Breast reconstruction surgery question

[ClandestineStar]

If my pt had DCIS, after mastectomy, how soon and what kind of breast reconstruction surgery is preferred?

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[doc05]

How is this not in your textbook?

 

[Winged Scapula]

Immediate reconstruction is the norm (>90% of members of the American Society of Breast Surgeons offer and advocate for it).

As for "preferred", there are numerous factors involved including smoking history, collagen vascular disorders, prior history of radiation, whether she'll need radiation, operative time vs safety, patient and plastic surgeon preference etc.

But the most common choice is implant based reconstruction: straight to implant for healthy non-smokers without prior history of collagen vascular disease or radiation to the chest wall who want to stay about the same size or smaller but there may also be regional differences and surgeon preference outside of patient issues where a tissue expander to implant two stage procedure is preferable.

Your patient should be discussing this with her surgeon rather than their neurologist.

 

[evilbooyaa]

If patient truly had DCIS alone and had a mastectomy, she would require an awful lot of surprises in her post-surgical pathology specimen to even sniff potentially requiring radiation. For DCIS treated with a Mastectomy, immediate recon would be the board answer, I'd imagine.

 

[Winged Scapula]

If patient truly had DCIS alone and had a mastectomy, she would require an awful lot of surprises in her post-surgical pathology specimen to even sniff potentially requiring radiation. For DCIS treated with a Mastectomy, immediate recon would be the board answer, I'd imagine.

Actually some radiation oncologists will radiate for a positive skin or chest wall margin after mastectomy for DCIS especially if there are other high risk factors such as high grade, microinvasion, estrogen negative or BRCA +.

But your point is taken that that's not the board answer and would be unusual. My point was to make her see that there is no one right answer for when or how breast reconstruction is done. Data from ASPS shows that only at minority of women are even offered reconstruction despite a nearly 20-year-old federal law mandating that insurance pays for it.

 

[evilbooyaa]

Actually some radiation oncologists will radiate for a positive skin or chest wall margin after mastectomy for DCIS especially if there are other high risk factors such as high grade, microinvasion, estrogen negative or BRCA +.

That logic certainly makes sense in an invasive carcinoma (especially for chest wall) but not for pure DCIS. Positive skin margin maybe if it was a nipple-sparing and it was in the retroareolar complex. Maybe some places radiate for fun but I don't see the overt benefit of that. Practice heterogeneity, however, is very real in Rad Onc.

 

[Winged Scapula]

That logic certainly makes sense in an invasive carcinoma (especially for chest wall) but not for pure DCIS. Positive skin margin maybe if it was a nipple-sparing and it was in the retroareolar complex. Maybe some places radiate for fun but I don't see the overt benefit of that. Practice heterogeneity, however, is very real in Rad Onc.

Yep.

I sometimes "manipulate" my consultations based on whom I think will offer the treatment I think is best suited for the patient. As far as radiating for "fun", remember outside of academics, RT pays good money so there may more nefarious reasons.