Outcomes of immediate perforator flap reconstruction after skin-sparing mastectomy following neoadjuvant chemotherapy

doi:10.1016/j.ejso.2014.09.001

European Journal of Surgical Oncology (EJSO)

Volume 41, Issue 1, January 2015, Pages 94-99

https://doi.org/10.1016/j.ejso.2014.09.001 Get rights and content

Abstract

Background

The impact of neoadjuvant chemotherapy (NACT) on immediate free flap breast reconstruction remains controversial. Furthermore, the oncological outcomes of immediate free flap breast reconstruction after skin-sparing mastectomy (SSM) following NACT remain unclear. This study aimed to investigate the surgical complications and oncological outcomes of immediate perforator flap reconstruction after SSM following NACT.

Methods

A total of 201 consecutive patients with indications for immediate perforator flap reconstruction after SSM were included between 2004 and 2012. Surgical and oncological outcomes were compared between patients with and without NACT.

Results

There were 38 patients in the NACT group and 163 in the non-NACT control group. The median age of the NACT group was 39.5 years, which was significantly younger than the control group (43.0 years; P < 0.05). Patients in the NACT group also had more advanced and aggressive disease (P < 0.05). There was no significant difference in the frequency of surgical complications between the groups, no difference in the type of complications, and no significant difference in the frequencies of major and minor complications. No patients in the NACT group had delayed adjuvant therapy. Eight patients (4%) developed recurrences, with a median follow-up time of 3.0 years. Local recurrences occurred in three control patients but no patients in the NACT group.

Conclusion

NACT does not affect short-term or interim outcomes after immediate perforator flap reconstruction and may thus represent a safe and practical treatment option for the multidisciplinary treatment of breast cancer.

Introduction

Neoadjuvant chemotherapy (NACT) is currently administered to some patients with early breast cancer who require adjuvant chemotherapy.1, 2, 3 In addition to the potential benefits of downstaging, NACT also provides an opportunity for direct and early observation of the response to treatment.

Although NACT can cause tumor shrinkage, some patients still require mastectomy because of widespread cancer, multifocal lesions, or for other reasons such as genetic factors. Reconstruction after mastectomy using a free perforator flap from the inferior abdomen was first described by Koshima in 1989,⁴ and has since become one of the most valuable techniques, characterized by its autologous nature, minimal invasion, and excellent esthetic outcomes. Immediate breast reconstruction in patients undergoing mastectomy offers numerous benefits compared with delayed reconstruction, including technical ease, less expense, better cosmetic results, and reduced total operative and recovery times.⁵ Moreover, the patient does not have to live with any deformity, even temporarily.

Most chemotherapeutic drugs are designed to inhibit cellular metabolism, rapid cell division, and angiogenesis. They can delay cell migration into the wound, decrease early wound matrix formation, lower collagen production, impair fibroblast proliferation, and inhibit wound contraction, as well as weakening the immune functions of patients.⁶ Animal studies have documented impaired wound-healing caused by chemotherapeutic drugs such as adriamycin, administered preoperatively.7, 8

Immediate perforator flap breast reconstruction is often a long procedure requiring extensive dissection of the chest wall and donor site. Its success relies on the successful anastomosis of the perforator artery with the recipient vessel, with a diameter of about 1.0 mm. Surgical options such as this need to be considered carefully after NACT.⁹ Previous studies10, 11, 12, 13, 14, 15 that evaluated the outcomes of immediate free flap breast reconstruction following NACT reported controversial results in terms of surgical complications and delayed adjuvant therapy.

In this study, we investigated the surgical outcomes and interim oncological outcomes in a relatively large number of patients who underwent immediate perforator flap reconstruction following NACT at a single institution. The aim of the study was to determine the safety and practicality of immediate perforator flap reconstruction following NACT.

Section snippets

Patients

Patients admitted to our department (Yokohama City University Medical Center) for mastectomy for breast cancer were informed about the option of immediate reconstruction with autologous grafting. Patients who chose to undergo this surgery using immediate perforator flap reconstruction were included in the study. All patients underwent tumor biopsy before treatment. Patients who were hormone-receptor negative, HER-2 positive, and/or clinically node positive were informed about NACT. Breast

Results

SSM and immediate reconstruction with perforator flap was performed in 201 patients from October 2004 to December 2012. The mean age of the patients was 42.2 years (range: 23–64 years) and the mean body mass index was 21.2 (range: 16.0–28.2). There were 38 patients in the NACT group and 163 in the control group. The characteristics of the patients and tumors and details of NACT are summarized in Table 1. Patients in the NACT group were significantly younger and had significantly more advanced

Discussion

NACT did not increase the incidence of complications following immediate free flap breast reconstruction after mastectomy. The outcomes of this procedure following NACT have been reported previously,10, 11, 12, 13, 14, 15 with a focus on surgical complications, and although recent studies10, 13, 15 found that NACT did not increase the complication rate or delay adjuvant treatment after immediate microvascular breast reconstruction, the numbers of patients undergoing NACT in these studies were

Conflict of interest statement

None of the authors have any relevant conflict of interest to disclose.

Funding

This work was self-funded.

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Cited by (27)

Effects of Neoadjuvant Chemotherapy on Autologous and Implant-Based Breast Reconstruction: A Systematic Review and Meta-Analysis of the Literature
2024, Clinical Breast Cancer
Neoadjuvant chemotherapy (NAC) is a standard modality of treatment for breast cancer. The exposure of patients to drugs that effect the cells and processes involved in healing prior to reconstructive surgical procedures is a source of concern for reconstructive surgeons. The reported effects of NAC on autologous and tissue expander to implant-based breast reconstruction vary from study to study and have not been comprehensively reviewed on a large scale. There is also significant variation from study to study regarding which outcomes are evaluated. The primary aim of this systematic review and meta-analysis is to evaluate the effect of neoadjuvant chemotherapy (NAC) on common and significant outcomes including total complication, reconstruction loss, and SSI (Surgical Site Infection) rates in breast reconstruction. The second aim of this study is to evaluate whether NAC has differing effects on implant-based reconstruction compared with autologous flap reconstruction. A systematic review of the literature published from 1991 to 2019 in the PubMed and Scopus library database was performed to identify studies reporting outcomes of breast reconstruction in patients receiving NAC. A meta-analysis was then performed. Primary outcomes reviewed included overall complication rates, SSI rates, and total loss of reconstruction (flap necrosis or premature tissue expander or implant removal). Outcomes were analyzed using a random effects model and chi-square statistical test. Our literature search yielded 22 manuscripts with a total of 3680 patients that fit our inclusion criteria, of which 12 reported on reconstruction loss, 14 reported on SSI rates, and 10 reported on overall complication rates. There was no significant difference in overall breast reconstruction loss rate (OR 1.30, P = .35), complication rate (OR 1.21, P = .06), and rate of SSI (OR 1.28, P = .85) between NAC vs. non-NAC groups. In patients undergoing autologous flap reconstruction there were no significant differences in complication (23.4% vs. 17.7%, P = 0.076), loss of reconstruction (3.1% vs. 4.4%, P = .393), or SSI (5.3% vs. 3.4%, P = .108) rates in patients who were treated with NAC compared to those who were not. Likewise, in patients undergoing TE/implant-based reconstruction there were no significant differences in complication (19.6 vs. 24.2 P = .069), loss of reconstruction (17.4% vs. 13.3%, P = .072), or SSI (7.9% vs. 5.1%, P = .073) rates in patients who were treated with NAC compared to those who were not. NAC was not associated with any significant differences in overall complication, reconstruction loss, or SSI rates in patients receiving implant-based or autologous flap breast reconstruction. Additionally, the lack of effect of NAC on overall complication, reconstruction loss or SSI rates did not differ with or depend on the type of reconstruction.
The effect of chemotherapy on the complication rates of breast reconstruction: A systematic review and meta-analysis
2023, Journal of Plastic, Reconstructive and Aesthetic Surgery
The impact of chemotherapy on complications following breast reconstruction surgery (BRS) is currently inconclusive. This meta-analysis investigates the impact of chemotherapy on complication rates in BRS.
Preferred Reporting in Systematic Review and Meta-Analysis (PRISMA) guidelines was used to search relevant studies published from January 2006 to March 2022. The complication rates of neoadjuvant systemic therapy (NST) and adjuvant systemic therapy (AST) were analyzed via RevMan software 5.4, and a P value of< 0.05 was considered significant. The quality of selected studies was performed using the Newcastle–Ottawa scale for quality assessment.
A total of 18 studies comprising 49,217 patients were included. There was no significant difference in the total complications rate, major complications, or minor complications between NST and BRS or control. The rate of wound dehiscence was higher in the NST group compared with the BRS only group [RR= 1.54, 95% CI, (1.08, 2.18), P = 0.02], and the rate of infection was lower in the NST group compared with the BRS only group, [RR= 0.75, 95% CI, (0.61, 0.94), P = 0.01]. No significant difference in the rates of hematoma, seroma, skin necrosis, and implant loss was detected between NST and AST, or NST with BRS only. No statistically significant differences in total complication rates were observed between flap and implant BRS types (P = 0.88).
No significant differences between AST and NST were detected for complications. Significantly, NST had more wound dehiscence and less infection rates compared with BRS only groups, possibly reflecting selection bias or issues in the design of reported studies.
I
A systematic review and meta-analysis on the effect of neoadjuvant chemotherapy on complications following immediate breast reconstruction
2021, Breast
Citation Excerpt :
Four studies reported on delays to adjuvant therapy (Fig. 4) and the pooled estimate showed no statistically significant difference between women receiving NACT compared with those who did not (RR: 1.59, 95% CI 0.66 to 3.87, p = 0.30; Fig. 4) [21,25,29,32]. The most common bias evident in the reports was in patient selection, whereby reconstruction after NACT was offered to significantly younger women [18,20,21,25]. In the study by Beugels et al., the control group had more smokers, leading to a protective association with NACT exposure.
The impact of neoadjuvant chemotherapy (NACT) on surgical outcomes following immediate breast reconstruction (IBR) remains unclear. While it is generally considered safe practice to perform an IBR post NACT, reported complication rates in published data are highly variable with the majority of studies including fewer than 50 patients in the NACT and IBR arm. To evaluate this further, we conducted a systematic review and meta-analysis on the effect of NACT on autologous and implant based immediate breast reconstructions. We aimed to assess for differences in the post-operative course following IBR between patients who received NACT with those who did not.
PubMed, EMBASE, and Cochrane Library were searched from 1995 to Sept 2, 2020 to identify articles that assessed the impact of NACT on IBR. All included studies assessed outcomes following IBR. Only studies comparing reconstructed patients receiving NACT to a control group of women who did not receive NACT were included. Unadjusted relative risk of outcomes between patients who received or did not receive NACT were synthesized using a fixed-effect meta-analysis. The evidence was assessed using the Newcastle Ottawa Scale scores and GRADE. Primary effect measures were risk ratios (RRs) with 95% confidence intervals.
A total 17 studies comprising 3249 patients were included in the meta-analyses. Overall, NACT did not increase the risk of complications after immediate breast reconstructions (risk ratio [RR]: 0.91, 95% CI 0.74 to 1.11, p = 0.34). There was a moderate, but not significant, increase in flap loss following NACT compared with controls (RR: 1.23, 95% CI 0.70 to 2.18, p = 0.47; I² = 0%). Most notably, there was a statistically significant increase in implant/expander loss after NACT (RR: 1.54, 95% CI 1.04 to 2.29, p = 0.03; I² = 34%). NACT was not shown to significantly increase the incidence of hematomas, seromas or wound complications, or result in a significant delay to commencing adjuvant therapy (RR: 1.59, 95% CI 0.66 to 3.87, p = 0.30).
Immediate breast reconstruction after NACT is a safe procedure with an acceptable post-operative complication profile. It may result in a slight increase in implant loss rates, but it does not delay commencing adjuvant therapy.
Long-Term Outcomes of Immediate Autologous Breast Reconstruction for Breast Cancer Patients
2020, Journal of Surgical Research
Citation Excerpt :
In our cohort, 43 patients (18.0%) received presurgical chemotherapy. We previously reported that there is no increase in the risk of surgical complications after presurgical chemotherapy.21 Radiation therapy plays an important role in the locoregional management of breast cancer.
There is limited information on the oncological outcomes of immediate autologous breast reconstruction in the Asian population. This study aimed to evaluate the oncological outcomes of immediate one-stage autologous breast reconstruction using a free perforator flap for breast cancer patients at a single institution in Japan.
We retrospectively reviewed 239 patients who underwent immediate one-stage autologous breast reconstruction using a free perforator flap after skin- or nipple-sparing mastectomy. The whole breast was pathologically analyzed in 5-mm sections. Clinical and pathological data were collected from medical records.
For tumor stage among the 239 patients, 101 (42.3%) had stage 0, 127 (53.1%) had stage I and II, and 11 (4.6%) had stage III. Twenty-three patients (9.6%) had margin involvement in the surgical specimen. Adjuvant chemotherapy was performed in 75 patients (30%), and endocrine therapy was administered in 153 patients (64%). Radiation therapy was performed in 15 patients (6.3%) because of multiple lymph node metastases or margin involvement. With a median follow-up time of 73 mo, local recurrence was found in 3.3%, distant metastases in 2.5%, and contralateral breast cancer in 3.7%. All patients with local recurrence did not receive radiation therapy as adjuvant treatment.
Among the patients who underwent immediate one-stage autologous reconstruction after breast surgery, 3.3% had local recurrence. For patients with margin involvement, radiation therapy is a promising option.
Effect of complete pathological response related factors after neoadjuvant chemotherapy on skin-sparing mastectomy and breast reconstruction
2020, Cirugia Espanola
La reconstrucción mamaria inmediata tras mastectomías ahorradoras de piel en pacientes sometidas a quimioterapia neoadyuvante todavía resulta controvertida. El objetivo es determinar factores relacionados con downstaging axilar y respuesta patológica completa (RPC), y como esta, condiciona la decisión de someterse a mastectomía bilateral con reconstrucción inmediata.
Se realizó un análisis retrospectivo de pacientes con cáncer de mama sometidas a quimioterapia neoadyuvante y mastectomía bilateral con reconstrucción inmediata entre 2000-2018. Se compararon dos grupos: 1) RPC y 2) no RPC. Se analizaron datos demográficos, anatomopatológicos y el estadio clínico inicial y final. Análisis estadístico descriptivo y comparativo.
Sesenta y nueve pacientes; Grupo1: 26 (37,68%) alcanzaron RPC y 43(62,32%) no RPC. Mediana de seguimiento 45,3 meses (RIQ: 23,0-94,0). En análisis bivariante, edad menor a 35 (p < 0,001), menor T al diagnóstico (p = 0,006) y subtipo HER2 (p< 0,001) se asociaron significativamente con mayores tasas de RPC. La indicación más frecuente fue la elección de la paciente (31,8%). La tasa de negativización axilar fue del 80% en el grupo 1 y 59,3% en grupo 2 y las tasas de linfadenectomía axilar fueron similares (73,1% y 83,72%).
La RPC tras la quimioterapia neoadyuvante no parece ser un factor de peso en la decisión de realizar la mastectomía bilateral con reconstrucción inmediata.
Immediate breast reconstruction after skin-sparing mastectomy in patients undergoing neoadjuvant chemotherapy is still controversial. The objective of this study is to determine factors related with axillary downstaging and complete pathological response (CPR), and how CPR influences the decision to perform bilateral mastectomy with immediate reduction.
A retrospective analysis of breast cancer patients who had undergone neoadjuvant chemotherapy and bilateral mastectomy with immediate reduction between 2000-2018 was performed. Two groups were compared:1) CPR and 2) non-CPR. Descriptive and comparative statistical analyses are provided.
69 patients; 26 (37.68%) reached CPR and 43 (62.32%) non-CPR. Median follow-up of 45.3 months (IQR: 23.0-94.0). Age under 35 (p < .001), small size tumor at diagnosis (p = .006) and subtype HER2 (p < .001) were associated with higher rates of CPR in bivariate analysis. Axillary negativization rate was 80% in group 1 and 59.3% in group 2, and lymphadenectomy rates were similar (73.1% and 83.72%).
CPR after neoadjuvant chemotherapy did not influence the decision to perform bilateral mastectomy with immediate reduction.
Persistent disparities in breast cancer surgical outcomes among hispanic and African American patients
2019, European Journal of Surgical Oncology
Racial disparities among patients who receive breast mastectomy and reconstruction have not been well characterized.
Records of patients undergoing breast extirpative and reconstructive surgery at a high-volume university-affiliated hospital over 5 consecutive years were reviewed. Patient demographics, breast cancer profiles, reconstructive modality, and outcomes were compared by race.
A total of 1045 patients underwent 1678 breast reconstructions during the five-year period. Mean age and standard deviation was 49.8 ± 10.6 years with a BMI of 27.9 ± 6.5. Hispanic and African American patients had significantly higher BMIs (p < 0.001), higher rates of ASA class III or IV (p = 0.025), obesity, diabetes, hypertension (p < 0.001 for these three comparisons), and smoking (p = 0.003), and had more prior abdominal surgeries (p = 0.007). Comparing oncologic characteristics, this population subset had higher rates of neoadjuvant chemotherapy (p = 0.036), history of radiation (p = 0.016), and were more likely to undergo modified radical mastectomy (p = 0.002) over nipple-sparing mastectomy (p = 0.035). Reconstructive complications revealed a higher overall complication rate (p = 0.023), higher rates of partial mastectomy flap necrosis (p = 0.043), as well as arterial (p = 0.009) and venous insufficiency (p = 0.026) during microvascular reconstruction among Hispanic and African American patients.
Compared to other patients, the present study identifies higher comorbidity burdens, higher rates of prior radiation and neoadjuvant chemotherapy, and higher post-surgical complication rates among Hispanic and African American patients with breast cancer.

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Outcomes of immediate perforator flap reconstruction after skin-sparing mastectomy following neoadjuvant chemotherapy

Abstract

Background

Methods

Results

Conclusion

Introduction

Section snippets

Patients

Results

Discussion

Conflict of interest statement

Funding

Eur J Surg Oncol

Br J Plast Surg

Surg Clin North Am

Eur J Surg Oncol

J Plastic Reconstr Aesthet Surg

Preoperative chemotherapy treatment of breast cancer–a review

Cancer

Neoadjuvant therapy for breast cancer

J Surg Oncol

The sooner the better: a study of psychological factors in women undergoing immediate versus delayed breast reconstruction

Am J Psychiatry

Factors affecting wound healing

J Dent Res