Timing of prophylactic hysterectomy-oophorectomy, mastectomy, and microsurgical breast reconstruction in BRCA1 and BRCA2 carriers

Abstract

In BRCA carriers, the order of TAH-BSO and microsurgical breast reconstruction does not affect complication rates. However, prior TAH-BSO may make DIEP flaps unfeasible, and robotic TAH-BSO after breast reconstruction takes longer, but can still be performed safely.

Perioperative Management of Women Undergoing Risk-reducing Surgery for Hereditary Breast and Ovarian Cancer

“…Rationale for Concurrent Risk-reducing Surgery RRSO can be performed before, concurrently, or after mastectomy and reconstruction as a staged procedure [69,70]. There is no consensus on the optimal sequence of procedures in women without a diagnosis of malignancy who are found to be carriers of a genetic mutation [69]. Practice patterns generally vary by provider and institution.…”

“…From a patient perspective, the oncologic status often dictates the timing of surgery (i.e., some patients undergoing mastectomy for the treatment of breast cancer may not be aware of their genetic risk before surgery and cancer treatment). On the other hand, BRCA mutation carriers are often diagnosed in the setting of strong family history and usually undergo prophylactic procedures under elective conditions [69]. BRRM with immediate reconstruction is the most common procedure performed in this patient population.…”

“…Hysterectomy and BSO performed before breast reconstruction (particularly if through a midline incision) place limitations on the use of an autologous flap as well as concerns regarding perfusion across the scar. Even after a laparoscopic or robotic approach, there is a theoretic risk that perforators of the deep inferior epigastric vessels would be injured during placement of ports or scarring of the rectus muscle, which would potentially compromise breast reconstruction [69]. Khansa et al [69] found that microsurgical breast reconstruction performed after hysterectomy and BSO did not increase the risk of abdominal wall hernia or the use of mesh.…”

“…Even after a laparoscopic or robotic approach, there is a theoretic risk that perforators of the deep inferior epigastric vessels would be injured during placement of ports or scarring of the rectus muscle, which would potentially compromise breast reconstruction [69]. Khansa et al [69] found that microsurgical breast reconstruction performed after hysterectomy and BSO did not increase the risk of abdominal wall hernia or the use of mesh. However, the ability to perform an abdominal flap reconstruction is minimized.…”

“…As such, some of these patients may have had prior abdominal flap reconstruction [24,72]. Although risk-reducing gynecologic surgery performed after breast reconstruction is feasible, the duration of surgery is significantly increased in this setting [69]. Abdominal insufflation during laparoscopy can be hindered by previous flap harvest.…”