Mastectomy with immediate breast reconstruction during “phase 1

Received: 14 September 2020

Revised: 21 September 2020

Accepted: 21 September 2020

DOI: 10.1111/tbj.14078

COMMENTARY

Mastectomy with immediate breast reconstruction during

“phase 1” COVID-19 emergency: An Italian experience

Gianluca Franceschini PhD

1,2

| Alejandro Martin Sanchez MD

Lorenzo Scardina MD

| Daniela Terribile PhD

1,2

| Antonio Franco MD

Sabatino D'Archi MD

| Alba Di Leone MD

| Francesca Moschella MD

Stefano Magno MD

| Flavia De Lauretis MD

| Giuseppe Visconti MD

Marzia Salgarello PhD

| Riccardo Masetti PhD

1,2

Multidisciplinary Breast Center, Dipartimento Scienze della Salute della donna e del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A.

Gemelli IRCCS, Rome, Italy

Istituto di Semeiotica Chirurgica, Università Cattolica del Sacro Cuore, Rome, Italy

Correspondence: Alejandro Martin Sánchez, MD, Multidisciplinary Breast Center, Dipartimento Scienze della Salute della donna e del Bambino e di Sanità

Pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS. Roma, Largo Agostino Gemelli 8, 00168 Rome, Italy.

Emails: martin.san[email protected]; martin.san[email protected]

Keywords:

breast cancer, breast reconstruction, COVID-19 pandemic, mastectomy, prosthetic breast reconstruction

Since the beginning of the COVID 19 outbreak, a number of guide-

lines and recommendations have been released on how to best re-

adapt clinical activities, including breast cancer care.

The American College of Surgeons' COVID 19 Pandemic Breast

Cancer Consortium (which comprises the National Accreditation

Program for Breast Centers, the Commission on Cancer, the American

Society of Breast Surgeons, and the National Comprehensive Cancer

Network) recommended to reprioritize breast cancer treatment

basing on three phases of acuity of the local COVID-19 situation

and of hospital capacities (“semi-urgent,” “urgent,” and “critical”

settings).

With regard to patients scheduled for mastectomy, the is-

sued recommendation was to defer breast reconstruction even in

semi-urgent settings.

A similar recommendation to delay breast reconstruction was

issued in Europe by the European Society of Medical Oncology

(ESMO) and other groups.

2,3

But immediate breast reconstruction is considered part of the

“gold standard” treatment for patients requiring mastectomy as it al-

lows significant benefits compared to delayed reconstruction: It pre-

serves self-esteem and normal perceptions of body image, improves

feelings of femininity, charm, sexuality, and sense of self, ultimately

enhancing the quality of life. Furthermore, immediate reconstruc-

tion improves body posture.

4-6

Denying immediate breast reconstruction to all patients under-

going mastectomy without taking into account the acuity of COVID-

19 settings would generate three unfavorable consequences:

• A significant backlog of patients requiring delayed reconstructive

procedures, with additional challenges and costs for the health

system months to follow.

• An unacceptable substandard of care, not supported by definitive

clinical evidence.

• An additional psychosocial distress, in patients undergoing sur-

gical treatment during the COVID era. These patients, as docu-

mented in a recent survey, have strained copying capacities due to

the fact that the fear for their breast cancer is strongly enhanced

by the fear of the virus.

5,7,8

These consistent concerns led our multidisciplinary team to

evaluate whether or not to adopt the indication to defer immediate

reconstruction in all cases. As our hospital remained in a “semi-ur-

gent” to “urgent” setting” during the entire pandemic trajectory,

the shared thinking was that by using a previously described strict

COVID-19 protection protocol,

we could maintain our regular vol-

umes of surgical interventions for breast cancer and continue to

offer immediate implant reconstruction to patients that asked for it

even during the pandemic outbreak.

During the 3-month period (February 1–April 30, 2020), of

the Italian “phase 1” COVID-19 pandemic, 326 patients with

Gianluca Franceschini and Alejandro Martin Sanchez contributed equally to this work.

COMMENTARY

histologically proven invasive breast cancer received surgical treat-

ment in our breast unit. Among them, 50 patients (15.3%) were

scheduled for mastectomy (Group A). Every woman in this group

was informed of risks and benefits of immediate reconstruction, and

as a result of a shared decision-making process, all patients opted

to receive it, confirming the extraordinary importance that patients

attribute to this procedure.

During the same trimester of the previous year (February 1–April

30, 2019), surgical treatment was performed in 341 patients with his-

tologically proven invasive breast cancer. Among them, 43 (12.6%)

received mastectomy and immediate reconstruction (Group B).

The performance of immediate breast reconstruction in pa-

tients undergoing mastectomy during the COVID pandemic did not

increase postoperative complications rates (8.0% vs 13.9%) in group

A and in group B, respectively, or postoperative hospitalization time

(2.9 days vs 4.5 days). These results were acquired without any sig-

nificant increase in exposure to COVID-19 infection (Table 1).

Two asymptomatic patients resulted positive at the SARS-COV2

quick test at the time of hospital check-in. They were immediately

confined in a specific unit and repeated two nasopharyngeal swabs

at 48-hour interval. Both swabs resulted negative for SARS-COV2,

confirming a false positivity of quick testing, so the patients received

scheduled surgical treatment while remaining in the confinement unit.

We did not observe any case of symptomatic COVID-19 infec-

tions during hospitalization or after discharge, with a mean follow-up

of 110 days.

These preliminary results seem to indicate that with the use of

a proper COVID-19 protection protocol, immediate breast recon-

struction can safely be offered at least in semi-urgent settings.

We clearly understand the limits of our study: It is a retrospec-

tive review of a single-center experience with a small number of pa-

tients and a short follow-up.

Despite these mentioned limitations, we hope that our results

can encourage breast units to adjust their treatment policies in

patients scheduled for mastectomy taking into account a focused

analysis of local COVID-19 diffusion and single institution capacities

rather than adopt of “one-size-fits-all” recommendations.

ORCID

Gianluca Franceschini https://orcid.org/0000-0002-2950-3395

Alejandro Martin Sanchez https://orcid.

org/0000-0002-4840-507X

Lorenzo Scardina https://orcid.org/0000-0002-5828-2851

Stefano Magno https://orcid.org/0000-0002-3721-9693

REFERENCES

1. COVID 19 Pandemic Breast Cancer Consortium. COVID-19 guide-

lines for triage of breast cancer patients. American College of

Surgeons. https://www.facs.org/covid -19/clini cal-guida nce/elect ive-

case/breas t-cancer. Accessed March 24, 2020

2. ESMO Management and treatment adapted recommendations in the

COVID-19 era: breast cancer. https://www.esmo.org/guide lines/

breas t-cance r/breas t-cance r-in-the-covid -19-era. Accessed May 01,

2020

3. Curigliano G, Cardoso MJ, Poortmans P, et al. Recommendations for

triage, prioritization and treatment of breast cancer patients during

the COVID-19 pandemic. Breast. 2020;52:8-16.

4. Hart AM, Pinell-White X, Losken A. The psychosexual im-

pact of postmastectomy breast reconstruction. Ann Plast Surg.

2016;77(5):517-522.

5. Al-Ghazal SK, Sully L, Fallowfield L, et al. The psychological impact

of immediate rather than delayed breast reconstruction. Eur J Surg

Oncol. 2000;26:17.

6. Fung KW, Lau Y, Fielding R, et al. The impact of mastectomy,

breast-conserving treatment and immediate breast reconstruction

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TABLE 1 Surgical aspects

Characteristic

2020 2019

Group A (50) Group B (43)

Type of mastectomy

Nipple-sparing mastectomy 39 (78%) 38 (88.4%)

Skin-sparing mastectomy 11 (22%) 5 (11.6%)

Side of mastectomy

Unilateral 36 (72%) 25 (58.1%)

Bilateral 14 (28%) 18 (41.9%)

Type of reconstruction

Tissue expander 11 (22%) 9 (20.9%)

Definitive prosthetic

reconstruction

39 (78%) 34 (79.1%)

Contralateral symmetrization 0 15 (34.9%)

Implant reconstruction

Prepectoral 28 (56%) 25 (58.2%)

Subpectoral prosthetic 11 (22%) 9 (20.9%)

Subpectoral tissue expander 11 (22%) 9 (20.9%)

Surgical timing (minutes) 258 (260;

126-515)

310 (312;

195-480)

Postoperative hospitalization

(days)

2.9 (3; 2-4) 4.5 (4; 3-7)

Number of outpatient visits 2.09 (2; 2-3) 6.2 (6; 6-10)

Postoperative complications

Seroma 3 (6%) 5 (11.6%)

Wound dehiscence 1 (2%) 0

CAC necrosis 0 1 (2.3%)