From prophylactic mastectomy to treatment of local relapse

Bilateral prophylactic mastectomy represents a paradox in breast cancer sur gery, since important efforts have been recently developed to reduce mutila ting surgery. In fact, since the 'extended radical mastectomy' has been que stioned by the results of the internal mammary node dissection trial, and F isher's paradigm has been adopted. indications for mastectomy have been dra matically reduced. Nowadays. the majority of primary infiltrating breast ca ncers can be solved by applying conservative techniques, while prophylactic bilateral mastectomy is proposed in certain high-risk situations. especial ly when genetic modifications have been found. Surgical treatment of local relapses should be discussed considering their clinical behaviour. A slow-growing unifocal local recurrence. next to the m astectomy scar, usually remains isolated for a long time and justifies a su rgical treatment. On the contrary, widespread multifocal recurrences on the thoracic wall, which show inflammatory signs, are frequently associated wi th distant metastases. In these cases, the best treatment is a systemic the rapy and local surgery mainly has a psychological purpose. Local relapses o ccurring after a conservative treatment are signs of primary treatment fail ure. They require a total mastectomy and sometimes cause a feeling of guilt in patients who regret that they accepted conservative surgery. However, t he majority ask for an immediate breast reconstruction, despite difficultie s due to previous radiotherapy. In certain extensive local relapses, psycho logical pressure could be so strong as to induce a wide surgical removal, e ven if surgery does not modify the prognosis in these patients. Thus, prophylactic mastectomy and surgical treatment of local relapses are both dealing with psychological benefits. The first is related to the fear of developing a cancer which does not yet exist at the time of the mutilati on, and the second consists frequently in partially removing the visible ca ncer, even if it does not provide higher chances of cure. (C) 2001 Harcourt Publishers Ltd.