Prophylactic mastectomy

Potential indications include women with atypical lobular or ductal hyperplasia, or lobular carcinoma in situ, and patients with increased genetic risk based on BRCA1 or BRCA2, or strong family history of breast cancer and a first degree relative, especially if the has multiple affected relatives with bilateral or pre-menopausal disease, atypical ductal hyperplasia, atypical lobular hyperplasia, lobular carcinoma in situ, or family history of male breast cancer (Giuliano AE).

Is an option for women with LCIS without additional risk factors

Bilateral prophylactic mastectomy is a consideration for other high risk groups including women treated for Hodgkin’s disease with mantle radiation, and women with non-BRCA hereditary breast cancer syndromes such as Cowden syndrome or Li-Fraumeni syndrome.

Can be utilized to prevent breast cancer and a contralateral breast after breast cancer diagnosis.

Women without breast cancer significantly overestimate their breast cancer risk: estimated probability of dying from breast cancer within 10 years is 2 fold higher than the Gail model, and the mean lifetime calculated risk using a Gail model in1 study was 15% with a median risk perceived by patients at 50% (Alexander NE et al, Goldflam K et al).

Bilateral prophylactic mastectomy dramatically reduces the development of breast cancer in high risk women (Hartmann LC).

Associated with a 90% reduction in frequency of breast cancer.

It is estimated to have bilateral prophylactic mastectomy for patients with BRCA mutations is associated with a risk reduction in breast cancer of about 90%.

The formation of breast cancer occurs only rarely in any residual breast tissue regardless of the type of mastectomy data as performed, that includes total mastectomy, or nipple sparing mastectomy, or subcutaneous mastectomy(Evans DG).

SEER data indicates that 3.3% in women with surgically treated invasive unilateral breast cancer and 4.1% of patients with unilateral DCIS undergo bilateral mastectomies as part of the first course of treatment (Tuttle TM).

Contralateral prophylactic mastectomy among patients with unilateral invasive breast cancer increased 150% from 1993 to 2003, with no evidence plateauing.

While contralateral prophylactic mastectomy reduces the risk for developing contralateral breast cancer, there is conflicting evidence on whether it reduces breast cancer mortality or overall death in women with sporadic breast cancer.

For women with early stage sporadic breast cancer with a minimal 0.5-0.75% annual risk for developing contralateral breast cancer and lifetime risk of 13% and 3.5% for women less than 50 years and greater than 50 years at diagnosis, respectively there is lack of definitive clinical evidence for the benefit of contralateral prophylactic mastectomy.

The 3 main surgical options: Bilateral simple mastectomy without obstruction, bilateral skin sparing mastectomy with immediate reconstruction, and bilateral nipple sparing mastectomy with immediate reconstruction.

Complications from bilateral skin sparing mastectomy occur in 20% of patients and include: Infection, flap necrosis,, loss of reconstruction.

Nipple sparing mastectomies are performed with either a radial or inframammary incision, and the ductal tissue beneath the nipple is excised for pathologic review

If DCIS or invasive cancer is identified in the tissue removed, then the nipple-and areola complex is excised.

In nipple sparing mastectomy nipple necrosis can occur in 5% of patients.

The occurrence of cancer following nipple sparing mastectomies in the nipple-areole a complex is extremely rare.

Studies show that there is no clear anatomic tissue plane that separates breast tissue from subcutaneous fat and residual breast tissue is present after mastectomy in 21-94% of patients (Robertson SA).

Breast tissue can at times be extended into the axilla and below the inframmamary fold.

Superficial fascial layer of the breast is present and identifiable in the thorax and abdominal wall

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