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In Reply

Division of Plastic Surgery, Department of Surgery, Kwong Wah Hospital, Hong Kong SAR, China
Breast Center, Department of Surgery, Kwong Wah Hospital, Hong Kong SAR, China
Division of Plastic Surgery, Department of Surgery, Kwong Wah Hospital, Hong Kong SAR, China
Breast Center, Department of Surgery, Kwong Wah Hospital, Hong Kong SAR, China

We would like to thank Dr. Gutman for his comment on this article. First, the purpose of this article was to look at the safety of preserving the skin envelope when skin-sparing mastectomy and immediate breast reconstruction were to be performed. It was not the purpose of this article to look at the indication for total mastectomy and breast-conservation treatment (BCT).

We agree totally that breast-conserving surgery would be ideal in small peripheral breast carcinomas. However, there are occasions when BCT is not the selected option. Some patients simply refuse to have breast-conserving treatment because they are reluctant to receive postoperative irradiation due to the duration and complexity of treatment. There are certain points that are particular to the Asian population. The breast size of Chinese females is in general smaller when compared with white females. Small tumors may be T1, but it may be difficult to achieve an adequate margin. Removing too much breast tissue in a wide local excision will result in significant distortion in the breast shape, which will be accentuated by postoperative irradiation. Of course this is a balance between the size of the tumor and the size of the breast.

Yau et al. reported 203 patients who had BCT.¹ Of the 178 patients who had invasive carcinoma, 127 were T1 (71%) and 51 were T2 (29%). In our institution, patients were given a choice of the different options of treatment believed to give equivalent oncological control. Over the period when this study was performed, 23% had BCT, 62% had total mastectomy, and 15% had total mastectomy with immediate breast reconstruction. Of the 223 patients who had BCT in our institution from 1994 to 2003, the median size of the tumor was 1.6 cm (mean + SD, 1.7 + .84).

The risk of skin involvement in large tumors (T3) is substantial. Three of the five patients in this study had skin involvement. All of them had extensive tumor spread in the skin and subcutaneous tissue via the lymphatics. Tumor could be identified in the skin and subcutaneous tissue 4 to 5 cm from the edge of the primary tumor. However, it is not certain whether a wider excision of the breast skin is able to remove the tumor completely. We do consider immediate breast reconstruction in patients who had T3 tumor if they are motivated.

REFERENCE

1. Yau TK, Lau Y, Kong J, et al. Breast conservation treatment in Hong Kong - early results in 203 patients: retrospective study. Hong Kong Med J 2002; 8: 322–8.[Medline]

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