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RISK-REDUCING
MASTECTOMY
Tim Davidson
Consultant Surgeon
Royal Free Hospital
February 2015
Breast surveillance in young
women : is it any different?
Ongoing breast surveillance
mammos - density of breast tissue
MRI – lack of specificity
lobular carcinoma, in-situ disease
confidence in screening process
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risk-reduction: prevention v
early detection?
“early” detection = ? good prognosis
grade: high at onset
receptors: triple negative
fear of chemotherapy
no confidence in screening process
ownership of risk management
RRM - what type of surgery?
management of the nipple
bilateral simple / total mastectomy
simple mastectomy + reconstruction
skin-sparing mastectomy + reconstruction
skin- and NAC-sparing mastectomy + reconstruction
areola-sparing mastectomy + reconstruction
RR bilateral salpingo-oophorectomy
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Halsted
mastectomy
simple / total mastectomy
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skin-sparing mastectomy
nipple-areola complex-sparing RRM:
(skin envelope reduction)
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RECONSTRUCTION
TECHNIQUES
BREAST VOLUME
PTOSIS
IMPLANTS
LATISSIMUS DORSI FLAP
(+/- IMPLANT)
EXPANDERS
DIEP FLAP
IMPLANTS + ADM
textured cohesive gel
round / low profile / high profile
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cohesive gel implant
acellular dermal matrix (ADM)
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ADM
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LD flap donor site
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Bilateral total mastectomy and
latissimus dorsi flap reconstruction
skin-sparing mastectomy and
LD flap reconstruction
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skin-sparing
skin-sparing
mastectomy
and free
DIEP flap
(no implant) free
DIEP flap
(no implant)
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awaiting nipple reconstruction
Breast and nipple reconstruction
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RRM + reconstruction :
postoperative complications
loss of skin / nipple sensation
skin flap / nipple necrosis 5 - 10%
infection
implant loss
haematoma / bleeding
asymmetry
need for further surgery
Risk-reducing mastectomy:
10d post-op (skin envelope reduction)
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Essential components of counselling
prior to risk-reducing mastectomy
• accurate assessment of risk / genetic predisposition
• full knowledge of all available non-surgical options
• full understanding of the extent of surgery and operative
complications
• appreciation of the limitations of breast reconstruction
• not smoking
• understanding likely extent of risk-reduction after RRM
= 90% reduction in both incidence & mortality)
Very high risk for breast cancer
BRCA1 gene mutation
• lifetime risk 70 - 85% breast cancer
60% ovarian cancer
BRCA2 gene mutation
previous irradiation for Hodgkin’s
• young, bilateral (15% v 3%)
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BREAST
CANCER
STANDARD
RISK 97%
(RR <2)
MOD RISK
2% (RR 2-3)
HIGH RISK <1%
(e.g. BRCA)
RISK GROUPS
Date of Meeting Hospital Hospital No:
Consultant Genetics Ref: NHS No:
Name of team member presenting this case at the
meeting
Forenames Surname
DOB Age Marital status
Referrer details:
Diagnosis:
Histology:
Adjuvant/predictive survival prognosis:
Genetic assessment: BRCA1 BRCA2
Past medical history:
Family cancer history:
Investigations: Surgical Procedures :
Date of last MRI: Gynaecology assessment Oophorectomy Salpingectomy Other procedures
Y / N Date: Y/ N Date : Y/ N Date :
Psychiatric/Psychotherapy Input:
Photographs Pre-op: Y / N Post-op: Y / N
Outcome/Treatment Plan:
Action:
Risk Reducing Mastectomy MDT
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risk-reducing v. cancer surgery :
is it any different?
Before undergoing RRM :
time to decide
information / booklets / websites
psychological support
realistic expectations from the surgeon / nurse
clinical photographs / patient volunteer
trust in the team / empathy
listen to the patient
