In Reply

Breast Reconstruction Following Cancer Treatment by Prof. Dr. med. Bernd Gerber, Dr. med. Mario Marx, Prof. Dr. med. Michael Untch, and Prof. Dr. med. Andree Faridi in issue 35–36/2015

We did not address the issue of lymphedema as this problem is significantly in decline today and typically develops with some delay. The downward trend started with the introduction of less radical axillary surgery—sentinel lymph node biopsy, no minimum number of removed lymph nodes (1). Nevertheless, pointing out that surgical techniques to treat lymphedema are available appears helpful. Whether breast reconstruction in the presence of lymphedema is of benefit to the patient has to be evaluated on a case-by-case basis.

Implant-based reconstruction can be performed with good cosmetic results over the long term. Many women do not want autologous reconstruction, no additional scars or do not have enough autologous tissue available because of their habitus. The overall complication rate of 76.4% and the rate of subsequent surgeries after implant-based reconstruction of 40.6% appear extremely high to us and cannot be applied to the situation in Germany. In the “Autologous versus Heterologous Reconstruction” section of our article, comparing implant-based reconstruction with autologous reconstruction, we highlighted that the costs of autologous reconstruction are 2.5 times higher and further increase as the result of complications and the high rate of subsequent surgeries–100% second, 53% third and 12% fourth operations (nipple reconstruction, late complications, adjustments).

Autologous reconstruction before radiotherapy—only very limited long-term data are available—is, of course, possible in individual cases (Table 3, level of evidence [LOE] 2a; grade of recommendation +/-). Under “Post-mastectomy Radiotherapy”, we reported fibrosis rates (meta-analysis of 13 studies) for autologous reconstruction before and after radiotherapy of 36.5% versus 2.7%, respectively. Given the conflicting local recurrence rate (LRR) and overall survival data, it should be contemplated to markedly restrict the indication for radiotherapy (Harris J. San Antonio, 2015).

Thankfully, the very rare implant-associated cutaneous anaplastic large-cell lymphoma (ALCL) has been highlighted in the correspondence; here, we can make reference to our case report on ACLC (2). It is a very rare adverse event—1 : 500 000 to 1 : 3 000 000 patients with breast implants per year. Of the 71 reported cases, the majority was preceded by cosmetic breast surgery with implants (3). After implant-based breast reconstruction—and this is what our article is about—only three cases of ALCL have been reported worldwide plus one “unusual“ case where ALCL occurred after breast reconstruction with saline-filled implants.

With regard to the comment about the requirement to provide comprehensive information to the patient, we stated under “Background” that “each and every patient must be given timely, detailed, […] information on all breast reconstruction procedures, expected outcomes, risks, and alternatives […] offer of a second opinion and information on surgical procedures that are not offered in the physician’s own hospital.” This wording by far exceeds the information requirements indicated by Prof. Fansa and Prof. Heitmann.

DOI: 10.3238/arztebl.2016.0270

Prof. Dr. med. Bernd Gerber
Dr. med. Mario Marx

Prof. Dr. med. Michael Untch

Prof. Dr. med. Andree Faridi

Universitäts-Frauenklinik Rostock, Germany

Conflict of interest statement

Prof. Prof. Faridi has received consultancy fees and reimbursement of conference fees from pfm medical ag, Cologne and DIZG gGmbH, Berlin.

Prof. Gerber has received consultancy and lecture fees from AstraZeneca, Novartis, Roche, TEVA, JanssenCilag, Celgene, and Pfizer.

Prof. Marx and Prof. Untch declare that no conflict of interest exists.

References

1. Gerber B, Marx M, Untch M, Faridi A: Breast reconstruction following cancer treatment. Dtsch Arztebl Int 2015; 112: 593–600

2. Stubert J, Hilgendorf I, Stengel B, Krammer-Steiner B, Freund M, Gerber B: Bilateral breast enlargement and reddish skin macules as first signs of acute lymphoblastic T cell leukemia. Onkologie 2011; 34: 384–7.

3. Ye X, Shokrollah K, Rozen WM, et al.: Anaplastic large cell lymphoma (ALCL) and breast implants: breaking down the evidence. Mutat Res Rev Mutat Res 2014; 762: 123–32