Immediate Reconstruction of Advanced Stage Breast Cancer Mehrara, et al

Immediate Free Flap Reconstruction of Locally Advanced Breast

Cancer: A 10-Year Review

Babak J. Mehrara, MD, Andrew Smith, MD, Eric Arcilla, MD, Timothy Santoro, MD, Jeffery Sebastian, MD, James P. Watson, MD, Andrew L. Da Lio, MD, and William W. Shaw, MD

Introduction

Immediate breast reconstruction (IBR) has many advantages over delayed reconstruction including improved cosmetic results, technical ease, lowered costs, and decreased overall recovery times.1, 2 In addition, numerous studies have demonstrated that breast reconstruction is an important coping mechanism and is associated with improvements in quality of life and body image. 3-8 Despite these benefits, IBR of locally advanced breast cancer (LABC) remains controversial. Concerns about delays in postoperative adjuvant therapy due to wound complications or prolonged recovery, as well as a theoretical potential for increased incidence of local recurrences or delays in the diagnosis of local recurrences have been cited as reasons to delay reconstruction in these patients. In addition, the ability of the reconstructed breast to withstand postoperative radiation has been questioned.9

The purpose of this study was to evaluate the safety and efficacy of microvascular autogenous IBR in women with LABC. In addition, we analyzed the effects of radiation therapy on the reconstructed breasts and evaluated patient satisfaction through telephone interviews.

Methods

A retrospective review of all patients who underwent microvascular breast reconstruction at UCLA Medical center from December 1991 to December 2002 was performed. All microvascular breast reconstructions were reviewed and patients with clinical stage IIB or worse breast cancer who were treated with mastectomy and IBR were identified. Patient demographics, early and late postoperative complications, local recurrences, distant metastases, and the effects of radiation on the reconstructed breast were studied. Multivariate logistic regression analysis was performed in an effort to identify potential risk factors for early and late postoperative complications. Telephone interviews were performed by physicians not involved in the original surgery and addressed overall satisfaction, cosmetic appearance, willingness to undergo immediate reconstruction again, willingness to recommend immediate reconstruction to a friend or colleague, and the effect, if any, of radiation on the reconstructed breast.

Results

Nine hundred and fourteen patients underwent microvascular breast reconstruction at UCLA Medical Center during the study period. Of these, 170 had locally advanced breast cancer. There were 157 unilateral and 13 bilateral reconstructions (183 reconstructions). The median age was 47 years and the median follow up was 24.0 months (range 1.4 to 142). Comorbid conditions were present in 26.5% of the patients. Patients with stage IIB cancer made up 35.9% of the total patient population, while 31.8% were stage IIIA, 22.5% stage IIIB, and 10.0% stage IV. TRAM flaps were used in most patients (149 patients). Radiation therapy was administered to 100 patients (28 preoperatively; 72 postoperatively) while 64 patients did not receive adjuvant radiation therapy.

Fifty-seven patients (33.5%) had early postoperative complications. Thirteen patients (7.6%) had major postoperative complications of which 10 occurred in the early postoperative period (1 total flap loss (0.6%), 3 arterial/venous thromboses (1.8%), 2 partial flap losses (1.2%), and 4 hematomas requiring return to the operating room (2.4%). Wound complications were noted in 39 patients (22.9%) and were usually mild mastectomy flap necrosis (21 patients). Eight patients experienced a delay in the start of postoperative chemotherapy due to wound healing complications. The longest delay was 3 weeks. Forty-nine patients experienced late postoperative complications (28.8%). By far the most common late postoperative complication was fat necrosis, which occurred with an overall incidence of 26.5%. In the majority of patients (53.3%) fat necrosis was small or insignificant in size (<3cm2). Five patients experienced partial flap loss after radiation therapy. Eleven patients (11%) treated with postoperative radiation therapy experienced moderate to severe flap shrinkage or distortion. Abdominal wall laxity or hernia occurred in 15 patients (8.8%). Univariate and multivariate analysis failed to identify significant risk factors for postoperative complications.

Local recurrences were noted in 15 patients (9.4%) after a median of 22.3 months (range 3.0-62.9 months). In all patients, local recurrences were noted in the remaining mastectomy skin flaps or within the scar. Thirty-nine patients experienced distant metastasis (24.5%) after a median of 16.2 months (range 0-85.2 months).

The majority of patients contacted were either satisfied or very satisfied with their reconstruction. In addition, having gone through the process most would still prefer immediate reconstruction over delayed reconstruction and would recommend it to a friend or colleague.

Discussion

Immediate breast reconstruction in women with locally advanced breast cancer is safe and well tolerated. Early surgical complication rates in our series are not significantly different than mastectomy alone in this population and are similar to pervious reports of breast reconstruction in early stage cancers.10-13 The majority of patients in our series did not have early postoperative complications (66.5%) and most early complications were minor representing wound healing complications in the breast or abdominal donor site. The rates of microvascular complications, average hospital stay, and the need for blood transfusions in this report are also comparable to published data on early stage breast reconstruction.

In this study, the administration of postoperative chemotherapy was delayed in 8 patients (4.7%) due to wound healing complications. This rate is comparable to, or less than, the rates reported after mastectomy without reconstruction in women with locally advanced breast cancer.14-16 In addition, even in the small minority of patients in whom postoperative chemotherapy was delayed, the maximal delay was only 3 weeks and was most likely oncologically insignificant.

Local recurrences were noted in 9.4% of our patients while 24.5% eventually had distant metastasis. The local and distant recurrence rates in our study are within the range of published data on recurrence rates of locally advanced breast cancer and do not indicate an alteration in tumor behavior.17 In addition, the diagnosis of local recurrences in our series was not delayed or obstructed in any patient due to the reconstruction.

Nearly 60% of our patients were treated with postoperative radiation therapy. While it is true that radiation had deleterious effects in some cases, the majority of patients experienced minimal distortion or shrinkage after treatment. Interestingly, most patients did not report significant changes in the reconstructed breast following radiation therapy and were satisfied with their outcome.

In conclusion, immediate free flap reconstruction of locally advanced breast cancers is surgically safe and well tolerated, is not associated with a significant delay in the initiation of postoperative chemotherapy, and does not appear to alter the biologic behavior of these tumors. The majority of patients are satisfied with their reconstruction, would undergo immediate reconstruction again, and would recommend it to a friend or colleague. In addition, although postoperative radiotherapy has a deleterious effect in a small number of patients, the improvements in quality of life and patient satisfaction may justify this risk in most instances. Careful preoperative patient counseling is particularly important in this patient population.

References

1.Kroll, S.S., Coffey, J.A., Jr., Winn, R.J. & Schusterman, M.A. A comparison of factors affecting aesthetic outcomes of TRAM flap breast reconstructions. Plast Reconstr Surg. 96: 860, 1995.

2.Elkowitz, A., Colen, S., Slavin, S., Seibert, J., Weinstein, M. & Shaw, W. Various methods of breast reconstruction after mastectomy: an economic comparison. Plast Reconstr Surg. 92: 77, 1993.

3.Dean, C., Chetty, U. & Forrest, A.P. Effects of immediate breast reconstruction on psychosocial morbidity after mastectomy. Lancet. 1: 459, 1983.

4.Noone, R.B., Frazier, T.G., Hayward, C.Z. & Skiles, M.S. Patient acceptance of immediate reconstruction following mastectomy. Plast Reconstr Surg. 69: 632, 1982.

5.Teimourian, B. & Adham, M.N. Survey of patients' responses to breast reconstruction. Ann Plast Surg. 9: 321, 1982.

6.Brandberg, Y., Malm, M., Rutqvist, L.E., Jonsson, E. & Blomqvist, L. A prospective randomised study (named SVEA) of three methods of delayed breast reconstruction. Study design, patients' preoperative problems and expectations. Scand J Plast Reconstr Surg Hand Surg. 33: 209, 1999.

7.Anderson, R.C. & Kaczmarek, B. Psychological well-being of the breast reconstruction patient: a pilot study. Plast Surg Nurs. 16: 185, 1996.

8.Goin, M.K. & Goin, J.M. Psychological reactions to prophylactic mastectomy synchronous with contralateral breast reconstruction. Plast Reconstr Surg. 70: 355, 1982.

9.Tran, N.V., Chang, D.W., Gupta, A., Kroll, S.S. & Robb, G.L. Comparison of immediate and delayed free TRAM flap breast reconstruction in patients receiving postmastectomy radiation therapy. Plast Reconstr Surg. 108: 78, 2001.

10.Schusterman, M.A., Kroll, S.S., Miller, M.J., Reece, G.P., Baldwin, B.J., et al. The free transverse rectus abdominis musculocutaneous flap for breast reconstruction: one center's experience with 211 consecutive cases. Ann Plast Surg. 32: 234, 1994.

11.Elliott, L.F., Eskenazi, L., Beegle, P.H., Jr., Podres, P.E. & Drazan, L. Immediate TRAM flap breast reconstruction: 128 consecutive cases. Plast Reconstr Surg. 92: 217, 1993.

12.Nejedly, A., Tvrdek, M. & Kletensky, J. Breast reconstruction using free tram flap transfer--ten years experience. Acta Chir Plast. 43: 35, 2001.

13.Nieminen, T., Asko-Seljavaara, S., Suominen, E., Kuokkanen, H. & von Smitten, K. Free microvascular tram flaps: report of 185 breast reconstructions. Scand J Plast Reconstr Surg Hand Surg. 33: 295, 1999.

14.Sauter, E.R., Eisenberg, B.L., Hoffman, J.P., Ottery, F.D., Boraas, M.C., Goldstein, L.J. & Solin, L.J. Postmastectomy morbidity after combination preoperative irradiation and chemotherapy for locally advanced breast cancer. World J Surg. 17: 237, 1993.

15.Schuster, R.H., Kuske, R.R., Young, V.L. & Fineberg, B. Breast reconstruction in women treated with radiation therapy for breast cancer: cosmesis, complications, and tumor control. Plast Reconstr Surg. 90: 445, 1992.

16.Vinton, A.L., Traverso, L.W. & Jolly, P.C. Wound complications after modified radical mastectomy compared with tylectomy with axillary lymph node dissection. Am J Surg. 161: 584, 1991.

17.Noone, R.B., Frazier, T.G., Noone, G.C., Blanchet, N.P., Murphy, J.B. & Rose, D. Recurrence of breast carcinoma following immediate reconstruction: a 13- year review. Plast Reconstr Surg. 93: 96, 1994.

1