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mastectomia profilactica
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5/16/2015 Contralateralprophylacticmastectomy
http://www.uptodate.com/contents/contralateralprophylacticmastectomy?topicKey=ONC%2F94744&elapsedTimeMs=0&source=search_result&searchTerm 1/7
OfficialreprintfromUpToDate www.uptodate.com2015UpToDate
AuthorAneesBChagpar,MD,MSc,MA,MPH,MBA,FACS,FRCS(C)
SectionEditorRussellSBerman,MD
DeputyEditorDonSDizon,MD,FACP
Contralateralprophylacticmastectomy
Alltopicsareupdatedasnewevidencebecomesavailableandourpeerreviewprocessiscomplete.Literaturereviewcurrentthrough:Apr2015.|Thistopiclastupdated:Dec03,2014.
INTRODUCTIONAcontralateralprophylacticmastectomy(CPM)isariskreducingmastectomyperformedintheclinicalsettingforthepatientdiagnosedwithaninvasiveoranoninvasivebreastcancer.WhilethereisnoclearsurvivalbenefitformostbreastcancerpatientswhodonotcarryadeleteriousBRCA1orBRCA2mutation[13],theratesofperformingaCPMhaveincreasedoverthelastseveralyears[4,5].
Theriskofacontralateralbreastcancer,thedecisionmakingprocesstoundergoaCPM,andoutcomeswillbereviewedinthistopic.Managementofpatientswithinvasiveandnoninvasivebreastcancer,withandwithoutaninheritedgeneticmutation,isreviewedseparatelyandincludes:
RISKOFCONTRALATERALBREASTCANCERPatientswithaunilateralsporadicbreastcancerareatamodestriskofdevelopingacontralateralbreastcancer(CBC),andmostwomenneverwilldevelopacontralateralsecondprimarybreastcancer[6,7].Forpatientswhopresentwithunilateralbreastcancer,theriskofdevelopingacontralateralbreastcancerisestimatedtobe0.5to1.0percent/yearcumulativeovertheirlifetime[8,9].However,areviewof162patientswithsporadicbreastcancerfoundthatthe10yearcumulativeincidenceofcontralateralbreastwas1percent[10].(See"Patternsofrelapseandlongtermcomplicationsoftherapyinbreastcancersurvivors".)
ForpatientswhocarryadeleteriousBRCA1orBRCA2mutation,theriskofacontralateralbreastcancerisapproximately10to25percent[10,11].However,somestudieshaveestimatedtherisktobeashighas65percentforBRCA1carriersand50percentforBRCA2carriers[12].(See"ManagementofhereditarybreastandovariancancersyndromepatientswithBRCAmutations",sectionon'Treatmentandprognosisofwomenwhodevelopbreastcancer'.)
CONTRALATERALPROPHYLACTICMASTECTOMYRISKREDUCTIONBaseduponaprospectivestudyof745womenwithbreastcancerandafamilyhistoryofbreastand/orovariancancerundergoingaCPM,theriskreductionofacontralateralbreastcancer(CBC)wasapproximately96percent[6].Inthiscohort,theriskreductionfollowingaCPMforwomenlessthanage50years(n=388)was94.4percentand96.0percentforwomen50yearsofageandolder.
DECISIONMAKINGPROCESSThedecisiontoundergoacontralateralprophylacticmastectomy(CPM)isfrequentlyanindividualchoiceandgenerallybaseduponpersonalpreferenceandmanagement(eg,mastectomy)ofthepresentingbreastcancer.Inaddition,manywomenoverestimatetheiractualriskforcancerintheunaffectedbreast.Otherinfluences,includingthesurgeon,primarycarephysician,friends,and/orfamilymembersareoftencitedassuggestingaCPM.Hence,thepatientandhersurgeonshouldfullydiscusstheactualrisksofacontralateralbreastcancerintermsofthepatientsownpersonalandfamilyhistoryandhergoalsfortreatment.
(See"Overviewofthetreatmentofnewlydiagnosed,nonmetastaticbreastcancer".)
(See"Ductalcarcinomainsitu:Treatmentandprognosis".)
(See"Treatmentprotocolsforbreastcancer".)
(See"BRCA1andBRCA2:Prevalenceandrisksforbreastandovariancancer".)
(See"ManagementofhereditarybreastandovariancancersyndromepatientswithBRCAmutations".)
5/16/2015 Contralateralprophylacticmastectomy
http://www.uptodate.com/contents/contralateralprophylacticmastectomy?topicKey=ONC%2F94744&elapsedTimeMs=0&source=search_result&searchTerm 2/7
PatientsmustbemadeawareoftherisksandcomplicationsofundergoingaCPM,asthisinvolvesamoreextensiveoperation(bilateralmastectomieswithorwithoutbilateralreconstruction),andthatwhileriskofcontralateralbreastcancerisreduced[2,20],thedataregardingsurvivalbenefitsaremixed.(See'Outcomes'below.)
POSTOPERATIVEMORTALITYANDMORBIDITYMortalityratesareuniformlylow(
5/16/2015 Contralateralprophylacticmastectomy
http://www.uptodate.com/contents/contralateralprophylacticmastectomy?topicKey=ONC%2F94744&elapsedTimeMs=0&source=search_result&searchTerm 3/7
OUTCOMES
OverallsurvivalThereisnoclearoverallsurvivalbenefitformostbreastcancerpatientswhoundergoacontralateralprophylacticmastectomy(CPM),andnorandomizedtrialshaveyetbeenperformed.However,forpatientswithadeleteriousBRCA1orBRCA2mutation,andinsomestudies,womendiagnosedatayoungage(
5/16/2015 Contralateralprophylacticmastectomy
http://www.uptodate.com/contents/contralateralprophylacticmastectomy?topicKey=ONC%2F94744&elapsedTimeMs=0&source=search_result&searchTerm 4/7
beapproximately1to2percent[27,28].
Psychosocialeffects
Bodyimage,femininityAdversechangesinbodyimageincludingdiminishedfeelingsoffemininity,sexualityandsexualsatisfaction,andselfesteemcanoccurfollowingaCPM[6,2932].Negativebodyimagewasalsoassociatedwithhighpreoperativecancerdistress[29].Inasurveyofwomenwhohadundergonecontralateralprophylacticmastectomy,42percentstatedthattheirsenseofsexualitywasworsethanexpected,and31percentfeltthattheirselfconsciousnessabouttheirappearancewasalsoworsethanexpected[19].However,80percentreportedthattheywereextremelyconfidentintheirdecisiontohaveCPM,and90percentwouldhavemadethesamedecisionagain[19].
ThepersonalsatisfactionfollowingaCPMisreportedlyhigh[32,33].Forexample,asurveyof583patientsfoundthatthemajority(83percent)ofwomenweresatisfiedwiththeCPM10yearsaftertheoperation,while8percentwereneutraland9percentweredissatisfied[32].However,33percentweredissatisfiedwithbodyappearance,26percenthadadversefeelingsoffemininity,and23percentreportedadversesexualrelationships.
However,suchahighlevelofsatisfactionmaybesecondarytocognitivedissonance,aphenomenondocumentedininvalidatedpatientsatisfactionmeasurements,andrelevanttoautonomoussurgicaldecisionmakingwhenthedecisionisdifficulttochange[2,3436].
QualityoflifeQualityofliferelatedmeasuresforwomenundergoingaCPMwerecomparabletowomeninthegeneralpopulation.Inaprospectivestudyof60womenwithbreastcancerwhohadalsoundergoneaCPM,mostpatientshadasatisfactoryhealthrelatedqualityoflifetwoyearsaftertheoperation,withnodifferenceinanxietyordepression[31].
OPERATIVEAPPROACHES
MastectomywithorwithoutreconstructionTypically,mostpatientsareadvisedtoundergothesametypeofmastectomy(eg,skinsparing,conventional)thatisusedforthemastectomytotreatthebreastcancer.Thetypeofmastectomyisdeterminedbythetumorcharacteristics,patientbodyhabitus,patientpreference,andsurgicalexpertise.Thereisnoadverseimpactofimmediatereconstructioneitherinthedevelopmentordetectionoffuturecancers[37].Reconstructionisdeterminedbytheuseofpostoperativeradiationtreatments,patientpreference,andsurgeonexpertise.
Specificapproachestoperformingamastectomyandbreastreconstructionarediscussedseparately.(See"Mastectomy:Indications,types,andconcurrentaxillarylymphnodemanagement"and"Breastreconstruction:Preoperativeassessment".)
SentinellymphnodedissectionWhiletherearedifferencesofopinion,asentinelnodelymphnodedissectionisnotrequiredwhenperformingaCPM[27,28,38].Somehavearguedthattheriskofthisminimallyinvasiveprocedureissmall,andwouldpreempttheneedforaxillaryevaluationifanoccultinvasivecancerwasfoundonfinalpathology[38].Others,however,arguethattheriskoffindingmetastaticdiseasewarrantingaxillarystaginginpatientsundergoingprophylacticmastectomyislow,andthereforesentinelnodebiopsyinthesepatientscanbeomitted[27].Randomizedtrialshavenotbeenperformedtoresolvetheissue.(See"Diagnosis,stagingandtheroleofsentinellymphnodebiopsyinthenodalevaluationofbreastcancer"and"Sentinellymphnodebiopsyinbreastcancer:Techniques".)
SUMMARYANDRECOMMENDATIONS
Patientswithaunilateralsporadicbreastcancerareatamodestriskofdevelopinganinvasivecontralateralbreastcancer(CBC),andmostwomenneverwilldevelopacontralateralsecondprimarybreastcancer.(See'Riskofcontralateralbreastcancer'above.)
ForbreastcancerpatientswhocarryaBRCA1orBRCA2mutation,theriskofacontralateralbreastcancerisestimatedtorangefrom10to65percent.(See'Riskofcontralateralbreastcancer'above.)
5/16/2015 Contralateralprophylacticmastectomy
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5/16/2015 Contralateralprophylacticmastectomy
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Disclosures:AneesBChagpar,MD,MSc,MA,MPH,MBA,FACS,FRCS(C)Nothingtodisclose.RussellSBerman,MDNothingtodisclose.DonSDizon,MD,FACPNothingtodisclose.Contributordisclosuresarereviewedforconflictsofinterestbytheeditorialgroup.Whenfound,theseareaddressedbyvettingthroughamultilevelreviewprocess,andthroughrequirementsforreferencestobeprovidedtosupportthecontent.AppropriatelyreferencedcontentisrequiredofallauthorsandmustconformtoUpToDatestandardsofevidence.Conflictofinterestpolicy
38. BurgerA,ThurtleD,OwenS,etal.Sentinellymphnodebiopsyforriskreducingmastectomy.BreastJ201319:529.
Topic94744Version4.0
Disclosures