From prophylactic mastectomy to treatment of local relapse

Bilateral prophylactic mastectomy represents a paradox in breast cancer surgery, since important efforts have been recently developed to reduce mutilating surgery. In fact, since the 'extended radical mastectomy' has been questioned by the results of the internal mammary node dissection trial, and Fisher's paradigm has been adopted, indications for mastectomy have been dramatically reduced. Nowadays, the majority of primary infiltrating breast cancers can be solved by applying conservative techniques, while prophylactic bilateral mastectomy is proposed in certain high-risk situations, especially when genetic modifications have been found. Surgical treatment of local relapses should be discussed considering their clinical behaviour. A slow-growing unifocal local recurrence, next to the mastectomy scar, usually remains isolated for a long time and justifies a surgical treatment. On the contrary, widespread multifocal recurrences on the thoracic wall, which show inflammatory signs, are frequently associated with distant metastases. In these cases, the best treatment is a systemic therapy and local surgery mainly has a psychological purpose. Local relapses occurring after a conservative treatment are signs of primary treatment failure. They require a total mastectomy and sometimes cause a feeling of guilt in patients who regret that they accepted conservative surgery. However, the majority ask for an immediate breast reconstruction, despite difficulties due to previous radiotherapy. In certain extensive local relapses, psychological pressure could be so strong as to induce a wide surgical removal, even if surgery does not modify the prognosis in these patients. Thus, prophylactic mastectomy and surgical treatment of local relapses are both dealing with psychological benefits. The first is related to the fear of developing a cancer which does not yet exist at the time of the mutilation, and the second consists frequently in partially removing the visible cancer, even if it does not provide higher chances of cure.