Sunday, October 10, 2004

Viability of performing the Prophylactic Mastectomy and Oophorectomy with Immediate Breast Reconstruction

Arturo H. Armenta, MD and Jeffrey D Friedman, MD.


Germ Line Mutations in the BRCA 1 and BRCA 2 genes have been associated with 5 % of all breast cancers and 10% of all ovarian cancers. Identification of these germ line mutations has afforded High Risk women options to reduce the risk of developing breast and/or ovarian malignancy. In addition to intense screening, prophylactic mastectomies and oophorectomies have been found to reduce the future incidence of breast and ovarian malignancies. The exact reduction of risks and gain in life expectancy from these modalities are currently being formulated in the medical literature. To date, the timing of the mastectomy with the gynecologic procedures remains unclear. There remains significant hesitation on behalf of both the ablative and reconstructive surgeons to perform all of these procedures concurrently due both to the perceived incurred risks of operative/peri-operative complications and the technical issues associated with trans-abdominal procedures. We sought to evaluate our experience with performing the breast and gynecologic procedures concomitantly while elucidating the risks related to these combined procedures.


We retrospectively reviewed such treatment of women with the BRCA 1/BRCA 2 mutations. Patients with mutations in the BRCA 1/BRCA 2 genes underwent bilateral mastectomies, bilateral breast reconstructions and prophylactic oophorectomies with hysterectomies concomitantly. Of these women, 4 underwent bilateral free TRAM breast reconstructions, and 1 underwent bilateral implant breast reconstruction. Following the surgical procedures, these patients were placed in serial compression devices and low molecular weight heparin was administered. Aggressive post-operative ambulation and rehabilitation efforts were initiated to further reduce any risks from prolonged inactivity.


In review of their post-operative experiences, we found that these women experienced no increased morbidity or mortality from their prolonged surgical procedures. No bleeding complications occurred secondary to anticoagulation use. Conversely, no thromboembolic events were seen and all flaps survived without wound healing complications. Long term follow up demonstrated no evidence of abdominal wall hernias or bulges, and patient satisfaction with the combined procedures was good.


In conclusion, having the option of performing two risk reducing procedures and immediate breast reconstruction concurrently is, in our small experience, a viable and worthwhile treatment of women with the BRCA 1/BRCA 2 genetic mutations. We believe that combining the breast and gynecologic procedures is a viable treatment modality without adverse effects, and it may also reduced the overall complications associated with 2 separate procedures. In cases of free TRAM reconstruction, access to the peritoneal cavity was easily achieved through the posterior rectus sheath without the development of postoperative hernias. A larger study however, is recommended to further elucidate the true statistical significance of these findings.