For patients facing a mastectomy for breast cancer there are many reconstructive options – perhaps too many.
First, there are timing issues: Should they and their doctors choose immediate reconstruction, delayed reconstruction, delayed immediate or delayed delayed?
Then there are choices of tissues used, ranging from various implants to natural tissues, mostly skin, fat and muscle, recycled from the customary position on the belly, buttocks or back.
Would the patient select the TRAM or the SIEA flap, or one of the various perforators, such as the DIEP, GAP (SGAP or IGAP), TDAP and ICAP flaps?
“There are just too many options even to describe, much less discuss,” according to one surgeon. How do you explain to a patient that the “internal oblique sometimes slips away from you?”
“Breast reconstruction is, without doubt, a fast-moving field,” said David Song, MD, MBA, section chief of plastic and reconstructive surgery at the University of Chicago, who organized a September 20 conference on the topic. “Many of the people driving that advance, the thought leaders in the field from all over the country, are here,” he said at the meeting, held at a Chicago hotel.
“Each of the programs represented here is evolving rapidly,” Song added, “but we are all evolving separately, in slightly different directions. One of the goals of this conference is to bring us back together, to share advances and trade secrets, discoveries and mistakes – what worked and what didn’t – and to do that with some candor.”
Conference speaker Liza Wu, MD, a reconstructive surgeon, highlighted the divergence. “I learned how to do breast reconstructions at the University of Chicago, where we preferred delayed reconstruction,” she said. Early in her subsequent fellowship, at MD Anderson Cancer Center, the section chief came to see her. He carefully explained, “here, we don’t do it that way.” Instead, they leaned toward delayed immediate reconstruction.
After completing her fellowship, Wu joined the faculty at the University of Pennsylvania. Shortly after her first breast cancer operation there, to be followed in six months by a delayed immediate reconstruction, the department chairman stopped by. “That’s not how we do it at Penn,” he said. They prefer immediate reconstruction.
Her patient, scheduled to return in six months, never came back.
Another topic of discussion was radiation therapy. Surgeons don’t like it, though they see the need for it.
Radiation gets rid of tumor cells that remain after surgery — and nothing mars an exquisite reconstruction like a cancer recurrence — but this effective treatment can distort the surgeon’s sculptural artistry. It can discolor the skin, damage tissue, decrease blood supply and delay healing. Pre-operative radiation can make subsequent surgery more challenging, leading to bleeding and poor recovery.
Sometimes, two surgeons noted, your beautifully contoured flap “ends up in a bucket.”
And, there are regional variations. Joseph Disa, MD, a plastic and reconstructive surgeon from Memorial Sloan Kettering Cancer Center, noted that every breast cancer patient at MD Anderson receives some radiation therapy, but at Sloan Kettering it is only used for selected patients.
“Radiation,” he pointed out, “is not radiation, is not radiation.”
The RadOnc speakers were particularly disapproving of tissue expanders, temporary implants inserted to preserve space for an anticipated living-tissue flap.
But the gold standard for radiation therapy planning is to hit “95 percent of the target tissue with 95 percent of the optimal dose,” said Yasmin Hasan, MD, a UChicago radiation therapist. “We don’t think that happens when an expander is present.”
Her colleague, Stephen Chmura, MD, PhD, a radiation oncologist at the University of Chicago, pointed out that such precision becomes impossible with an expander in the radiation field.
Many of them have metal parts. When radiation beams hits the expander, especially metal, they bounce off unpredictably. That produces hot spots, he said, with a 20 percent boost in the dose, plus multiple cold spots, with suboptimal doses, often to the chest wall, a key target.
Although one of the surgeons insisted this was “not a problem,” and that he was “not seeing recurrences,” the radiation experts objected.
It was hard enough, even without expanders, to cover the target tissues without damaging the heart or lungs, they insisted.
Chmura suggested there had to be a better way. Surgical and radiation experts should talk to each other, he said, and develop tools to improve reconstructive outcomes without causing serious injury.
Hasan, was more succinct. “We do not like expanders,” she explained. The risks outweigh the benefits.
The time has come, she demurely told the surgeons, to “suck it up.”
Given the myriad of treatment options and styles where there are multiple “right answers” and some wrong ones, conferences like Song’s annual Chicago Breast Reconstruction Symposium are “crucial to the advancement of science and artistry of reconstructive breast surgery,” he said. Specialists from multiple disciplines “come, discuss, argue and ultimately walk away with better knowledge.”