Reconstruction With IBC

Akevia

You're welcome Bride and I didn't notice that either that we were diagnosis about the same time. Yeah freaking out and being scared will not make it go away. I'm not scared of death but that being said I don't feel BC is a death sentence and I know I'm not got to die from it. I play an very active role in my treatment and I found an oncology that cool with me doing so and respect my opinion. I did cry once when I realized I was going to get my breast removed, call it vain but I wanted to leave with all my body parts if I could have helped it. like we say in the medical field and what I was taught in school it's all trial and error nothing is promised and like you say no right or wrong answer. :-)

sbelizabeth

Akevia, you're so right.  There is no one perfect way.  My 90-year-old momma visited over the weekend and I helped her in the shower.  Her 100% flat chest, with the mastectomy scars completely faded, was really lovely--smooth and clean.  She wears no prosthetics--mostly a camisole with a loose button-up shirt--and she looks and feels great.

And I have two reconstructed breasts that feel just like breasts, since they were made out of abdominal skin and fat.  I love them.  They make me feel whole and beautiful again.

My momma and me--we're very different, but both very happy.

Akevia

Sbelizabeth your mother is 90 yo. That's awesome, when did she have breast cancer? Now that's a survival story, I have no doubt your breast are wonderful and my plan is to get DIEP flap also and that seem the most natural looking to me.

sbelizabeth

Her first cancer was found when she was in her 60's.  Mastectomy, axillary node dissection, chemo, the works.  The second cancer was found when she was in her 70's, and they'd started using sentinel node biopsy by then, so she kept her nodes on that side but had the mastectomy.  As you can tell, she's going strong.

Akevia

Yes she is!!!! That's good to hear that she battled through BC twice and she's still here at 90!! 

amarantha

Donna,  have you now had your nipple reconstruction ? I'm interested in hearing about how it went. 

Bride, and Akevia I was diagnosed just a few weeks or so before you, actually mid-November 2013, but I already knew, so we can be buddies. Bride what do you mean you lack perspective ?

Akevia

wow I see that Amarantha was something in the water last year that we all had a drink of!! 

Donna2012

amarantha - 

Yes, I had nipple reconstruction 1 week ago.  It was easy and I think it is going to look great.  It is now twice the size of a normal nipple, because it will shrink by about 1/2.  The placement is great & I am very happy that I had it done.  

Nel138281

Akevia,

Like many others I was told to wait at least a year.  I was not really wanting to do reconstruction anyway, but at the end  of the year, no way.  I am just not up for any more surgery, particularly elective.  Two years later I just go lopsided most of the time.I am relatively small breasted so simpler from that regard.  I am somewhat cautious about clothing choices, but today t-shirt and lopsided.  It is easier in the winter, sweaters and scarves., but now if people look - there issue not mine. 

You will make the choice that is right for you.  Just remember there are many options

Nel

Akevia

Thanks Nel for responding and I think if my breast were small I wouldn't mind so much either. After going through so much I can see how you wouldn't want to do more surgery. 

amarantha

My surgeon told me yesterday, that I will have to wait at least a year

Akevia

Amarantha for reconstruction?

Faith316

With IBC, that is pretty typical.  I initially thought I would do immediate reconstruction (DIEP) but they wouldn't let me since I had IBC.

Kicks

I, too; was told that with IBC that's a year before thinking about recon.

jos

FROM MD ANDERSON - hope it helps. I plan to follow this protocol with tissue expanders..

Chapter 7Surgical Therapy for Inflammatory
Breast Cancer

Sarah M. Gainer, Hideko Yamauchi, and Anthony Lucci

Abstract Surgicaltherapyforinflammatorybreastcancer(IBC),themostaggressive
and fatal form of breast cancer, continues to challenge surgeons. Surgical therapy
should only be undertaken in patients with IBC who respond to neoadjuvant chemo-
therapy (NAC). The recommended definitive surgical treatment for IBC is modified
radical mastectomy. Currently, breast conserving therapy, skin-sparing mastectomy,
nipple-sparing mastectomy, sentinel lymph node biopsy, and immediate breast
reconstruction are contraindicated for patients with IBC. Multimodality treatment,
including surgery, is crucial for achieving optimal outcomes.

Keywords Inflammatory breast cancer • Surgery for inflammatory breast cancer
• IBC • Modified radical mastectomy • MRM • Multimodal therapy for IBC • Axillary
lymph node dissection • Chemotherapy response • Postmastectomy radiation
• Local control for breast cancer

7.1 A Historical Perspective

In 1924, Lee and Tannebaum described 18 cases of inflammatory breast cancer
(IBC). Three women in this series underwent radical mastectomy, and all three died
of recurrent disease, prompting Lee and Tannebaum to recognize the “inefficiency of
surgery” for IBC [1]. In 1951, Haagensen and Stout reported on a series of 29 patients

S.M. Gainer • A. Lucci

Surgical Oncology, The University of Texas MD Anderson Cancer Center,
1400 Pressler st, Unit 1484 Houston, TX 77030

e-mail: sgainer@mdanderson.org; alucci@mdanderson.org

H. Yamauchi (*)

Breast Surgical Oncology, St Luke’s International Hospital, 9-1,
Akashi-Cho, Chuo-ku, 104-8560, Japan

e-mail: hidekoyamauchi@mac.com

N.T. Ueno and M. Cristofanilli (eds.), Inflammatory Breast Cancer: An Update, 67
DOI 10.1007/978-94-007-3907-9_7, © Springer Science+Business Media B.V. 2012

68 S.M. Gainer et al.

with IBC treated with radical mastectomy alone. The mean survival time in these
patients was 19 months, and all had died by 5 years [2]. In 1961, Barber et al. pre-
sented 53 cases of IBC. Of the 50 patients who underwent surgical therapy, two were
treated with simple mastectomy, six were treated with radical mastectomy, and 42
were treated with radical mastectomy and postoperative radiation. The overall mean
survival time was 25 months, and five patients were alive at 5 years. They concluded
that this finding “would suggest that a more positive surgical attack on this highly
malignant form of carcinoma [was] indicated” [3]. In 1981, Bozzetti et al. reported
on a series of 114 patients with IBC. Eight patients underwent radical mastectomy
alone, and only one was alive at 5 years, whereas 24 underwent radical mastectomy
followed by radiation therapy, and seven were alive at 5 years [4]. These series had
dismal results for patients treated with surgery alone and established that surgery in
this setting yielded minimal survival benefit. In addition, local recurrence rates of
approximately 50% were reported in patients treated with surgery alone [5, 6].

In the 1970s, doxorubicin-based chemotherapy was introduced. Shortly thereafter,
oncologists began using chemotherapy in the neoadjuvant setting [7]. Neoadjuvant
chemotherapy (NAC) was shown to improve overall survival time in patients with
IBC, although local recurrence rates continued to be high [8–10]. Continued advance-
ments in NAC regimens, including the introduction of taxanes and herceptin, have
perpetuated improvements in both overall survival and local recurrence in patients
with IBC [11–17]. The current recommendation of the panel at the First International
Conference on IBC is a multimodality approach to treatment including NAC, modified
radical mastectomy, and postoperative radiation therapy [18].

7.2 Selection of Surgical Candidates

Most patients with IBC have locoregional disease at diagnosis and are therefore
initially considered inoperable. NAC is recommended for potentially shrinking the
primary tumor and/or eradicating axillary disease, thereby rendering previously inop-
erable patients eligible for definitive surgical therapy. This approach has been reported
to be successful in 86–95% of patients [11, 19, 20]. Kell and Morrow noted a trend
toward increased use of mastectomy in multimodality treatment of IBC, despite a
change in the use of surgery from an initial modality to a post-NAC modality [21].

Response to NAC should be monitored using both physical examination and
radiographic imaging. Physical examination should be performed every 6–9 weeks
during chemotherapy [22]. Imaging for assessment of response should be performed
at the conclusion of chemotherapy and should be compared to baseline imaging.
The panel at the First International Conference on IBC recommends using both
mammography and ultrasonography to evaluate response to NAC. In addition,
although data are limited, magnetic resonance imaging is recommended if parenchy-
mal lesions are not detected on routine imaging or prior to enrollment in protocols
examining the role of breast magnetic resonance imaging in patients with IBC [18].
Pictures of the affected breast are also required to determine the surgical field.

7 Surgical Therapy for Inflammatory Breast Cancer 69

Patients who do not respond to NAC have lower rates of both local control and
survival than patients who do respond [21]. Thus, definitive surgical therapy should
be undertaken only in patients who respond to NAC, as there is no benefit from
surgery in patients who have no significant response to NAC [22–25]. Thoms et al.
showed that a partial response to NAC resulted in a lower local control rate (33%)
following definitive surgical therapy than did a complete response (89%) [7]. Harris
et al. examined mastectomy specimens for the degree of response to NAC and
reported that 5- and 10-year overall survival rates were 52% and 31%, respectively,
in patients with a partial response and 65% and 46%, respectively, in complete
responders [26]. Surgical therapy is necessary for those with favorable response to
NAC, because physical examination and imaging modalities underestimate the
amount of residual disease in approximately 60% of patients with IBC [27, 28].

Surgical planning is important for optimizing outcomes. The surgical field must
incorporate all involved skin. However, it is important to leave enough skin to ensure
wound closure without tension, as tension may result in wound breakdown, which
would delay the administration of radiation [29]. The current recommended defini-
tive surgical treatment in patients who have responded to NAC is modified radical
mastectomy [18].

7.3 Contraindicated Operations in Patients with IBC

Breast conserving therapy, skin-sparing mastectomy, and nipple-sparing mastectomy
are contraindicated in patients with IBC. IBC is characterized by a diffuse pattern of
extensive intraparenchymal lymphovascular invasion with tumor emboli. This diffuse
pattern of disease involvement impedes obtaining negative margins, which is the
primary oncologic principle in any patient with breast cancer [18]. Outcomes in
patients with IBC are closely linked to margin status [30]. Consequently, use of
breast conserving therapy, skin-sparing mastectomy, and nipple-sparing mastectomy
are all oncologically inappropriate and thus contraindicated in patients with IBC.

7.4 Surgical Evaluation and Treatment of Axillary Disease
in Patients with IBC

Although sentinel lymph node biopsy (SLNB) is the standard of care for axillary
lymph node evaluation in breast cancer, this technique is currently contraindicated
in patients with IBC. IBC results in lymphatic blockage by tumor cells, thus hindering
localization of the sentinel lymph node (SLN) with either blue dye or radioactive
colloid. In addition, SLNB following NAC has been a debated topic. The National
Surgical Adjuvant Breast and Bowel Project (NSABP) B-27 addressed the use of
SLNB after NAC and concluded that SLNB is suitable for patients with operable

70 S.M. Gainer et al.

breast cancer after NAC [31]. Classe et al. evaluated the use of SLNB after NAC in
patients with advanced breast cancer. The detection rate, false-negative rate, and
accuracy of SLN detection did not differ between patients treated with or without
NAC [32]. Stearns et al. described the use of SLNB in women with locally advanced
breast cancer, including IBC. The overall SLN detection rate was 85%, and concor-
dance between SLNB and axillary lymph node dissection was 90%. The overall
false-negative rate and negative predictive value were 14% and 73%, respectively.
However, when patients with IBC were excluded from the analysis, the false-negative
rate and negative predictive value were 6% and 88%, respectively. They concluded
that axillary disease could not be reliably staged with SLNB after NAC in patients
with IBC [33]. Currently, the standard of care for evaluation and treatment of axil-
lary disease in patients with IBC is axillary lymph node dissection [18].

7.5 Issues Surrounding Reconstruction

Although postmastectomy reconstruction is an eventual option in patients with IBC,
the timing of reconstruction is of utmost importance [34]. Postmastectomy radiation
therapy is required for patients with IBC, and current recommendations include
incorporating the supraclavicular and internal mammary lymph nodes as well as the
chest wall and axilla (i.e., traditional four-field postmastectomy radiation therapy).
Immediate reconstruction in these patients may limit the delivery of radiation,
including radiation to the internal mammary nodes, and thus may negatively affect
oncologic outcomes [35, 36]. In addition, postmastectomy radiation therapy may
negatively affect cosmesis [37–39]. Therefore, delayed reconstruction is routinely
recommended for patients with IBC.

7.6 Conclusion

As the treatment of IBC evolves, surgical therapy will continue to be an integral part
of a multimodality treatment approach. In patients who have had complete resolution
of inflammatory changes of the breast following NAC, the standard of care is modi-
fied radical mastectomy with adjuvant radiation therapy. Currently, breast conserving
therapy, skin-sparing mastectomy, nipple-sparing mastectomy, SLNB, and immedi-
ate breast reconstruction are contraindicated.

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Akevia

Thanks Jos for this info.

Meadow

great article Jos, thank you for this info. My team did not tell me recon was contraindicated for IBC. I had implants placed at mastectomy. Then 33 rads. The affected side implant seems to have held up ok to rads, but now am wondering about having the implants in during radiation. I am NED, so maybe I am wondering(worrying a bit) for no reason. Kicks, Akevia and all, what do you think

Akevia

Meadow, I'm not sue reading that article made me think about waiting at least a year or more even if my Doc says it's okay sooner. To be honest the odds doesn't look great for us according to the article. I think since you have your implants already try not to worry to much. You know what to look for in IBC, if you find changes in your breast. I'm just surprise your Doc did immediate reconstruction but that you had to have a modified racial mastectomy. You didn't need TE first?

Faith316

"Odds may not look great........."

I've been NED for nearly 5 years now since my IBC dx back in June 2009 and plan on staying that way!

Meadow

Akevia, no, my plastic surgeon was able to put in implants that were the same size as the tissue the surgeon had removed....425 is the number I remember him saying, I guess that is cc? I wasnt busty before, a 36 nearly B cup, now I am prob a 38 B. I seem bigger around than before, I am a little wider I think. My PS said he learned this implant technique from MD Anderson and had been doing it about 2 years and was really happy with it. So I got silicone implants at mastectomy. I have read since then, is this called a once step reconstruction? I am not sure mine is the called that, I will have to ask the PS when I have a follow up as this term is new from my reading. I am the only person I know of that has had this, although he did give me names of patients in his practice who gave him permission to be contacted by patients like me with questions. I called one lady, she was happy with hers, as I am currently. As I said earlier, even the radiation did not change the radiated implant too much. It is slightly smaller. I am only now second guessing the immediate recon as I see now it is contraindicated for IBCers. But as you say it is done

Faith I am thrilled at your five years, I too am NED and plan to stay that way! I will not give in to fear of statistics. hings are changing for the better in IBC and we are all a part of that.

Kicks

Akevia - As Faith said she's almost 5 yrs out from IBC DX and still NED - I am also almost 5 yrs post IBC DX and still NED.  I was DXd in early Aug, '09 so I'm  just 2 months behind her timewise

My 'take' on 'odds'/stats.  They do not individually apply to me or any other individual personally.  'They' are just numbers gained from 'all' that are used (in whatever study/research being stated).  There are a lot of 'things' not taken into consideration with the individual but lump all together.  We each enter this journey being unique individuals - not only our health at time of DX but also our outlook/beliefs on life.  Another way of looking at 'odds'/stats (at least to me) is that my 'odds' are either 0% or 100%.  I will either stay NED which is 0% or I won't which is 100%.  I can't be any % between 0% and 100% as either I stay NED (0%) or don't (100%).   So, individually/personally it's an either/or, not a personal %.

I can only speak for myself - I was 63 when DXd, but I was very healthy, active and fit - still am.  I always planned/figured I'd live into my mid/late 90's as 1 GMother and 3 GGMothers had - I still plan on doing that.  I will fight any fight I have to along that journey - that's LIFE.  I also believe that our outlook on life and beliefs/faith plays a large roll in how we handle what is on our journey.  Our loved ones can also play a part.  Agan, I can only speak for myself.  Hubby was devastated at first when I was DXd - he had lot his Mom to Cervical Cancer when he was 9.   Adult Son got through to him quickly - he wasn't 9 now, I'd handled 20yrs as a Navy wife and I'd fight to win.  They decided the 2 of them had to be positive, that the 'hard headed' old me would fight to win but they needed to take over all chores  (but allow me to do what I wanted to/felt like doing knowing all would be cared for).  Son took over all barn chores, Hubby took over house/cooking/dogs. 

We are each so different and our individual ssituations are different.  There is no 'One Size Fits All' BUT we can learn that there are different ways of anything/everything being handled.

Akevia

kicks I agree 100%, that's why I said according to that article. I won't let no man tell me how long I will live. It has a lot to do with the will to live also and the fight! I'm in for the battle!! :-)

Kicks

Meadow - I think if I were you, I'd see/talk to my Drs and ask about why they did what they did.  We are each so different and where we  were with the DX.  I was told from the first day I saw my surgeon, that recon was not an option for at least a year - within the next 3 days I also saw chemo and rads and they both said the same thing.   When I hit the year mark, I found out that they weren't expecting me to still be 'here' then - especially still NED.

I had originally planned on recon but when I had my appt with PS, a blizzard hit.  When I got the next appt, it was heading into spring/summer and I did not want to possibly miss any of our short time of having fun outside because of elective surgery.  When fall as coming and I was thinking agian about checking it out, I was at least somewhat having second thoughts - would I result with limitation because of more surgery, had developed LE/what effect would more surgery have on it?  Hubby (of 34 yrs at the time) had always been very supportive of me doing what was right for me - butI never told me what he wanted me tto do.  I finally got him to tell me he would rather I didn't but was my ddecision and he'd be there for me.  That was the end of thinking about recon, I've never regretted my decision.   We are each so unique. 

Meadow

Kicks thanks I will ask the team as I follow up about the recon. I cannot say how it encourages me to hear of your 5 year victory. I do not know how I would have been with no recon for a year.....sounds like I prob should have gone that way but I wasnt directed to, or I am sure I would have. I asked my husband if he remembered any of the doctors talking about the year delay, and he said no. He was with me when I consulted with each specialty, I just had to double check the ol memory.  I like to think I am strong, the spouse says I am and he doesnt hand out false compliments, so I would like to think I could have gone there with grace. To those doing this and currently going through it I hold you up.

amarantha

Great Article, thank you for posting. My surgery is for the 20th of May. My surgeon told me I would need to wait at least a year for reconstruction.

Akevia

Good luck with your surgery Amarantha!! 

jos

Hi, 

I wrote to the breast surgeon at MD Anderson and he's telling me what my platic surgeon in San Fran is telling me for IBC. I respect everyone's choices and I'm just posting info. Here is the MDA surgeon's reply:

"At MDA we typically deflate the expanders before patients begin radiation and then reinflate after xrt is finished. This is not the standard across the country where most do not deflate the expander before starting xrt. Most institutions will radiate with the expander in place and to my knowledge has not been associated with worse outcomes. The reason why we deflate at MDA is to target lymph nodes under the breast bone. Again that is not the gold standard across the country.

Following radiation, an implant reconstruction is at higher risks for complications so that should be discussed with your plastic surgeon. I hope this was helpful, please met me know if there's any other question you have. "

I hope this helps!

Akevia

I'm not planning on using an implant for reconstruction. I want a DIEP flap, most time the implant doesn't take after radiation. 

Meadow

Akevia, I met with my PS today for a follow up. I had implants in a one step surgery at my MX, and now after radiation my affected implant has shrunken, and is hard and uncomfortable. I am feeling blue about the thoughts of needing another surgery to revise. So the flap may be a wise choice. 

Akevia

Meadow, sorry to hear about that. I though  PS were stop recommending implants if you had radiation?!? Implants and radiation don't get along at all and most times the implants are rejected and fail. I think you should just do the flap because I had heard of your situation so many times. I hope you don't have to do to many more surgeries and let me know what happens. Goodluck!