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7 Patient Counselling forBreast Oncoplasty andReconstruction
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procedure and an important part of counselling is
to make them aware that mastectomy does not
offer an advantage in survival outcome. Patients
considering breast conservation are also counselled for the possibility of needing further surgery in the event of having involved margins,
particularly in those centres where the facility of
having intraoperative frozen section is not
available.
7.1.2 Partial Breast Reconstruction
Breast conserving procedure with partial reconstruction offers an added advantage of achieving
good cosmetic outcome and improved quality of
life in all the age groups [14–16]. Partial breast
reconstruction can be performed using various
local perforator aps. The choice of aps is
dependent on the size and location of the tumour,
skin involvement, and also the availability of tissue at the donor site. As scars vary for different
aps, the type of local perforator ap used for
partial reconstruction is an important aspect of
counselling. It is also important to discuss if partial breast reconstruction will be performed in the
same setting or as a staged procedure along with
the implications of having positive margins after
the rst procedure.
7.1.3 Total Breast Reconstruction
All patients undergoing mastectomy are given
the options for immediate or delayed reconstruction if clinically feasible. Several studies have
shown that higher patient satisfaction and better
aesthetic results can be achieved in immediate
reconstruction versus delayed reconstruction [17,
18]. Also, there is reduced psychological morbid-
ity in the post-operative period in patients undergoing immediate reconstruction [19] but despite
this, an immediate reconstruction may not be
option for every patient. Previously, women
needing post-radiotherapy were not offered
implant-based reconstruction; however, recent
studies have shown that this is not an absolute
contraindication to implant-based reconstruction
but these women have to be counselled about the
high risk of capsular contracture after radiotherapy [19]. In some cases, a staged reconstruction
may be a better option particularly the ones who
want to increase the size of their reconstructed
breasts, those with a higher risk of post-operative
complications or undergoing delayed implantbased reconstruction.
7.1.4 Nipple Preservation
When offering skin sparing mastectomy, it needs
to elucidated whether the nipple areolar complex
can be preserved and this is mainly dependent on
the oncological safety and technical feasibility.
Previously, nipple preservation was offered to
patients with small tumour or when the tumour to
nipple distance is >2cm [20–22] but more recent
studies have shown that leaving a 2–3mm rim of
peripheral subcutaneous tissue around the nipple
removes most of the ductal tissue while preserving the vascularity of the nipple [23]. Similarly,
in patients with ptotic breasts, nipple preservation on a dermal pedicle may not be feasible due
to high risk of necrosis. Preservation of nipple
has a bearing on the incision placement and
patients are shown appropriate clinical photographs. In cases where nipple is preserved,
patients are warned about the risk of nipple
necrosis, loss of sensation, and arousal symptoms
[24].
When nipples are not preserved, the option of
having nipple reconstruction should be discussed
at the time of initial consultation for breast reconstruction [25]. The option of having nipple reconstruction, areolar tattooing as a subsequent
procedure should be discussed with the patient.
Three-dimensional tattooing has shown promising results in patients who do want to undergo
nipple reconstruction and some women may just
decide to use stick-on nipples after surgery.
Although these procedures are carried out at a
later stage, studies have shown high satisfaction
levels in patients who opt for nipple reconstruction after having breast reconstruction [26–28].
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7.1.5 Types ofReconstruction
During pre-operative counselling, most of the
discussion is around the options for
reconstruction.
Autologous and implants are two broad types
of reconstruction. The procedures vary in surgical complexity, time to recovery, types of complication, and aesthetic outcomes. Most surgeons
generally focus on the acute phase of physical
recovery which involves post-operative pain and
regaining functional ability to walk and move
about normally and nurses who are trained for
pre-operative reconstruction counselling not only
support them about the physical aspects of recovery but also provide them emotional support.
Implant-based reconstruction is an attractive
option for patients who have inadequate tissue
for autologous reconstruction or the ones who
want to avoid donor site morbidity. The operative procedure is relatively simpler but implant
reconstruction often requires revisional surgery
particularly in the long term if they develop capsular contracture which is especially the case
after radiotherapy [29]. Tissue expanders and
implants are often used for post-mastectomy
reconstruction. An educational discussion should
be conducted with the patient on both the choice
of the implant type and the realistic size of
implant appropriate to her body gure. Tissue
expanders are also used to recruit more skin
envelope if skin is decient or if a bigger implant
is desired at a later stage. Patients should be
warned that they will require serial expansions
and exchange at a later stage. The anatomical
implants are generally used to give a more natural appearing breast mound [30]; however,
patients undergoing subpectoral reconstruction
are also given the option for having a round
implant if they wish to have upper pole projection of the reconstructed breast.
Autologous reconstruction places greater
demand on patients in the short term as the operative time and post-operative recovery are longer
but patients require few revisional surgery when
compared with implant-based reconstruction
[31]. The commonly performed autologous
reconstruction are the pedicled latissimus dorsi
aps and free abdominal aps. Abdominal ap
reconstruction is a viable technique in patients
who have a suitable abdominal pannus as it gives
natural consistency of a native breast but it is
associated with abdominal pain, protracted convalescence, and risk of ap failure. Patients opting for abdominal ap also need to be counselled
that they cannot have the same procedure if they
require contralateral breast reconstruction in
future.
Patients considering latissimus dorsi reconstruction are screened for high sporting activities,
occupational shoulder function requirements, or
pre-existing shoulder pathology. Temporary
shoulder dysfunction is routinely seen with latissimus dorsi ap reconstruction, most studies
have not seen long-term impact on shoulder function but some authors have suggested the loss of
power and endurance [32, 33]. In patients undergoing LD ap reconstruction, it is imperative to
pre-operatively counsel them for intensive postoperative physiotherapy [34].
7.1.6 Sensory Changes
Although excellent cosmetic outcomes can be
achieved with reconstruction, most reconstructed
breasts do not regain complete sensation. A study
showed that nipple preservation does not improve
long-term skin sensation [35]. Another study
which specically looked at sensation in patients
breast reconstruction showed that patients undergoing nipple sparing mastectomy had better preserved light touch and pleasurable sensation [36].
According to the theory of Leder [37], generally
there is no awareness of healthy body parts but
once a body part is impaired, one suddenly
becomes aware of it. It is therefore not uncommon to see women complain more about their
breasts not feeling like their own and paradoxically they become more aware of the reconstructed breast although no sensation is present.
Women who have undergone breast reconstruction report the unnatural feeling of the breast and
loss of movement which if not discussed pre-
7 Patient Counselling forBreast Oncoplasty andReconstruction
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operatively leads to dissatisfaction [38–40].
Women undergo breast reconstruction to restore
a sense of wholeness [41] and it cannot be
emphasised to make patients aware of that they
would lose the normal sensation after breast
reconstruction.
7.1.7 Anaplastic Large Cell
Lymphoma
There is now increasing awareness about breastimplant associated anaplastic large cell lymphoma (BIA-ALCL) which is a rare T-cell
lymphoma. Although BIA-ALCL has demonstrated good prognosis, the development of lymphoma is a serious adverse event for any patient
[42–44]. All patients undergoing implant-based
reconstruction are therefore warned about this
rare complication pre-operatively. This commonly presents as a delayed uid collection
around a breast implant. The estimated incidence
of ALCL is 0.1–0.3 per 100,000 women with
prostheses per year. So far, the reported cases
with known involved devices have been with textured implants rather than smooth implants [45].
Treatment for ALCL involves capsulectomy with
removal of implant and adjuvant chemotherapy is
required depending on the stage of disease.
Patients need to be counselled that this is not
related to breast cancer and differs in treatment
from breast cancer.
7.1.8 Implant Reconstruction
andMesh
Techniques for implant-based reconstruction
have revolutionised over the last two decades.
Implants were placed previously under the muscle with partial or complete coverage of implant
but in the current era, implants are generally
placed in the prepectoral pocket. There are no
specic contraindications for prepectoral reconstruction but patients requiring adjuvant radiotherapy are better served with prepectoral
reconstruction as radiation induced pectoralis
brosis is avoided [46]. Although the complication rates with both techniques are comparable,
the pros and cons of each technique should be
discussed with patients, i.e. rippling and implant
visibility with prepectoral implants and animation deformity with subpectoral reconstruction
[47, 48].
With either techniques, patients need a mesh
for partial or complete coverage of implants
unless dermal sling can be used for implant coverage. There is a variety of meshes available and
patients are counselled pre-operatively about the
mesh to be used for reconstruction. Studies have
shown a low incidence of capsular contracture
with the use of acellular dermal matrix [49]. It is
important to ascertain patients’ beliefs and
choices with the use of meshes as patients with
certain religious beliefs would have reservations
in having a biological mesh.
7.1.9 Eect ofAdjuvant
Radiotherapy
Women undergoing risk reducing surgery are
warned about the risk of nding cancer in the
histology specimen and may need adjuvant
treatment but in patients undergoing mastectomy for cancer, the likelihood on needing
radiotherapy and its impact on breast reconstruction is discussed pre-operatively. A metaanalysis had shown less morbidity with
autologous reconstruction compared with
implant-based reconstruction when patients
receive radiotherapy [50]. Traditionally, implant
reconstructions were carried out with complete
muscle coverage but low complication rates
have been reported with the use of acellular dermal matrix [51, 52]. Implant-based reconstruction is therefore no more considered as an
absolute contraindication for radiotherapy. If
patients are undergoing a staged reconstruction
and there is a likelihood of receiving adjuvant
radiotherapy, expanders with a remote port are
often used. It is a good practice to advise patients
on the type of expander which will be used during the procedure.
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S. Jaerbhoy et al.
7.1.10 Revisional andSymmetrising
Procedures
Breast reconstruction is not always a one-step
procedure and patients have to be informed about
the likelihood of needing further procedures to
achieve asymmetry or an acceptable cosmetic
outcome. Patients undergoing nipple sacricing
surgery will need nipple reconstruction and areolar tattooing as a nal step. Patients with ptotic
breasts often require a symmetrising mastopexy.
Patients should be counselled for revisional surgery if opting for implant reconstruction as capsular contracture is a known sequalae requiring
exchange of implants or have an autologous
reconstruction. Patients who develop rippling
often require lipolling to improve cosmesis particularly when prepectoral reconstruction is carried out and those patients with subpectoral
reconstruction may require replanning to correct
the animation deformity.
It is not uncommon that women undergoing
mastectomy often want contralateral mastectomy
as they overestimate the risk of developing contralateral disease or to improve survival. Various
existing tools can be used to predict the risk of
having genetic mutation and genetic tests should
be offered in appropriate cases before offering
contralateral risk reducing surgery. It is essential
to allow the cooling off period before patients
make any decisions regarding genetic testing or
contralateral surgery. However, patients undergoing DIEP reconstruction have a one-off option for
this ap to be used and tools such as Manchester
scoring system can be used to predict the risk of
contralateral surgery before offering any surgical
intervention [53].
7.1.11 Recovery Following Surgery
Patients should be well-informed about what to
expect in the post-operative period. Studies have
shown that many women encounter unanticipated
struggles in the recovery period [39]. Recovery
following surgery involves physical as well as
emotional recovery and this generally involves
physical as well as emotional recovery. Physical
recovery time is affected by many factors, especially in relation to the actual surgical procedure
itself, the degree of pain and fatigue experienced,
post-operative complications or if reconstruction
failure occurs. Physical recovery generally has
two phases, rst one is shorter in duration and
involves overcoming the postsurgical pain and
regaining functional ability. The second is marked
by longer period of physical recovery and is more
experienced by women undergoing more complicated surgery. Emotional recovery is more complex that deals with women’s reaction to the
diagnosis itself, loss of breast, and the anxiety
and fear of cancer recurrence. If women start
accepting the reconstructed breast as part of their
normal body, the emotional recovery is quicker
but post-operative complications and a different
feeling of the reconstructed breast may take longer for women to recover emotionally following
breast reconstruction.
To conclude, pre-operative counselling for
breast reconstruction is a complex process which
involves a few visits before surgery. This can be
effectively achieved by using multimodal
approach to counselling to discuss various options
and complications associated with a reconstruction technique. Providing adequate pre-operative
information improves patients experience and
recovery following breast reconstruction.
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Applied Aspects ofSystemic
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Therapy inBreast Oncoplasty
andReconstruction
SudhirKirar, AjayGogia, andS.V.S.Deo
8
8.1 Introduction
Systemic therapy in non-metastatic breast cancer
reduces the risk of distant recurrence by acting on
subclinical distant metastasis and thus potentially
improves survival. Over the last two decades, the
use of neoadjuvant systemic therapy (NAT) has
almost doubled in clinical practice and in addition
to improved oncoplastic techniques, NAT has
made breast conservation increasingly feasible [1].
NAT has multiple benets over the adjuvant use of
systemic therapy. Foremost, NAT can downstage
the tumor in the breast and/or axilla, thus improving resect- ability, increasing breast conservation
surgery (BCS) rates, improving cosmetic outcomes [2]. In addition, tumor sensitivity to neoadjuvant systemic agents bears therapeutic and
prognostic implications. The persistence of residual disease after NAT in aggressive subtypes like
TNBC or Her-2 positive breast cancer heralds
poor prognosis and additional adjuvant therapy is
now known to improve outcomes in these highrisk subtypes [3]. NAT also buys time in the
patients who are not candidates for immediate surgery; for example, those pending germline muta-
S. Kirar · A. Gogia (*)
Department of Medical Oncology, All India Institute
of Medical Sciences, New Delhi, India
S. V. S. Deo
Department of Surgical Oncology, BRA-IRCH,
AIIMS, New Delhi, India
tion testing, patients on short term anticoagulation
due to various causes, breast cancer in a pregnant
female and when you need time to decide on risk
reducing and reconstructive surgical options.
8.2 Indications andTypes ofNAT
Currently NAT is indicated in all patients with
locally advanced (stage III) breast cancers,
patients with stage I and II breast cancer with
adverse tumor breast ratio, and in patients with
TNBC and Her 2 neu positive breast cancers with
more than 2cm size tumor and positive axillary
nodes. Role of NAT in operable hormone receptor positive cancers is less clear.
At present, chemotherapy is the most common
form of NAT.While the addition of anti-HER2
target therapy in HER2 amplied breast cancer
has become the standard of care, neoadjuvant
endocrine therapy has a role in a small subset of
postmenopausal patients.
8.3 Multidisciplinary Approach
andRole ofSurgeon
inPlanning NAT
Multidisciplinary protocol based approach is
essential for planning NAT and the surgeon
should be actively involved from the beginning
for overall planning, surgical decision making,
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023
S. V. S. Deo (ed.), Breast Oncoplasty and Reconstruction,
https://doi.org/10.1007/978-981-99-5536-7_8
57
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S. Kirar et al.
tumor and nodal response assessment and localization in close collaboration with radiologist.
Surgeon should meticulously document the clinical details including number, size and location of
tumor, tumor versus breast ratio, axillary node
status, and feasibility of breast conservation therapy prior to NAT.Treating surgeon should decide
regarding choice of imaging technique in consultation with radiologist and plan timing and
location of metal marker placement to facilitate
tumor localization following NAT. Extent of
resection should be tailored according to postNAT residual disease and not according to preNAT size. Pathologist also plays an important
role in the evaluation of post-NAT surgical specimens and evaluation of histopathological
response and residual tumor burden.
8.4 Neoadjuvant Therapy
inHER2-Negative Breast
Cancer
In this subtype, NACT is primarily indicated to
downstage locally advanced tumors and improve
surgical or cosmetic outcomes. Broad consensus
based on a few randomized studies and individual patient data meta-analyses suggests that chemotherapy regimens appropriate for adjuvant
treatment are also optimal for NACT except for
use of carboplatin in TNBC. Four cycles of
anthracycline based regimens (cyclophosphamide with cyclophosphamide: AC; epirubicin
with cyclophosphamide: EC) given in sequence
with 4cycles of a taxane as NACT improves pCR
rates and reduces 10-year breast cancer mortality
by one-third; thus, making this regimen the preferred choice in HR+ Her2-negative early breast
cancer, especially in high-risk disease eld [4, 5].
The taxane of choice after 4cycles of AC or EC
is weekly paclitaxel, although evidence from the
adjuvant setting suggests that 3-weekly docetaxel
is a fair substitute in patients with HR+ disease
eld [6, 7]. In patients who are not candidates for
anthracyclines (advanced age, cardiac disease),
four to six cycles of TC regimen (docetaxel and
cyclophosphamide) are an optimal alternative,
particularly in those with low or intermediate
clinical risk. The evidence for use of TC regimen
comes from an adjuvant setting where 4cycles of
TC are associated with superior DFS (81% vs
75%) and OS (87% vs 82%) compared to 4cycles
of AC.Also, 4AC followed by 4T is associated
with only 2.5% relative increase in 4-year iDFS
(invasive disease-free survival) over 6 cycles of
anthracycline free TC- regimen in Her2-negative
disease and similar OS [8].
In TNBC, neoadjuvant chemotherapy is the
standard of care in ≥cT2, cN0, and all cN+ diseases owing to robust data suggesting high rates
of pCR (35–40%). Those who achieve pCR show
a 75% reduction in risk of recurrence and their
overall survival is similar to non-TNBC subsets
[3]. By the same token, patients with residual disease after NAT have a higher risk of recurrence
and once identied, their survival is known to
improve with subsequent adjuvant systemic
agents like capecitabine. Like other HER2 negative subtypes, anthracycline and taxane containing regimens are most used. An anthracycline
free regimen containing docetaxel and cyclophosphamide is an option in patients with low
disease burden. A meta-analysis of 9 RCTs demonstrated that improvement in pCR with carboplatin comes at the cost of signicantly increased
grade3 or 4 adverse events without any increase
in EFS or OS [9, 10]. Therefore, the use of platinum agents in TNBC is not standard of care and
detailed discussion with all patients is warranted
before adding them to standard NACT.
The planned number of cycles of NACT are
completed in one go to maintain dose intensity
even if there is a signicant resolution of tumor,
provided it is being tolerated well and there is no
progression of the disease. When standard chemotherapy is delivered in a dose-dense manner, it
improves DFS and OS, especially in nodepositive high-risk disease [11] and has become
the current standard of care. The planning of chemotherapy should be individualized in patients
aged more than 70years depending on their biological age and medical tness (Table8.1).
8 Applied Aspects ofSystemic Therapy inBreast Oncoplasty andReconstruction
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Table 8.1 Neoadjuvant therapy regimens for HER2-negative disease
pCR
Drugs and regimes Schedule
Epirubicin (E) or doxorubicin
(A) plus cyclophosphamide
(C) followed by paclitaxel
(P)
Docetaxel (T) plus
cyclophosphamide (C)
Epirubicin (E) or doxorubicin
(A) plus cyclophosphamide
(C) followed by docetaxel(T)
Docetaxel (T), doxorubicin
(A), and cyclophosphamide
(C)
4EC (E=90mg/m2, C=600mg/
m2) or 4AC (A=60mg/m2,
C=600mg/m2) every 14days
followed by 4P (175mg/m2) every
14days or 12P (80mg/m2) once
weekly
4TC (T=75mg/m2, C=600mg/
m2) every 21days
4EC (E=90mg/m2, C=600mg/
m2) or 4AC (A=60mg/m2,
C=600mg/m2) every 21days
followed by 4T (100mg/m2) every
21days
6TAC (T=75mg/m2, A=50mg/
m2, C=500mg/m2) every 21days
rates Common toxicities
8–34% Nausea, myelosuppression,
7–17% Myalgias, edema,
26% As with AC/EC-T regimen
8–36% Nausea vomiting, higher
59
sensory neuropathy febrile
neutropenia, cardiac
dysfunction, secondary leukemia
myelosuppression, febrile
neutropenia
incidence of myelosuppression
or febrile neutropenia
8.5 Neoadjuvant Therapy
inHER2 Positive Breast
Cancer
HER2 amplication is seen in 25–30% of breast
cancers and is associated with an aggressive disease. NAT is the standard of care in HER2 positive tumors >2cm and/or node-positive disease
as high rates of pCR (40–50%) are expected that
translate into better survival [3, 12]. NAT in these
tumors helps identify the high-risk subgroup
(which did not attain pCR) where stepping up of
adjuvant anti-HER2 therapy using trastuzumab
emtansine (TDM-1) would help improve survival, especially in node-positive HR+ patients
[13]. Dual HER2-blockade with trastuzumab and
pertuzumab in combination with chemotherapy
improves pCR rates (45–50%) and has low rates
of left ventricular dysfunction rendering it the
current standard of care in HER2 positive breast
cancer [14, 15]. The most common chemotherapy used is an anthracycline-taxane sequence
with dual anti-HER2 therapy given concurrently
with taxane rather than anthracycline as this
approach yields higher pCR [16]. Docetaxel and
carboplatin are other effective options. There is
evidence that primary surgery followed by less
intensive adjuvant systemic therapy (12cycles of
weekly paclitaxel with 3 weekly trastuzumab for
1 year) yields excellent outcomes (7-year DFS:
93%) in HR+, HER2 negative and node-negative
tumors ≤2 cm [17, 18]. At present anti-HER2
therapy for 1year is standard of care as 2years of
therapy did not add benet over 1year and data
on non- inferiority of 6months of therapy as compared to 1year is inconsistent [19] (Table8.2).
60
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Table 8.2 Neoadjuvant therapy regimens for HER2-positive disease
Drugs and regimes Schedule
Pertuzumab (P), trastuzumab (H),
docetaxel (T), carboplatin (C)
Trastuzumab (H), docetaxel (T),
carboplatin (C)
Epirubicin (E) or doxorubicin
(A) plus cyclophosphamide (C)
followed by paclitaxel
(T)+trastuzumab
(H)+pertuzumab (P)
6PTCH (P=840mg in cycle 1 and
420mg in subsequent cycles,
T=75mg/m2, C=AUC 6, H=8mg/
kg loading dose followed by 6mg/kg)
every 21days followed by 1year of
anti-HER2 therapy
6TCH (T=75mg/m2, C=AUC 6,
H=8mg/kg loading dose followed by
6mg/kg) every 21days followed by
1year of anti-HER2 therapy
4EC (E=90mg/m2, C=600mg/m2)
or 4AC (A=60mg/m2, C=600mg/
m2) every 14days followed by 4P
(175mg/m2) every 14days or 12P
(80mg/m2) once weekly + P=840mg
in cycle 1 and 420mg in subsequent
cycles + H=8mg/kg loading dose
followed by 6mg/kg every 21days
followed by 1year of anti-HER2
therapy
S. Kirar et al.
pCR
rates Common toxicities
45.3–
51.9%
45.8%
61.8% As with AC/EC-T regimen
Sensory neuropathy,
myelosuppression, febrile
neutropenia, congestive
heart failure
8.6 Neoadjuvant Endocrine
Therapy
Neoadjuvant endocrine therapy is primarily indicated in postmenopausal females with HR+
breast cancer, who are not candidates for upfront
surgery or NACT (advanced age, multiple uncontrolled comorbidities, high tumor burden) and
warrant downstaging of tumor to facilitate resection or improve cosmetic outcomes. NET is not
recommended in premenopausal patients due to a
lack of data [20]. Contemporary evidence suggests that NET yields similar clinico-radiological
response rates, rates of BCS, and lower toxicity
as compared to NACT; however, long-term survival outcomes of patients treated with NET followed by surgery are sparse [22]. Tumors with
strong estrogen or progesterone receptor expression (Allred score of 7 or 8) and/or low proliferative index (Ki67 < 10%) are more likely to
respond to NET.In terms of efcacy of neoadjuvant endocrine therapy, aromatase inhibitors (AI)
were associated with superior clinical response
rates (OR=1.69) and higher rates of breast conservation (OR=1.62) as compared to tamoxifen
[21]. The optimal duration of NET is controversial at present and 3–4 months of NET is routinely given based on experience from clinical
trials of neoadjuvant chemotherapy as the
majority of patients who will respond do so in
3–6months.
8.7 Assessment ofResponse
toNeoadjuvant Therapy
Progression of disease during NAT generally
means signicantly worse PFS and OS; early
identication of this small fraction of patients
(3%) helps obviate toxicity of non-benecial
NAT and guides change of therapeutic modality.
There is a lack of prospective evidence regarding
the preferred technique, frequency of monitoring,
denition and management of disease progression if identied. It is routine practice to perform
a physical examination, bilateral mammography,
and/or breast ultrasound (USG) at baseline to
accurately determine the extent of disease in the
breast and axilla to avoid over- or under- treatment. During NAT, however, broad consensus is
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