REVIEW

International Journal of Surgery 10 (2012) 429e435

Contents lists available at SciVerse ScienceDirect

International Journal of Surgery

journal homepage: www.theijs.com

Review

Issues related to advances and controversies in breast cancer management:

A multicultural experience
Marek K. Dobke a, Hamdy El-Khatib b, *, Habib Al-Basti b
a
b

Division of Plastic Surgery, Department of Surgery, University of California San Diego, CA, USA
Department of Plastic and Hand Surgery, Plastic Surgery Unit, Romailah Hospital, Hamad Medical Corporation, Doha, Qatar

a r t i c l e i n f o

a b s t r a c t

Article history:
Received 13 April 2012
Received in revised form
22 July 2012
Accepted 22 July 2012
Available online 27 July 2012

The overview of current diagnostic and therapeutic advances and controversies in the management of
breast cancer is presented. Specic topics and their impact on breast reconstruction surgeons practicing
in culturally different areas and with variable access to breast education and health care are discussed.
The following approaches to the most common types of problems are presented: prophylactic mastectomy for women at high risk of breast cancer, size and location of the primary tumor and feasibility of
breast conserving surgery and oncoplastic approach, management of the axilla, post-mastectomy radiation and chemotherapy, emerging breast reconstructive techniques (fat transfer, stem cells) and cancer
risk, oncological follow up and imaging of the reconstructed breast, including illustrative cases. This
material should help oncological and plastic surgeon specialists to understand each others considerations for the best possible outcome of the breast cancer treatment.
2012 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.

Keywords:
Cancer breast
TRAM ap
Cultural concepts

1. Introduction
In the 1980s the indications for breast reconstruction were
liberalized as a result of increasing experience with the various
procedures, including microsurgery, development of implants and
tissue expanders designed for breast reconstruction, recognition of
the benecial psychological effects of immediate breast reconstruction, and most importantly, due to the clinical evidence that
reconstructive procedures did not negatively impact the results of
a mastectomy (at that time the mainstay of the primary breast
cancer treatment).1,2
However, the natural evolution of breast cancer development
risk assessment, diagnostic and surveillance methods, development of breast conservation strategies, and changes in the design of
comprehensive breast cancer management, necessitate ongoing
evaluation of reconstructive approaches to ensure that reconstructive approaches do not hinder cancer detection or treatment
as those modalities may be changing. Issues controversial yesterday
are not controversial today and new questions are emerging. The
question to reconstruct or not to reconstruct? itself was
a controversy yesterday.2 Notably, practice guidelines for the
treatment of the breast cancer do not include details of reconstructive recommendations.3,4 Reconstructive approaches vary

* Corresponding author.
E-mail address: hamdya24@yahoo.com (H. El-Khatib).

from surgeon to surgeon, from center to center, and from one sociocultural region to another, etc. In general, patient impact on
management decisions has increased. The level of self-education on
relevant issues (e.g., through Internet sources) is high among breast
cancer patients, however, the perception and application of this
information varies depending on socio-economic and cultural
patient background.5e7 This overview is an attempt to update the
discussion of current diagnostic and therapeutic advances and to
discuss old and new controversies and their impact on reconstructive approaches while considering management determinants
resulting from the diversity of global cultures.1,2,5
2. Prophylactic mastectomy for women at high risk of breast
cancer
A woman is considered to be at high genetic risk for the
development of breast cancer if she has a BRCA1 or BRCA2 mutation
or her family history suggests an autosomal dominant pattern of
inheritance.8 A woman with a breast malignancy who presents at
a young age, or has relatives affected by breast cancer, should
consider testing for BRCA1/2 mutations. Breast cancer prevention
measures for these women include ovarian ablation, Tamoxifen
administration, bilateral prophylactic mastectomy, and a variety of
new agents entering clinical trial.9 It is a difcult decision whether
or not to undergo a prophylactic bilateral mastectomy to reduce the
risk of breast cancer in general, and it is equally as difcult to decide
to undergo a contralateral mastectomy in an effort to decrease the

1743-9191/$ e see front matter 2012 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.ijsu.2012.07.008

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risk of the second cancer. Recent evidence indicates the overall

survival advantage by prophylactic mastectomy in addition to
therapeutic mastectomy.10 The annual risk of contralateral breast
cancer is approximately 0.6% for most patients; however, for
patients with unfavorable genomics, the annual risk is about 3%
with a 10-year cumulative risk of about 30%.11 To undergo or not to
undergo a prophylactic mastectomy (or even mastectomy) is too
frequently decided based on fear and inuence by non-evidenced
based factors (e.g. family and friends, beliefs, rumors, etc.) and it
is imperative to develop educational material and decision-aids for
patient and surgeons that are evidence-based but customized to
address traditions, prevalent religious issues (Fig. 1, Fig. 2, Fig. 3a
and b), and access to care (e.g., surveillance for breast cancer).4,11
Consider for example the impact of religious traditions, as Islam
welcomes any surgical procedure as long as it is performed for the
benet of the patient, even if it considers changing the creation of
Allah. This judgment (fatwa) is based on the Quran (holy book)
and Sunnah (prophets words), so a prophylactic mastectomy
and breast reconstruction are permitted from this religious point
of view.
Regarding prophylactic simple or skin-sparing mastectomy:
since all forms of mastectomy leave behind some breast tissue it
should not be a surprise that a subcutaneous mastectomy, in which
the nipple-areola complex is preserved along with a small layer of
nipple-areola supporting breast tissue, is associated with a greater
risk of development of breast cancer compared with a total or skin

Fig. 2. A proactive patient, an opposite to the patient depicted on Fig. 1: 23 year old
female, BRCA2 positive, with mother and grandmother who had prophylactic
mastectomies because of the family history, with 32 year old maternal aunt who
passed away because of the breast cancer, and with 28 year old maternal cousin just
diagnosed. Her options included; careful observation (with serial mammograms,
however, quality of mammograms for dense, young breast is not reliable), possibly
repeated ductal lavage, oophorectomy (systemic consequences unknown at such
young age), Tamoxifen (long term benets and systemic effects also unknown for
young age patients). Patient choice: bilateral prophylactic mastectomy including
nipples-areolas and reconstruction with tissue expanders and implants followed by
nipple/areola reconstruction.

sparing mastectomy.12 Consequently more aggressive forms of

prophylactic mastectomy should be recommended to high risk
women: total mastectomy, which involves the removal of breast
tissue, nipple, areola, and the axillary tail, is generally considered
the preferred procedure for a prophylactic mastectomy.13,14
Currently, a prophylactic mastectomy is often followed by immediate breast reconstruction.14,15
From the standpoint of breast reconstruction, identication of
high risk patients is important. For example, if a patient with breast
cancer undergoes unilateral postmastectomy reconstruction (e.g.,
with a TRAM ap), the same anatomical unit is not available for the
contralateral side should the patient undergo a prophylactic
mastectomy following testing positive for BRCA1/2 mutations after
initial surgery. Results of bilateral reconstructions, whether
accomplished by means of pedicled or free TRAM aps, latissimus
dorsi and/or implants, are superior if the same technique on each
side is utilized to ensure maximum symmetry16 (Fig. 4a and b).
3. Size and location of the primary tumor and breast
conservation via customized plastic surgery approaches

Fig. 1. A 45 year old California woman with access to modern Western medicine who
did not want mastectomy at all because she believed in homeopathic, herbal medicine
and allowed her breast cancer to grow for ten years until the cancerous growth
virtually destroyed both breast and anterior chest wall.

Conceptually, the treatment of breast cancer (except lobular

carcinoma in situ, LCIS) includes the treatment of local disease with
surgery and/or radiation therapy and the treatment of systemic
disease with cytotoxic chemotherapy and hormonal therapy.
The approach to breast cancer surgery is trending toward less
radical and disguring procedures that will not compromise the
treatment of cancer. Conguration of incisions, as long as they
provide an adequate margin and include lesion biopsy site, should
not inuence the outcome. Small, centrally-located breast cancers
can be removed utilizing a Wise-pattern breast-reduction type of
incision with a tumor-directed segmental mastectomy.17 Lower
quadrant tumors can easily be removed via vertical mammaplasty techniques. Both these techniques allow relatively large

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Fig. 3. a. 43 year old patient with history of multiple lumpectomies and radiation to
the left breast for lobular breast carcinoma prepared for reconstruction utilizing TRAM
ap. The patient should consider prophylactic mastectomy on the right side and
undergo simultaneous reconstruction on both sides! b. Five years later the same
patient developed right breast cancer (also lobular) and underwent mastectomy with
reconstruction utilizing latissimus dorsi myocutaneous unit. Poor esthetic result of
reconstruction utilizing different types of aps on each side.

tumors in large breasts to be removed with good cosmetic results.

Finally, upper outer quadrant tumors can be removed by single
axillary incision for quadrantectomy, axillary clearance and reconstruction with a latissimus dorsi ap.17,18
The reconstruction of deformities after breast conserving
surgery is not always the concern of a surgeon performing straight
ablation. The shift of the therapeutic paradigm toward oncoplasty
allows the simultaneous ability to repair a defect by a local ap or to
replace a missing breast tissue segment with a latissimus dorsi ap,
or TRAM ap or to restore symmetry by adjustment of the
remaining breast contour by a plastic surgeon which is a frequent
oncoplastic management scenario. Subsequently, a question arises
of who should be the primary surgeon for these patients. Perhaps
a plastic surgeon familiar with oncological issues would not be
a bad choice.19e21
A skin-sparing mastectomy is typically dened as removal of the
breast, nipple-areola complex, previous biopsy incisions, and skin

431

Fig. 4. a. A patient who underwent subcutaneous mastectomy, in which the nippleareola complex is preserved. b. Same patient, postoperatively, the defect was treated
with TRAM ap. 4-month follow-up.

overlying supercial tumors. The cosmetic outcome signicantly

improves with the preservation of the skin envelope in general and
the inframammary crease in particular.22,23 Regarding skin-sparing
mastectomies; they are currently performed predominantly in
patients with in situ, T1, or T2 lesions. A skin-sparing mastectomy
and immediate autologous tissue reconstruction is an accepted
method of managing primary malignancies with very good esthetic
outcomes. Introduction of immediate reconstruction techniques
utilizing allogeneic materials (e.g., Alloderm) for implant protection
and retention or establishment of the inframammary crease both
aimed to allow a single stage of breast mound reconstruction is an
important relatively recent advance. Could this approach be
utilized for the previously irradiated breast? Preliminary observations indicate that a skin-sparing mastectomy and immediate
autologous tissue breast reconstruction can be safely performed in
patients with previous whole-breast irradiation.22
The next consideration in improving esthetic outcomes is the
issue of feasibility of preservation of the nipple-areola complex.
However, whether the nipple-areola skin-sparing mastectomy
should even be an option for patients is questionable.24 Based on
results of the study examining the incidence of areolar and nipple
malignant involvement separately, it was concluded that because

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the areolar complex is much less frequently involved than nipple

itself (which was found to be involved in as many as 10.6% of
patients), only the areola should be spared.25 Even if the nippleareola complex is preserved, the removal of subareolar tissue
may devascularize the native nipple-areola complex, possibly
leading to localized brosis, retraction, contour distortion, loss of
pigment, and ultimately to inferior cosmetic results when
compared to reconstruction de novo. Similarly, nipple dissection in
the plane between dermis and ducts to remove a core of duct tissue
out of the nipples center, practically leaving the nipple remnant as
a full-thickness or composite graft, may remove all risk-bearing
ducts, but may also substantially thin the nipple and adversely
affect its viability.26 The specimen of the nipple duct tissue should
be subjected to a separate histopathological assessment and if
malignancy is found the nipple has to be removed. Alternatively,
proposed cryopreservation of autologous nipple-areola complex
puts the long-discredited concept of nipple-areola preservation by
banking at the time of mastectomy for invasive cancer and reconstructive options into new perspective due to the fact that this
approach allows (since there is an unlimited period of time)
proper histological evaluation of the nipple-areola complex to
conrm tumor-free status.27 In addition to oncological concerns,
esthetic outcomes will help to answer the question of whether or
not cryopreservation offers advantages over techniques using de
novo nipple reconstruction.
Breast conservation via a customized plastic surgery approach
may require advanced lesion localization techniques, e.g., multiple
needles, intraoperative ultrasound to localize hematomas persisting after percutaneous-stereotactic (specically vacuum assisted),
and breast biopsy.28 Actually, an intraoperative hematoma-directed
ultrasound-guided operative technique (during biopsy or breastconserving lesion excision) as an alternative to techniques relying
on needle localization of the clip (which may migrate) may have
superior results.29 Clip migration leading to imprecise lesion
removal may contribute to positive margins which may be of great
oncological signicance if breast conservation via customized
plastic surgery approach is utilized. Simple re-excision of the tumor
containing area or targeting radiation therapy may be difcult due
to rearrangement of the breast tissue anatomy or marker
displacement.30 Potentially reducing re-excision and problems
related to margins and malignancy site orientation, a postlumpectomy cavity shave margin removal may be helpful to
a reconstructive surgeon diminishing the probability of need for
reconstruction revision for oncological reasons.31 Similarly, neoadjuvant chemotherapy in early-stage breast cancer, which has
been shown to increase the number of candidates eligible for breast
conservation surgery, requires marking the shrinking lesion prior to
surgery.32
4. Management of the axilla in operable breast cancer treated
by breast conservation and breast reconstruction
The appropriate management of the axilla patients with T1 and
T2 breast cancer treated with breast-conserving therapy and the
extent of the axillary dissection in patients with invasive cancers
have been a topic of controversy for years.33,34 Such questions as:
What is the appropriate extent of axillary dissection?, Is axillary
dissection alone sufcient to control the disease?, Could axillary
irradiation sufce?, and How can the morbidity of axillary
surgery be minimized? remain unanswered.
Sentinel node biopsy, whereby the rst lymph node draining
a specic tumor is isolated and removed, is a technique that has
become the standard in breast cancer management.36 Therefore,
the reconstructive surgeon could add to this list of questions
another one: Do certain reconstructive techniques, for example,

transfer and passage the latissimus dorsi myocutanous ap through

the axillary region, impact the oncological surgeons ability to
follow with periodic axillary examinations or detection of the rare,
but possible, axillary recurrence?.33,34
A remarkable advancement in the management of secondary
lymphedema results from progress and new applications of
microsurgery. Accumulating evidence demonstrates that
lymphatic-venous microsurgical anastomoses at the time of axillary dissection to prevent upper extremity lymphedema are effective.35 Considering a possibility of microanastomoses compression
in the immediate postoperative period, a question arises for
a plastic surgeon: is immediate breast reconstruction with a pedicled latissimus dorsi myocutaneous ap feasible in a clinical
scenario when microsurgery connecting arm lymphatics with
collateral branches of the axillary vein was just performed?
5. Postmastectomy radiation and chemotherapy
The increasing use of radiotherapy after mastectomy, including
partial mastectomy, has signicant implications for breast reconstruction. In general, there is a consensus that the combination of
radiation and implants is associated with a greater than 50% risk of
complications in wound healing, capsular contracture, and pain.
Patients who undergo expander/implant type of breast reconstruction after radiotherapy have a higher rate of complications
than patients who do not receive radiotherapy. However, no
signicant difference is found in general patient satisfaction with
expander/implant reconstruction regardless of whether or not
the patient received radiotherapy.5,37 Autologous fat transfer
techniques in delayed breast reconstruction appear to be a promising adjunct modality for patients with tissue expanders or
implants and history of radiation. A great improvement of tissue
quality, with reduction of problems related to scarring and capsular
contracture and improved contour modeling (axillary tail, cleavage,
inframammaray crease), can be provided.38
Expansion of indications for post-mastectomy radiotherapy may
affect the timing and the reconstructive options available, possibly
decreasing the use of immediate reconstruction, especially with
implants.22,39 Delayed reconstruction, even with microsurgically
transferred free TRAM aps, was recommended for those patients
undergoing adjuvant radiotherapy because of the increased rate of
such complications as fat necrosis, loss of ap volume, brosis and
ap contracture.40 Unfortunately, for immediate reconstruction, it
is often unknown whether or not subsequent radiotherapy will
follow. The prospect of radiation also impacts axilla management
and lymphedema prevention: if possible, microanastomoses
between the arm lymphatics and axillary vein branches are performed at the upper lateral part of the axilla, thus protecting the
site of anastomosis from the impact of postmastectomy radiation.35
Microscopically positive margins in breast-conserving surgery
and immediate reconstruction scenario pose special dilemmas.31
Many re-excisions result in a re-excision specimen in which no
disease can be detected. Since the nding of microscopically positive margins after breast-conserving surgery is generally considered an indication for re-excision, one has to ask whether
a segment of tissue ap adjacent to positive margins should be
excised as well. And, how about implanted devices? Emerging data
suggest that patients with carefully scrutinized close or focally
positive margins have low ipsilateral breast tumor recurrence rates
after irradiation.41 Therefore, the question arises whether radiation
alone could sufce to control local disease? Could tissue aps
delivered for breast reconstruction be re-elevated and used to
deliver brachytherapy material?2,42
Targeted intraoperative radiotherapy (IORT) considered by some
useful to replace standard post-lumpectomy external beam

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radiation may also require application of plastic surgery techniques

for breast conservation. A photon radiosurgery system surrounded
by a conical sheath with a sphere tip is inserted into the lumpectomy cavity at the time of tumor removal. The radiation consists
of soft X-rays and very little radiation activity can be detected few
centimeters distally. Intraoperative therapy is specically targeting
local tissue which surrounds the lumpectomy cavity (tumor site). In
the opinion of some authors, early results demonstrate lower local
recurrence rates when comparing IORT to external beam radiation
results (clinical trials are underway). In early trials a few patients
developed local wound problems impacting cosmetic results. It is
probable that reconstructive surgeons will be consulted for late
reconstruction of breast defects, especially in higher-risk cases for
post-IORT radiation deformity (cases with relatively supercial
location of primary tumor and radiation site).43,44
Given the signicant rate of post-radiation complications
impacting esthetic outcomes, saline inatable, and specically
volume-adjustable implants, seem to be a more logical implant
choice for reconstruction of the breast mound if one decides to
proceed with the initial, potentially temporary, stage of reconstruction prior to radiotherapy. The partial saline inatable/partial
silicone lled device (Becker type of implant) and form-retaining
implants offer technical advantages which are useful to overcome
texture and contour problems.45 Permanent or temporary reduction of implant volume may be helpful in the management of pain
or wound healing problems; temporary overexpansion may be
helpful in preventing or managing the effects of radiation brosis.45
However, considering all arguments pros and cons, autologous
tissue breast reconstruction seems to be a preferred immediate
breast mound reconstruction option for women with a signicant
probability of post-mastectomy radiotherapy by reconstructive
surgeons. Excellent local and regional disease control and satisfactory cosmetic results by autologous tissue breast reconstruction
are consistently reported.1,4,7,39,40,45
Relatively little evidence exists regarding fears that chemotherapy might affect healing and both induction and adjuvant
chemotherapy may impact results of reconstructive procedures.46
Coordinating breast reconstruction procedures with induction
and postoperative chemotherapy (as well as with postmastectomy
radiation) is an important issue. It was found that the performance
of immediate reconstructive procedures in patients with locally
advanced breast cancer may slightly delay the interval between
mastectomy to postoperative chemotherapy, however, there is no
noted effect on survival associated with this delay.46,47 Immediate
breast reconstruction does not seem to delay the start of adjuvant
chemotherapy.48
6. Emerging breast reconstructive techniques and cancer risk
Historically, diagnostic and therapeutic advances in the breast
cancer management were impacting reconstructive approaches.
Although there is consensus that surgical reconstructive procedures do not negatively impact the results of a mastectomy as the
mainstay of the primary breast cancer treatment, however, questions are raised whether new emerging reconstructive modalities
such as fat transfer, stem cells and tissue engineering affect
malignancy risks. Fat injection to the breast itself was not accepted
until very recently. It appears that in post-mastectomy patients
who received radiotherapy, autologous fat grafting in addition to
traditional, tissue expander and implant breast reconstruction
achieves better reconstructive outcomes with the revitalization and
improvement of mechanical quality of the radiated tissue, creation
of new subcutaneous tissue, accompanied by improved skin quality
of the reconstructed breast without capsular contracture and
without negative impact on oncological outcome.49 Benecial

433

effects of fat transfer are attributed to the angiogenic capacity of

preadipocytes, or stem cells, in the fat.38 Regarding stem cells
themselves, preliminary experimental and clinical studies indicate
that adipose-tissue derived stem cells injected to correct limited
(post-lumpectomy or post-radiation) breast defects or seeded on
scaffold structures to form mini-implants may be useful in breast
reconstruction. Studies are underway to demonstrate that fatderived stem cells taken from a breast cancer patient behave biologically no differently than those from healthy women. Moreover,
it has to be proven that stem cells do not activate or differentiate to
cancer cells themselves.50
Muslim women with breast cancer, even in countries with
a strict form of Islamic laws, have wishes and desires that did not
differ from those of non-Muslim breast cancer patients from relatively secular countries. It is necessary that the breast surgeon
should be respectful of their customs and traditions. Islam,
however, has the exibility to respond to new biomedical technologies, and because it shares many foundational values with
Judaism and Christianity, breast surgeons of a Judeo-Christian
background will nd Islamic bioethics quite similar, therefore, the
technology of stem cells for breast reconstruction is permitted in
Islam halal as long as it is for the patients benet.51 Regarding
Jehovahs Witnesses who in general do not accept blood transfusions, the decision to accept blood or adipose tissue fraction (and
stem cells or processed fat tissue in general) is up to the individual
congregant.52
7. Oncologic follow-up and imaging of the reconstructed
breast
There are no standard practice guidelines for follow-up and
imaging of the reconstructed breast.3 In addition, surgical followup is often neglected when the plastic surgeon takes over the
reconstructed breast management. Mammographic surveillance
after breast conservation surgery is recommended. However,
difculties associated with interpretation of mammograms after
local surgery and radiotherapy should be expected.53,54 Differential
diagnosis may be difcult due to residual hematoma, scarring, fat
necrosis, skin and fascia thickening, increased and nonhomogenous soft tissue density in the breast, and microcalcications. Certainly breast tissue re-arrangement for reconstructive purposes may only result in an even higher rate of false
positive and false negative mammograms. Many institutions have
adopted screening mammography after implant or autologous
tissue reconstruction, thus enabling the same mammographic
look of the skin, chest wall and remaining breast tissue as would
be done for a women who has not had mastectomy.54,55
Mammography could be also useful for identifying a postoperative complication or implant failure and for differentiating
such complications from local recurrence. Mammography of the
post-mastectomy breast reconstruction has not been routine for
most patients although some suggest that it should be.54 A reported
case of local recurrence involving ap tissue reafrms the notion of
a need for diligent oncological follow-up and evaluation of tissue
delivered to the breast area.56
For difcult radiated reconstruction, newer use of contrastenhanced magnetic resonance imaging or PET scanning enables
differentiation of recurrent tumors versus scar or fat necrosis.57,58
For the implant reconstruction, many centers recommend a quick
single-view mammogram just so the chest wall can be better
evaluated. However, evolving, more complicated techniques, such
as three-dimensional mammography, digital breast tomosynthesis
or MRI, can be used to evaluate both for recurrence and implant
status.23,56,59 A study was conducted comparing the sensitivity and
specicity of clinical examination, screening ultrasound, and

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screening MRI in detecting local recurrence in patients who

underwent mastectomy for invasive breast cancer. It was found that
the sensitivity and specicity for clinical examination alone was
poor (70% and 35.2% respectively) but could be signicantly
improved by the use of ultrasound (90% and 88.2% respectively) or
MRI (100% and 100% respectively).59 Considering that ultrasound is
relatively inexpensive, easy to repeat, and since most of recurrences
occur in the quadrant of the original primary tumor, directed,
focused frequent ultrasound follow-up examination may be
warranted.23,59
As to physician follow-up, the plastic surgeon who performs
breast reconstruction must become skilled and attentive to the
follow-up exam of the breast cancer patient. Anything suspicious or
worrisome must be further examined. On the other hand, the
surgical oncologist must not assume that new areas of thickening,
fullness, mass, pain, etc., are just due to the breast reconstruction;
these ndings should be treated with the same level of cancer
suspicion as the same ndings in the non-reconstructed breast.
Ethical approval
Its a review article.
Funding
No.

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27.

28.

Author contribution
All authors are sharing equally in data collection, data analysis,
and writing.

29.
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Conicts of interest
No nancial interest.

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