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

Abstract

BACKGROUND: BRCA (breast cancer susceptibility gene) carriers are at high risk for breast and ovarian malignancies, and often undergo prophylactic total abdominal hysterectomy-bilateral salpingo-oophorectomy (TAH-BSO), bilateral mastectomy, and microsurgical breast reconstruction. Our goal was to determine whether abdominal wall complications and flap choice are affected by the order of those procedures. METHODS: All BRCA carriers who underwent microsurgical breast reconstruction between 2007 and 2012 were studied. Abdominal wall complications and changes in the reconstructive plan were analyzed depending on the order of breast reconstruction and TAH-BSO. RESULTS: 442 patients underwent 612 microsurgical breast reconstructions, 47 of whom were BRCA carriers. TAH-BSO was not a predictor of requiring mesh for fascial closure (OR 1.1, P = 0.8), or of hernia/bulge (OR = 1.6, P = 0.65). In five patients, a DIEP flap was altered to another flap as a direct result of prior TAH-BSO. Robotic TAH-BSO after breast reconstruction took longer to perform than before breast reconstruction (4.48 ± 1.00 hours vs. 3.23 ± 0.70 hours, respectively, P = 0.023), due to abdominal wall tightness. However, none were converted to open. Full-muscle free TRAM flaps (compared to other flaps) and bilateral reconstructions (compared to unilateral) were the only predictors of mesh (OR = 9.85, P < 0.001 and 4.01, P < 0.001), and hernia/bulge (OR = 6.18, P < 0.001 and 2.13, P = 0.07). The order of TAH-BSO and breast reconstruction did not affect complications. CONCLUSIONS: 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.