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Pre-mastectomy Sentinel Lymph Node Biopsy: A Possible Strategy to Enhance Outcomes in Immediate Breast Reconstruction
Shailesh Agarwal, MD1, Chad M. Teven, BS2, Nora Jaskowiak, MD2, David H. Song, MD, MBA2.
1University of Michigan, Ann Arbor, MI, USA, 2University of Chicago, Chicago, IL, USA.
Purpose: Sentinel lymph node biopsy (SLNB) at the time of mastectomy is the standard of care for patients with clinically node-negative breast cancer. SLNB timing can pose a challenge to patients who desire immediate breast reconstruction, as they are not fully aware of their need for post-mastectomy radiotherapy, which may affect the outcome of immediate reconstruction. The pre-mastectomy SLNB (PM-SLNB) is a technique in which the SLNB is performed as a separate outpatient procedure 1-2 weeks prior to mastectomy thereby informing patients of their need for adjuvant radiotherapy, which will dictate the decision for immediate vs. delayed reconstruction. Here we study the role of PM-SLNB as a safe and effective procedure to aid in the planning and timing of the patient’s therapy and reconstruction.
Methods: A retrospective chart review of our experience with PM-SLNB from 1/1/2004 to 3/1/2010 was performed. In order to be considered for a PM-SLNB, all patients must have had clinically node-negative breast cancer, and expressed a strong interest in undergoing mastectomy followed by immediate breast reconstruction. Charts were reviewed for histology, SLN pathology, complications associated with PM-SLNB, need for adjuvant radiotherapy, timing of reconstruction, and method of reconstruction.
Results: During the past 6+ years, 69 patients underwent PM-SLNB at our institution. PM-SLNB was positive in 14 (20%) patients. There were no complications associated with the PM-SLNB procedure. Fifty-three patients had infiltrating ductal carcinoma, 7 patients had infiltrating lobular carcinoma, and 9 patients had DCIS. Mastectomy was performed in 67 patients, a mean of 34 days after PM-SLNB (range: 4-184 days); 2 patients with negative PM-SLNB opted to undergo lumpectomy. Nine patients (64%) with positive PM-SLNB received adjuvant radiotherapy; 5 patients with positive PM-SLNB did not have documented radiotherapy. None of the 14 patients with positive PM-SLNB underwent immediate breast reconstruction, sparing the reconstructed breast from radiation. Of these 14 patients, reconstruction was performed with autologous tissue in 5 patients, implants in 3 patients, and autologous tissue with implant in 1 patient; 6 patients are scheduled for delayed reconstruction. Mean wait time to reconstruction after mastectomy was 601 days (range: 366-1,076 days).
Conclusions: Our experience demonstrates the utility, accuracy, and safety of the PM-SLNB in breast cancer patients. PM-SLNB allows us the benefit of knowing the need for adjuvant radiotherapy prior to making a decision regarding immediate reconstruction, thus avoiding the adverse affects of radiation to immediately reconstructed breasts in 20% of our study patients. We believe appropriate patient selection is paramount to implementing this technique. As such, we have utilized this technique with clinically node-negative breast cancer patients who are interested in immediate breast reconstruction thus allowing us to avoid adversely affecting the reconstructed breast with radiation in all of our patients. This experience has been possible due to the close relationship between the surgical oncologists and plastic surgeons at our institution with the unified goal of optimizing aesthetic outcomes.
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