancer Trialists’ Collaborative Group (EBCTCG), which included over 10,000 women (known to be either pathologically node-negative or -positive) in 17 trials. Lumpectomy followed by WBRT resulted in a nearly 50% reduction in the 10-year risk of any first recurrence compared with lumpectomy alone and showed an absolute reduction in the 15-year risk of breast cancer death by 3.8%. The conventional dose of WBRT delivered to the entire breast is 1.8–2 Gy in daily fractions over 5 to 7 weeks for a total dose of 45–50 Gy, with a 10–14 Gy boost for most patients. A more current, patient-preferred method of delivery is hypofractionated WBRT. A greater amount of RT is delivered per dose, but the overall treatment duration is shorter, with 40–42.5 Gy administered in approximately 3–5 weeks with or without a boost. This newer approach has been associated with equivalent tumor control, has fewer toxicities, has comparable overall survival, and improved cosmetic outcomes compared to traditional WBRT.


Accelerated partial breast irradiation (APBI) refers to the use of focused RT centered around the tumor cavity. Options for the delivery of APBI include brachytherapy, intraoperative RT, or external beam radiation. Compared with WBRT, APBI delivers a higher dose of RT per day over a shorter period of time (i.e., 5 days) and potentially fewer breast symptoms and late skin side effects. This approach may be reasonable in patients >50 years of age with small (<2 cm) node-negative breast cancer. However, in preliminary trials, it is still unclear if APBI is as effective as traditional or hypofractionated WBI in terms of local control, survival, and cosmesis. ,


Last, in a subgroup of women aged >65 years with node-negative, early stage, and hormone receptor-positive breast cancer who are treated with endocrine therapy, omission of RT may be a reasonable option depending on the preferences of the patient as the risk of in-breast recurrence is low. ,


Mastectomy


Mastectomy is an option for breast cancer patients with contraindications to BCT, as well as prophylaxis, to reduce the risk of breast cancer in high-risk women. The rate of mastectomy has been increasing in the United States over the past decades as patients may choose to undergo mastectomy, rather than BCT. This is due to various reasons, including fear of recurrence and a desire to avoid the need for postoperative radiation or future biopsies. Mastectomy options include modified radical mastectomy, total mastectomy (simple mastectomy), skin-sparing mastectomy, and nipple-areolar- sparing mastectomy (NSM). A modified radical mastectomy involves complete removal of the breast and the underlying fascia of the pectoralis major muscle along with the removal of level I and II axillary lymph nodes. With the adoption of sentinel lymph node biopsy (SLNB) for axillary staging in patients with clinically negative axillary lymph nodes, modified radical mastectomy is performed less frequently. Total mastectomy removes most of the overlying skin and the entire breast parenchyma, with preservation of the pectoral muscles and axillary contents. Total mastectomy is generally performed when the patient does not undergo immediate reconstruction.


For skin-sparing mastectomy, the majority of the natural breast skin envelope is preserved, which facilitates immediate reconstructive procedures such as preservation of the skin, and the inframammary fold provides the reconstructed breast with a more natural shape and contour. Multiple studies have demonstrated this procedure to be oncologically safe with comparable local recurrence rates to total mastectomy ranging from 0% to 7%. NSM preserves the nipple-areolar complex and skin envelope but removes the major ducts from within the nipple lumen. This approach was initially used as an option for patients having prophylactic mastectomy with immediate reconstruction; however, this approach is increasingly used in the therapeutic setting as well. There are no randomized trials comparing NSM to other mastectomy techniques, and long-term follow up in clinical series is limited, reporting local recurrence rates of 2%–5%, with a median follow up ranging from 2 to 5 years. As such, patients undergoing therapeutic mastectomy should be carefully selected for a nipple-sparing procedure. Indications for NSM in patients with invasive carcinoma vary by institution. At a large, tertiary, designated cancer institute, the current criteria include patients with tumors <3 cm and at a distance of at least 1 cm from the nipple with no extensive calcifications.


Role of Postmastectomy Radiotherapy


Postmastectomy radiotherapy (PMRT) has been shown to decrease rates of locoregional recurrence and increase long-term breast cancer-specific and overall survival for certain patient populations. , Indications for PMRT include patients with four or more involved lymph nodes and a tumor greater than 5 cm. PMRT in women with between one and three positive lymph nodes and T1-2 breast cancers is an area of ongoing debate. , In this subset of patients, the decision to administer PMRT should be approached in a multidisciplinary setting.


Axillary Staging


The status of the axillary lymph nodes is one of the most important prognostic factors as it is usually the initial site of metastasis. Preoperative evaluation of axillary lymph nodes separates patients into two categories: patients with clinically positive nodes and patients with clinically negative nodes. SLNB has replaced ALND as the initial assessment of axillary lymph nodes in patients with clinically negative axillary lymph nodes. , ALND is indicated for most patients with clinically positive ipsilateral axillary lymph nodes either by fine needle aspirate or SLNB. Based on the pathologic results obtained by SLNB, no further axillary treatment is indicated for patients who meet all of the following criteria: clinically negative nodes based on clinical evaluation, T1 or T2 (≤5 cm) primary breast cancer, less than three metastatic sentinel lymph nodes (SLNs), and plan for lumpectomy procedure followed by WBRT. A completion ALND is indicated for patients who have three or more metastatic nodes on SLNB, matted nodes found intraoperatively, or those with one or two metastatic SLNs who do not desire WBRT. ,


The next section will describe plastic surgery reconstructive approaches for breast cancer surgery.


Plastic and Reconstructive Surgery


Postmastectomy Breast Reconstruction


Along with increasing rates of mastectomies, , more women are undergoing postmastectomy reconstruction (PMR). , A critical consequence of mastectomy is the psychosocial effect of the physical and esthetic deformity leading to anxiety, depression, and negative effects on body image and sexual function. As such, the goal of PMR is to restore a breast mound and to maintain the quality of life without affecting the prognosis or detection of recurrence of cancer.


Women have three main options following mastectomy: (1) no reconstruction, (2) prosthetic-based breast reconstruction using tissue expanders or implants, or (3) tissue-based, autologous breast reconstruction using the patient’s own tissue. Most women are considered reasonable candidates for either implant-based or flap-based breast reconstruction. The choice of reconstruction technique is dictated by a variety of factors, including the size and shape of the native breast, the location and type of cancer, the availability of breast and donor site tissue, patient age and comorbidities, additional neo- and adjuvant therapies, and personal choice.


In general, breast reconstruction can be performed at the time of mastectomy (immediate) or during a subsequent operation at some point after mastectomy (delayed). Many patients undergoing mastectomy are candidates for immediate reconstruction. This includes patients having prophylactic mastectomy and mastectomy for invasive or in situ carcinoma. Delayed reconstruction may be preferred in certain patients, such as those with inflammatory breast cancer or those who are at an increased risk for adverse outcomes due to comorbidities. Surgeons and patient preferences also dictate the timeline for reconstruction. The disadvantages of delayed reconstruction include the need for additional surgery and the negative psychologic effects of body disfigurement for a period of time.


Types of Breast Reconstruction Modalities


Prosthetic-based Breast Reconstruction


Implant-based reconstruction is currently the most common choice for PMR. Current options for implant-based reconstruction include immediate reconstruction with a standard or adjustable implant (single-stage implant), two-stage reconstruction with a tissue expander followed by an implant, or reconstruction with a combination of an implant and autologous tissue. The ideal candidate is a thin female undergoing bilateral mastectomy or a thin female undergoing unilateral mastectomy with little to no ptosis on the remaining breast where obtaining symmetry is easier. An absolute contraindication to tissue expansion/implant reconstruction is the lack of an available skin envelope for tension-free coverage. Although not absolute contraindications, smoking, obesity, hypertension, and radiation therapy age have been implicated in complications after implant-based reconstruction.


Immediate, Single-stage Implant Reconstruction


Single-stage immediate breast reconstruction creates a definitive breast mound at the time of oncologic resection. In general, single-stage implant reconstruction is appropriate for women with small, non-ptotic breasts whose mastectomy preserves an adequate amount of skin envelope and pectoralis muscle. In this case, the implant is placed at the time of the mastectomy. A remote, removable port may be left in place to allow for the subsequent addition of volume. The port is removed at a later date, leaving the initial implant in situ as the final product. Another option for single-stage reconstruction is to incorporate an acellular dermal matrix (ADM) with an implant. , In this method, the ADM offers additional support and implant soft-tissue coverage to allow for appropriate healing. The disadvantages of the single-stage approach include the view that esthetic outcomes tend to be inferior compared to two-stage reconstruction, and in many cases, the need for a second, revisionary procedure. Consequently, this approach is not used for the majority of implant-based reconstruction, although it may be successful in select patients.


Immediate or Delayed Two-staged Implant Reconstruction


The most common technique for implant breast reconstruction is two-stage reconstruction. Traditionally, total submuscular coverage has been used in which a tissue expander is placed in a plane under the pectoralis muscle medially with lateral coverage with a portion of the serratus anterior muscle. Although cosmetic results have been described to be excellent, total submuscular reconstruction can be associated with significant postoperative pain, potential for breast animation deformity, lateral deviation of the breast mound, and insufficient lower pole fullness. , To reduce manipulation of the pectoralis muscle and associated morbidity, partial subpectoral or partial sub-ADM reconstruction was popularized. This dual-plane reconstruction is performed by release of the inferior and medial inferior insertions of the pectoralis with placement of a tissue expander under the muscle with the inferior portion of the implant supported by an ADM sling. This obviates the need for elevation of the serratus anterior, which may make subsequent expansion less painful and has been shown to have comparable cosmetic outcomes, similar safety profiles, better early fill volumes, and less postoperative pain compared with total submuscular coverage. ,


In properly selected patients, a tissue expander may be placed in a prepectoral position. This method avoids the morbidity associated with muscle elevation and muscular distortion of the implant in the final reconstruction and has gained increasing popularity in the past decade. Furthermore, patients may experience less pain due to the avoidance of pectoral muscle disruption, there is minimal breast animation deformity with pectoral muscle contraction, and a natural breast contour can be maintained. , Comparative studies between prepectoral and total muscle coverage breast reconstruction have demonstrated similar complication profiles with regard to infection, superficial skin necrosis, and seroma. There is also the potential benefit of decreased rate of capsular contracture. , Prepectoral tissue expander potentially presents an opportunity to improve upon current reconstructive methods; however, currently available studies are retrospective in nature with limited cohort size and lack of long-term follow up in patients. As such, the associated risks have yet to be fully described, warranting a large multicenter prospective trial to provide better guidance.


Mixed Implant and Autologous Reconstruction


Many patients who are candidates for implant reconstruction have a skin-muscle envelope that is inadequate for expansion. Contributing factors include large skin resection at the time of mastectomy and/or multiple scars and radiation injury to the skin or muscle, resulting in a nonexpandable pocket. In such cases, the addition of autologous tissue (most commonly a latissimus dorsi myocutaneous flap) may be required for adequate coverage of the expander and implant. The addition of autologous tissue to implant reconstruction increases the length and complexity of the procedure, as well as the risk of potential morbidity at the donor site (i.e., on the back). Thus the combination of both reconstruction modalities is generally reserved for select patients.


Tissue Expander Expansion


The expansion process begins at approximately 2 weeks postoperatively. Saline is injected into the integrated port of the expander on a weekly or biweekly basis, depending on patient tolerance, until the expander reaches its final volume (usually after 6 to 8 weeks). The main drawbacks of skin expansion are frequent outpatient visits to gradually fill the expander, the need for an additional procedure (i.e., expander removal for permanent implant or flap), and the relatively high rate of complications, including infection, capsular contracture, and skin perforation. The exchange of the tissue expander to the final implant is then performed as an outpatient procedure and should occur no earlier than 4 to 6 weeks after the final expansion or completion of adjuvant therapy.


Types of Implants


Implant selection is based on dimensional planning and should involve the patient’s input. The patient’s skin laxity and desired shape are considered when deciding on the type of implant, as well as details of height, width, and projection. In the United States, saline-filled and silicone gel-filled breast implants with a silicone shell are predominantly used. The major difference between the implants is the fill material, and the need for subsequent monitoring for rupture. If a saline implant ruptures, the implant deflates and physical exam can diagnose the defect. Silicone implants, on the other hand, maintain their shape for the most part, should a rupture occur. Radiologic imaging, typically with MRI, is required to detect rupture. Silicone implants generally provide a more natural feel, and appearance, while saline implants tend to be firmer, provide less natural fullness in the upper portion of the breast, and are more likely to lead to visible rippling. Overall, patient satisfaction appears to be higher when silicone implants are used for reconstruction, as opposed to saline. In addition, the surface of the breast implants is either smooth or textured. Regardless of the implant chosen, the exchange usually requires capsulectomy for adequate symmetry and cosmesis.


Autologous Breast Reconstruction


Although autologous approaches remain less common than prosthetic reconstruction, the use of a patient’s own tissue has distinct advantages. Autologous reconstruction has the benefit of replacing “like with like,” which may lead to a softer, more ptotic and natural-appearing breast mound in a single procedure. In addition, methods using abdominal tissue donation have the added benefit of concomitant abdominoplasty, which many patients find appealing.


Ample tissue at the desired donor site is necessary for successful autologous reconstruction. Prior failed implant reconstruction, history of previous abdominal surgeries, and thin body habitus may make autologous reconstruction challenging. A variety of donor sites have been described for breast reconstruction, including the abdomen, back, buttocks, and thighs. Skin, fat, and muscle are transferred either as a pedicled flap, with its own vascular supply, or as a free flap that requires microvascular reattachment of the blood vessels. For patients who desire autologous reconstruction but who have a paucity of donor site tissue, stacked flaps may be considered in which two flaps are used to create one breast. ,


Autologous reconstruction can be performed in either an immediate or delayed fashion. Immediate reconstruction has several advantages, including the need for only one operation and potential ease for surgeons who are presented with a more predictable mastectomy skin flap envelope. Precise planning of the location of the skin island may be designed on the abdomen before transfer, thus improving the efficiency and precision of the operation. Delayed reconstruction requires reelevation of the skin flaps, which can be scarred and less compliant, and commonly requires replacement of skin to create a naturally appearing, ptotic breast.


Techniques


Over the last few decades, autologous breast reconstruction techniques have evolved to achieve acceptable morbidity and superior esthetic outcomes. The most commonly considered gold standard donor site is the abdomen. The benefits of using abdominal tissue are the availability of ample tissue to form and shape the tissues to recreate the breast and contouring the abdomen for an abdominoplasty-type effect. Current modalities include a pedicled transverse rectus abdominis myocutaneous (pTRAM) flap, free TRAM flap, deep inferior epigastric artery perforator (DIEP) flap, and superficial inferior epigastric artery (SIEA) flap.


The most common pedicled myocutaneous flap is the pTRAM flap. This flap consists of excising excess skin and soft tissue in the infraumbilical area overlying the rectus abdominis muscle together with the rectus muscle itself along with its supply of superior epigastric vessels. However, this procedure has significant disadvantages, including a high tissue-to-blood supply ratio of the flap; protracted recovery time; and abdominal wall morbidity, including weakness, bulging, and herniation. To overcome the drawbacks and associated morbidity of the pTRAM flap, further refinements led to techniques, including the muscle-sparing free TRAM flap and perforator flaps (DIEP and SIEA). The free TRAM flap technique requires a more limited harvest of the rectus abdominis muscle, safer transfer due to improved perfusion originating from the larger caudal pedicle (deep inferior epigastric artery instead of deep superior epigastric artery), and an improved medial breast contour due to the lack of tunneling of the flap’s cranial pedicle compared to pedicle TRAM flap. , The DIEP flap is based on perforating vessels that pass from the inferior epigastric vessels through the rectus muscle into the fat and skin. The DIEP flap has become the gold standard for autologous breast reconstruction because it maximizes the amount of tissue transfer without sacrificing the rectus muscle. Furthermore, it results in less donor site morbidity and excellent esthetic results compared to the traditional TRAM flap. Other advantages include decreased pain, quicker recovery, preservation of abdominal wall function, lower incidence of hernia, shorter hospital stay, and decreased cost.


Given that not every woman is suitable for breast reconstruction using abdominal skin and fat, several more donor sites have been recently described to harvest the most suitable microvascular flap to best personalize breast reconstruction. These flaps include the superior gluteal artery perforator flap, the inferior gluteal artery perforator flap from the gluteal region, fasciocutaneous infragluteal flap, profunda femoral artery perforator flap from the infragluteal region, and the transverse myocutaneous gracilis flap from the inner thigh region. The latissimus dorsi myocutaneous flap also remains an option for autologous breast reconstruction. It is typically not used for initial reconstruction because of the lack of appropriate volume; however, it may serve as a salvage flap or a combined prosthetic approach, as previously discussed.


Nipple Reconstruction


Following the completion of breast reconstruction, women are given the option of nipple-areolar reconstruction. The goal of nipple and areolar reconstruction is to achieve symmetry of the position of the nipple-areolar complex in the contralateral breast with comparable appearance and color. Multiple techniques can be used to create a nipple and areola. Surgical methods involve local tissue rearrangement procedures or skin grafts, while others use donor sites that are primarily closed. Nipple projection varies among different techniques, but adequate results can be achieved with most. An alternative to surgical reconstruction of the nipple is a three-dimensional tattoo. The tattooing of a surgically created nipple includes tattooing of the nipple and the creation of a new areola with pigmentation. ,


Advantages and Disadvantages of Modalities


Implant-based reconstruction has the advantages of being a less invasive procedure, technically easier, does not require any special equipment, and may be performed by most plastic surgeons. The procedure itself is short, avoids significant donor site morbidity and additional scar formation, and results in a shorter recovery time. Important disadvantages of implant-based reconstruction include the prolonged time to achieve a breast mound and the need for multiple visits for inflation of the tissue expander. Early complications after placement of the tissue expander include infection, hematoma, and extrusion of the implant. Late complications may occur after insertion of the final implant, including capsular contracture (scarring and contracture around the implant causing deformity), leak or rupture, and infection, all of which can potentially lead to removal or exchange of the implant. , The incidence of complications is significantly increased in patients with a history of radiation and in those who receive radiation after mastectomy. , For many of these patients, autogenous tissue may be a better option for reconstruction.


The advantage of reconstruction with autologous tissue includes the creation of a softer, more ptotic and natural-appearing breast mound in a single procedure. Disadvantages include a longer duration of anesthesia (5 to 10 h), more blood loss, a longer recovery period, risk of necrosis of portions of the transferred fat and skin, and problems at the donor site, which include wide, unsightly scars, abdominal weakness, and abdominal bulge or hernia. , The risk of complications tends to be higher in older and more obese patients, as well as those with compromised vascular microcirculation such as smokers and patients with diabetes.


All procedures for breast reconstruction are associated with an increase in morbidity beyond that associated with mastectomy alone. Each procedure has advantages and disadvantages that must be weighed by the patient and physician to reach an appropriate decision. In multiple studies assessing overall complications and reoperative complications comparing modalities, autologous reconstruction is associated with significantly higher odds of complications compared with prosthetic techniques. , , However, failure rates were low across both procedure types. As such, reconstruction may be associated with a high risk of complications, but successful reconstruction may still be achieved in most patients.


Special Considerations


Radiation Therapy


Radiation is an essential component of breast cancer treatment, but it often has a detrimental effect on reconstructive results. Women who require postmastectomy radiation therapy present a unique reconstructive challenge. Radiation therapy leads to fibrosis, which compromises the quality of the skin and underlying tissue, resulting in a higher incidence of complications from the reconstructive procedure, and ultimately may produce a less esthetically pleasing result. Patients who undergo radiation prior to reconstruction experience high rates of prosthetic device loss. Postmastectomy radiation therapy can also cause prosthetic device loss, capsular contracture, and higher rates of infection. Although autologous reconstruction may be better able to withstand radiation-induced damage, these patients still have high rates of intraoperative microvascular issues , and related complications including fat necrosis, flap shrinkage, and contour deformities. Revision rates, however, are unchanged.


Regarding patient-reported outcome measures (PROM), irradiated patients have lower HR-QoL outcomes compared to those who did not receive radiation. However, few differences have been elucidated between or within reconstructive modalities, with studies suggesting higher PROM in autologous patients. To date, the best method of integrating radiation therapy into any reconstruction method remains controversial. ,


Breast Implant-associated Anaplastic Large Cell Lymphoma


BIA-ALCL is an important public health concern because the use of breast implants has increased over the past two decades in the United States and internationally. It is estimated that as of 2015, more than 3 million textured devices have been used in patients in the United States. The risk of developing BIA-ALCL appears to be associated with prolonged exposure to textured implants, with most case series documenting a median exposure time ranging from 6.4 to 15.5 years, although shorter times of 0.4–2 years have also been reported. However, a recent study estimated the current incidence at 1.79 per 1000 patients and 1.15 per 1000 implants—a higher incidence than previously thought. The US Food and Drug Administration (FDA) has recently recalled certain textured breast implants. Patients who are interested in textured implants should be counseled about these risks prior to surgery.


The FDA does not currently recommend breast implant removal for asymptomatic women who already have this type of implant. The recall does not include smooth surface devices that use either saline or silicone gel as the filler material. Management options for patients with textured devices include continued implant monitoring, exchange for smooth devices, or conversion to autologous tissue reconstruction. It is unknown how the removal of a textured device impacts the likelihood of future BIA-ALCL, although it is reasonable to hypothesize that removal of the implant capsule substantially decreases the risk.


Patient-reported Outcomes


Breast reconstruction offers significant quality-of-life benefits in many patients undergoing mastectomy. PMR is an essential component in the therapeutic course following breast cancer and mastectomy and enhances postmastectomy quality of life by improving a woman’s sense of sexuality, body image, and self-esteem, compared with mastectomy alone. , , Differences in surgical outcomes, complications, and costs between these two modalities have been well characterized, yet these outcomes may not correlate with a patient’s perception of outcomes of care. , Several studies have assessed patient-reported outcomes (PROs) in breast reconstruction patients, demonstrating that the type of reconstructive modality appears to affect postoperative satisfaction outcomes. , A recent study of PROs using the BREAST-Q demonstrated that autologous breast reconstruction patients have higher long-term satisfaction compared to implant breast reconstruction patients. However, this study also found that patients who received implant-based reconstruction had satisfaction scores that remained stable over a long-term period. With a growing focus on health outcomes research and a move toward value-based medicine, patients and surgeons must now not only evaluate clinical differences between implant-based and autologous techniques but also consider a deeper understanding of PROM within each modality.


The decision to choose or decline breast reconstruction should be made by the patient after she has had the opportunity to learn about, discuss, and consider possible options. Contributions from the patient’s care providers, including breast oncologic surgeons, medical oncologists, radiation oncologists, and plastic surgeons, may aid the patient in the decision-making process. Studies report that a patient’s satisfaction with the decision about reconstruction is highest when the patient has been adequately informed and when their level of involvement in the decision is consistent with their own wishes and expectations. ,


The final section is an overview of perioperative anesthesia considerations for breast cancer surgery.


Anesthesia for Breast Surgery


Perioperative Anesthesia Considerations for Breast Cancer Surgery


Anesthesia and Type of Breast Cancer Surgery


The preoperative assessment should take into account: (1) patient comorbidities and whether the patient is medically optimized prior to surgery, and (2) type of procedure being performed with an understanding of the incision sites, extent of dissection and tissue trauma, and expected postoperative pain. As described in the previous sections, breast cancer surgeries include a wide range of procedure types from breast-conserving surgery with or without sentinel and/or ALND to mastectomy with or without reconstruction. Breast reconstruction may entail temporary placement of a tissue expander, placement of a permanent implant, or autologous flap reconstruction.


For minimally invasive outpatient procedures such as partial mastectomy or lumpectomy, monitored anesthesia care with a continuous propofol infusion in conjunction with surgeon infiltration of local anesthesia is generally appropriate. ALND involves deeper tissue invasion and typically requires general anesthesia with a laryngeal mask airway. Because of the proximity of the brachial plexus and its branches to the axilla, breast surgeons often prefer avoidance of muscle relaxant medications in order to monitor nerve response during dissection. Consideration should be given to placing the intravenous catheter and blood pressure cuff on the arm opposite to the side of the planned surgery.


Reconstruction after mastectomy may be an immediate or delayed procedure. When immediate reconstruction is planned after mastectomy, general endotracheal anesthesia is generally preferred, particularly if the placement of the tissue expander is subpectoral which may be facilitated by muscle relaxation. Tissue expander reconstruction is a risk factor for worse pain after breast reconstruction compared to autologous flap approaches ; hence an optimal multimodal analgesic regimen should be planned. Patients undergoing exchange of tissue expanders with permanent implants, which typically occurs at least 3 months but not sooner than 6 weeks after initial tissue expander placement, usually require general endotracheal anesthesia due to frequent upright positioning changes to enable surgeons to assess for symmetry, which limits access to the airway.


General endotracheal anesthesia is standard for patients undergoing autologous flap reconstruction. Due to the prolonged nature of these procedures, the anesthesia team should be mindful of noninvasive blood pressure (NIBP) cuff pressure injuries and consider rotating between two separate sites for NIBP measurement, using invasive blood pressure monitoring, or a continuous NIBP monitoring technique. Pressure point checks of the head and extremities at regular intervals throughout the procedure should also be performed.


Neoadjuvant Chemotherapy


During preoperative evaluation, it is important to understand the cardiac implications of neoadjuvant chemotherapy. Chemotherapy-related cardiac dysfunction has been classified as type I and type II. Type I is associated with anthracycline drugs (e.g., doxorubicin) and may lead to cardiomyopathy with significant morbidity and mortality. The diagnosis of anthracycline-induced cardiotoxicity is confirmed in a patient with new symptoms of heart failure or significant decline in left ventricular ejection fraction following exposure to anthracycline after exclusion of other causes. Risk factors include extremes of age, preexisting cardiovascular disease, hypertension, smoking, hyperlipidemia, obesity, diabetes, and high cumulative anthracycline exposure. , Additional risk factors include combined treatment with radiation therapy and trastuzumab. There is no established treatment other than supportive measures for patients who have developed doxorubicin heart failure.


Type II cardiac dysfunction is typically associated with trastuzumab, an agent that targets HER2. For 15%–20% of patients with breast cancer whose tumors overexpress HER2, trastuzumab therapy is important in the treatment of both early and advanced disease. However, its use may place patients at a modest risk for cardiotoxicity which is typically manifested by an asymptomatic decrease in left ventricular ejection fraction and less often by overt heart failure. In contrast to cardiotoxicity from anthracyclines, trastuzumab-related cardiotoxicity does not appear to be related to cumulative dose. It is often reversible with treatment discontinuation and rechallenge is often tolerated after recovery. Risk factors associated with a higher likelihood of developing trastuzumab-related cardiotoxicity include older age and previous or concurrent anthracycline use.


Limited data are available to guide the assessment and surveillance of patients receiving anthracycline and trastuzumab. Recommendations include obtaining a comprehensive clinical history, electrocardiogram, and cardiac examination prior to initiation of anthracycline-based chemotherapy. Patients should be evaluated at least every 3 months during treatment. For patients who develop symptoms or signs of heart failure, repeat echocardiography should be performed. After completion of anthracycline therapy, monitoring should be performed yearly. Increased vigilance for signs and symptoms of cardiotoxicity is appropriate for high-risk patients. In the adjuvant setting, a baseline evaluation of cardiac function with monitoring every 3 months thereafter is recommended.


The preoperative evaluation of patients who have received neoadjuvant chemotherapy should include an assessment of clinical status, focused examination, and review of electrocardiogram, echocardiography, and any other pertinent data to assess for signs or symptoms of heart failure. New concerning ECG changes or an acute reduction in left ventricular ejection fraction with poor functional status warrants further investigation prior to surgery.


Enhanced Recovery after Surgery (ERAS) for Breast Procedures


In a health care climate increasingly focused on optimizing quality and patient experience clinical settings are increasingly incorporating Enhanced Recovery After Surgery (ERAS) programs as quality improvement initiatives in perioperative care. ERAS is a multidisciplinary, evidence-based, and protocol-driven approach to the management of surgical patients. , Main principles include preoperative optimization of the patient, avoidance of prolonged fasting, standardized multimodal analgesic and anesthetic regimens, early resumption of diet, and early mobilization in the postoperative period. While ERAS is not a new concept, it is not yet widely described in breast surgery. Suggested elements for breast surgery include preadmission counseling, anxiolysis, optimal pain management including regional anesthesia when feasible, prevention of postoperative nausea and vomiting (PONV), early mobilization, and physical therapy with arm exercises postoperatively. More studies are needed to determine the clinical efficacy of each of these interventions, including analgesic medications, in breast surgery-specific trials.


While ERAS is not yet the standard of care in breast cancer surgery, there is growing evidence of its benefits. Compared with conventional care models, ERAS programs have been shown to reduce morbidity, hospital length of stay, and opioid consumption in patients undergoing microvascular breast reconstruction. Implementation of an ERAS program for patients undergoing mastectomy with immediate reconstruction at a single short-stay facility was associated with improved PONV postoperative nausea and vomiting and pain control. Despite these promising findings and the potential for ERAS to optimize perioperative care, gaps in education and execution call for future studies on implementation. In a meta-analysis assessing ERAS pathways in breast reconstruction patients, inconsistent and incomplete implementation of all elements of the ERAS program was observed across the nine included studies.


Pain, Regional Anesthesia, and Breast Surgery


Postoperative pain is a major challenge for patients undergoing complex breast cancer surgery and reconstruction. Suboptimally treated pain results in prolonged hospitalizations, additional resource utilization, and a decrease in HR-QoL outcomes. , Furthermore, approximately 50% of all patients undergoing mastectomy and breast reconstruction experience chronic postoperative pain syndromes. Poorly controlled pain in the acute postoperative period has been demonstrated to be one of the largest contributors to chronic pain syndromes and disability in breast surgery patients. , While opioid medications are the traditional approach to perioperative pain management, there are several disadvantages to their use in breast surgery patients. Opioids contribute to PONV in this high-risk patient population and there is ongoing concern about the current opioid crisis in the United States. Regional anesthesia as a component of a multimodal opioid-minimizing approach to pain management should be considered for patients undergoing complex breast cancer surgery.


Paravertebral Blocks


A variety of regional anesthetic techniques have been described for breast surgery, including thoracic epidural anesthesia, intercostal blocks, and thoracic paravertebral blocks. Paravertebral blocks are considered the gold standard regional anesthetic technique for breast surgery and have been shown to decrease postoperative pain, limit PONV, and reduce length of stay. , , The technique involves injecting local anesthesia in the paravertebral space to anesthetize the thoracic spinal nerves as they emerge from the intervertebral foramina. Thoracic dermatomal coverage of levels T1–T6 ( Fig. 23.1 ) is required for mastectomy surgery, particularly if axillary node dissection is planned. Using an ultrasound-guided approach, the spinous process at the appropriate thoracic level is identified. In a transverse or parasagittal orientation, the probe is moved laterally to identify the transverse process, pleura, and costotransverse ligament ( Fig. 23.2 ). The block needle is advanced beneath the costotransverse ligament and successful placement is confirmed by visualization of pleural depression as local anesthesia is infiltrated into the paravertebral space. The clinician may choose to perform a single injection, multilevel injections, or place an indwelling catheter in the paravertebral space. Pneumothorax remains the most significant concern for clinicians; however, this complication is rare.


Jun 26, 2022 | Posted by in ANESTHESIA | Comments Off on Perioperative Care of the Cancer Patient: Breast Procedures
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