SYNCHRONOUS ELECTIVE CONTRALATERAL MASTECTOMY AND IMMEDIATE BILATERALBREAST RECONSTRUCTION IN WOMEN WITH EARLY-STAGE BREAST-CANCER

Background: The role of elective contralateral mastectomy (ECM) in wom en with early-stage breast cancer who elect or require an ipsilateral mastectomy and desire immediate bilateral breast reconstruction (IBR) is an intellectual and emotional dilemma for both patient and physicia n. In an attempt to clarify the rationale for this approach, we review ed our experience with ECM and IBR and evaluated operative morbidity, the incidence of occult contralateral breast cancer, and patterns of r ecurrence. Patients and Methods: We retrospectively reviewed the recor ds of 155 patients with primary unilateral boast cancer (stage 0, I, o r II) and negative findings on physical and mammographic examinations of the contralateral breast who underwent ipsilateral mastectomy and s imultaneous ECM with IBR between 1987 and 1995. Results: The median ag e of the patients was 46 years (range, 25 to 69 years). Clinical stage at diagnosis was stage 0, I, and II in 19.4%, 54.2%, and 26.4% of pat ients, respectively. Factors likely to influence the use of ECM were f amily history of breast cancer in first-degree relatives (30%), any fa mily history of breast cancer (56%), difficulty anticipated in contral ateral breast surveillance (48%), associated lobular carcinoma in situ (23%), multicentric primary tumor (28%), significant reconstructive i ssues (14%), and failure of mammographic identification of the primary tumor (16%). Skin-sparing mastectomies were performed in 81% of patie nts. Overall, 70% of patients underwent reconstruction using autogenou s tissue transfer. Reoperations for suspected anastomotic thrombosis w ere performed in seven patients. Two patients experienced significant partial or complete flap loss. Histopathologic findings in the ECM spe cimen were as follows: benign, 80% of patients; atypical ductal hyperp lasia, 12% of patients; lobular carcinoma in situ, 6.5% of patients; d uctal carcinoma in situ, 2.7% of patients; and invasive carcinoma, 1.3 % of patients. Eighteen patients (12%) had evidence of locoregional or distant recurrences, with a median follow-up of 3 years. In one patie nt (0.6%), invasive ductal carcinoma developed on the side of the elec tive mastectomy. Conclusions: The use of ECM and IBR cannot be justifi ed if the only oncologic criterion considered is the incidence of occu lt synchronous contralateral disease. However, in a highly selected po pulation of young patients with a difficult clinical or mammographic e xamination and an increased lifetime risk of developing a second prima ry tumor, ECM and IBR is a safe approach.