Sunday, October 8, 2006
11110

Sentinel Lymph Node Dissection and Immediate Breast Reconstruction: Can Delayed Axillary Dissection be Safely Performed?

Colleen M. McCarthy, MD, Andrea L. Pusic, MD, MHS, Babak J. Mehrara, MD, Joseph J. Disa, MD, Jane Fey, RN, MPH, Leslie L. Montgomery, MD, and Peter G. Cordeiro, MD.

Introduction: The role of sentinel lymph node (SLN) mapping for breast cancer continues to evolve. Currently, the standard of care for patients who have a positive SLN is completion axillary lymph node dissection (ALND). For patients who elect to undergo immediate reconstruction, however, the SLN status on permanent histology may complicate management. If a metastasis is found that was not recognized on frozen section, the reconstructed patient may require re-operation to remove remaining axillary nodes. Some have suggested this re-operation may compromise the success of reconstruction.

The purpose of this study was thus to: i) determine the incidence of delayed, completion axillary dissection following concomitant mastectomy, sentinel lymph node biopsy and immediate reconstruction; and ii) determine the incidence of complications following completion axillary dissection in the newly reconstructed breast.

Methods: A retrospective review was performed. Patients who underwent immediate reconstruction following mastectomy and concomitant SLN from September 1996 to December 2004 were identified. Demographic, oncologic and reconstructive data was obtained from a prospectively-maintained, clinical database. Descriptive statistics were reported as a mean (range) and as a percentage of patients having the characteristic.

Results: From September 1996 to December 2004, 1557 patients had mastectomy and concurrent SLN biopsy followed by immediate, postmastectomy reconstruction (expander-implant reconstruction, n=1403 autogenous tissue reconstruction, n=154). Of these patients, 404 (25.9%) had a concomitant ALND; 1151 (74.1%) did not. Following review of permanent histology, 95 patients (8.3%) who did not have a concurrent ALND, were deemed to have a metastatic SLN requiring delayed, completion axillary dissection. Tissue expander/implant reconstruction had been initiated in 88 patients. Autogenous tissue reconstruction was performed in 7 patients: 5 patients had a free TRAM flap using the thoracodorsal artery vessels (n=4) and internal mammary vessels (n=1); 1 patient had pedicled latissimus flap; and, 1 patient had a pedicled TRAM flap. Mean patient age was 45.7 years (n=95; range, 23–77 yrs). Mean tumor size was 1.9 cm (n=79 invasive cancers; range, 1.9-6.0 cm). ALND was performed a mean 22.8 days following immediate reconstruction (range, 7-70 days). Mean number of axillary nodes excised at the time of completion ALND was 13.8 (1-29 nodes); mean number of positive axillary nodes was 1.3 (0-3 nodes). The overall rate of complications following immediate reconstruction and delayed, completion ALND was 2.1% (2/95). Infection (n=1) and expander exposure (n=1) resulted in premature expander removal in 2 patients. There were no partial or total flap failures. All patients successfully completed reconstruction.

Conclusions: This data suggests that mastectomy and concomitant SLN biopsy is a safe option for breast cancer patients undergoing immediate reconstruction. In well selected patients, completion axillary dissection can be safely performed in patients who have undergone immediate, implant and/or autogenous tissue reconstruction.
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