Does immediate breast reconstruction using free flaps lead to delay in the administration of adjuvant chemotherapy for breast cancer?

Anatomic Location of Tissue Expander Placement Is Not Associated With Delay in Adjuvant Therapy in Women With Breast Cancer

BACKGROUND

Tissue expanders in breast reconstruction are traditionally placed retropectoral. Increasingly, patients are undergoing prepectoral placement. The impact of this placement on the initiation of adjuvant treatment is unknown.

METHODS

A retrospective review was conducted to identify women diagnosed with breast cancer who underwent mastectomy followed by radiation and/or chemotherapy. Women were divided into 3 groups: prepectoral tissue expander placement, retropectoral tissue expander placement, and no immediate reconstruction. A treatment delay was defined as greater than 8 weeks between tissue expander placement and adjuvant therapy.

RESULTS

Of 634 women, 205 (32%) underwent tissue expander placement, and 429 (68%) did not have immediate reconstruction. Of those with tissue expanders placed, 84 (41%) had prepectoral placement, and 121 (59%) had retropectoral placement. The median time to adjuvant therapy was 49 days for the entire cohort: no reconstruction, 47 days; prepectoral, 57 days; and retropectoral, 55 days. Treatment delays were observed in 34% of women: no reconstruction, 28%; prepectoral, 51%; and retropectoral, 46% ( P < 0.001). Tissue expander placement was associated with a delay to adjuvant therapy when compared with no reconstruction ( P < 0.001). The location of the tissue expander did not impact the odds of having a delay. On multivariable analysis, having reconstruction, having postoperative infection, not undergoing chemotherapy treatment, and being a current smoker were associated with a delay to adjuvant therapy. A delay to treatment was not associated with worse survival.

CONCLUSIONS

Placement of a tissue expander delayed adjuvant therapy. The location of tissue expander placement, retropectoral versus prepectoral, did not impact the time to adjuvant treatment.

Does Immediate Breast Reconstruction Lead to a Delay in Adjuvant Chemotherapy for Breast Cancer? A Meta-Analysis and Systematic Review

Timely delivery of adjuvant chemotherapy is crucial. With an increasing frequency of immediate breast reconstructions (IBR) following mastectomy (MAS), concerns have arisen regarding its complication rates and effects on time to chemotherapy. The aim was to conduct a systematic review and meta-analysis to determine if there is a prolonged time to chemotherapy (TTC) after IBR and MAS. Electronic databases, reference lists and relevant articles were searched systematically. Eligibility criteria included women receiving adjuvant chemotherapy who underwent either MAS only or MAS and IBR. Random-effects models were used in the analysis. A total of 29 studies were included in qualitative analysis, comprising of 156,000 patients (IBR: 57,159; MAS: 98,841). But 23 studies had sufficient data to be included in the meta-analysis. Sixteen papers concluded there was no difference in TTC compared to MAS. There was a difference of 3.50 days between TTC in IBR versus MAS (95% CI [0.42, 6.57], P value = .0256; IBR = 43.56 days, MAS = 40.38 days). The rate of patients being delayed past 90 days was not significantly higher in IBR (OR = 1.34, 95% CI [0.76, 2.38], P = .310). IBR patients were more likely to have complications compared to the MAS group (OR = 2.04, 95% CI [1.04-4.01], P < .01). We concluded that there is a statistically significant longer time to chemotherapy following IBR of 3.50 days, yet there is no difference in delays past 90 days. Therefore, the longer TTC in IBR is unlikely to be of any clinical significance.

Reverse Abdominoplasty for Mastectomy Defect Closure in Advanced Breast Cancer

BACKGROUND

Breast cancer patients with locally advanced breast cancer who require radical mastectomy are left with large chest wall defects. This poses a significant reconstructive challenge as many high-risk patients require timely postmastectomy adjuvant therapy. While the reverse abdominoplasty technique is commonly used for aesthetic improvement of the anterior trunk, it can be also be effectively used for closure of extensive mastectomy defects in this patient population.

METHODS

We conducted a retrospective cohort study of all consecutive patients who underwent an extensive radical mastectomy followed by immediate closure with the reverse abdominoplasty technique at a single tertiary cancer center from June 2017 to July 2022. Patients who had concurrent skin grafting or breast mound flap reconstruction were excluded. Demographic, medical, oncologic, and reconstructive data were collected.

RESULTS

Six patients were treated with reverse abdominoplasty for 9 chest wall defects after surgical excision of locally advanced breast cancer. The median tumor size was 10.7 cm (range, 6.7-10 cm) and the median mastectomy weight was 865.7 g (range, 356.4-1247.7 g). On average, the operation length was 191 minutes (range, 86-257 minutes) and the postoperative length of stay was 2.2 days (range, 1-5 days). All patients underwent systemic adjuvant therapy and the median time from surgery to initiation of therapy was 44.5 days (range, 32-75 days).

CONCLUSIONS

Reverse abdominoplasty is a simple and safe technique to reliably close large defects after locally advanced breast cancer excision. It has a short operative time, hospital stay, and turnaround time to initiation of adjuvant therapy.

Delay in the initiation of adjuvant chemotherapy in patients with breast cancer with mastectomy with or without immediate breast reconstruction

Background

Patients with breast cancer undergoing mastectomy should be offered the option of immediate breast reconstruction (IBR). The aim of this retrospective study was to assess whether there is a delay in the initiation of adjuvant chemotherapy in patients undergoing mastectomy with or without IBR.

Method

The study included patients aged 70 years or younger with clinically node-negative breast cancer who underwent unilateral mastectomy with IBR (IBR group) or mastectomy alone (no-IBR group) followed by adjuvant chemotherapy at the Helsinki University Hospital between January 2012 to July 2018.

Results

A total of 645 patients were included; 186 in the IBR group and 459 in the no-IBR group. Sixty-six (35.5 per cent) patients in the IBR group and 102 (22.2 per cent) patients in the no-IBR group received their first chemotherapy cycle later than 6 weeks after surgery (P &lt; 0.001). The respective numbers for later than 8 weeks were 17 (9.1 per cent) and 14 (3.1 per cent) (P = 0.001). Among all 645 patients, postoperative complications were a significant risk factor for a delay in the initiation of chemotherapy. Sixty-seven (39.9 per cent) patients with and 101 (21.2 per cent) patients without complications had a delay in chemotherapy (P &lt; 0.001). The delay in chemotherapy was due to complications in 39 (59.1 per cent) in the IBR group and in 28 (27.5 per cent) in the no-IBR group (P &lt; 0.001).

Conclusion

Patients undergoing mastectomy alone were more likely to receive adjuvant chemotherapy within 6 weeks after surgery compared with the IBR patients. IBR significantly increased the risk of postoperative complications in comparison with mastectomy alone. The complications, in turn, were a significant risk factor for delay in adjuvant chemotherapy.

Neoadjuvant chemotherapy and radiotherapy for locally advanced breast cancer: Safety and efficacy of reverse sequence compared to standard technique?

BACKGROUND

The reverse sequence of neoadjuvant chemotherapy, preoperative radiotherapy, mastectomy then immediate breast reconstruction is currently proposed for selected patients with locally advanced breast cancer. Few studies have compared it to the standard sequence of neoadjuvant chemotherapy, mastectomy and radiotherapy with or without differed reconstruction. Our study compares overall (OS) and recurrence-free (RFS) survivals of breast cancer patients treated with reverse sequence compared to the standard technique.

METHODS

In this retrospective, single center study at a Comprehensive Cancer Center in France, patients were included if: female, age <65y, had received neoadjuvant chemotherapy, mastectomy and radiotherapy, and were M0. Outcomes for patients treated by reverse sequence (RS) are compared to those for patients treated by standard sequence (ST). Data was collected from medical records.

RESULTS

From January 2009 to April 2018, 222 eligible patients were treated, 46 by RS and 176 by ST. Mean follow-up was 61.7 months. Five-year OS and RFS did not differ between groups. 5-yr OS: 88.4% 95%CI [74.1-95.0] for RS and 81.5% 95%CI [74.0-87.0] for ST (P = 0.4412); 5-yr RFS: 78.3% 95%CI [61.9-88.3] for RS and 70.1% 95%CI [62.2-76.7] for ST (P = 0.3003). Overall treatment time was significantly shorter in the RS group, and the rate of severe surgical complications did not differ between groups.

CONCLUSIONS

For locally advanced breast cancer patients with an indication for radiation therapy the reverse sequence offers similar safety and efficacy results as the standard treatment while allowing immediate breast reconstruction. However, careful patient selection is necessary, particularly with regard to preoperative lymph node invasion.

[Postoperative course after immediate breast reconstruction: Comparison between five surgical techniques]

INTRODUCTION

This study analyzes postoperative course of different immediate breast reconstruction techniques: deep inferior epigastric perforator flap (DIEP), gracilis, latissimus dorsi flap, expander implants and definitive implants.

METHODS

All women operated on IBR between 2012 and 2017 in the CHU Strasbourg were included in this retrospective study. The main data collected were healing time, complications, surgical revisions and failure rates. These data were compared between the five IBR techniques to find a significant difference. Two groups were distinguished according to the surgical techniques: free flaps and implants. Data of those groups were compared too.

RESULTS

One hundred and ninety three patients have had a breast surgical treatment between 2012 and 2017. Among them, 44 had a bilateral IBR (23%). Early and unserious complications, were less frequent in the implants group than in the free flaps group: 8.6% vs. 33.3% (P<0.01) for unilateral reconstructions and 10.9% vs. 38.9% (P<0.01) for bilateral reconstructions. No surgical failures were found in the free flaps group versus 6.2% for definitive implants and 3.6% for expander implants. Healing time was longer for the free flaps group than for the prothesis group: 5.6 weeks vs. 4.2weeks, (P<0.01).

CONCLUSION

IBR with free flaps is associated with a higher risk for early and unserious complications as healing disorders, which extend the dressings time. However the failure rate is not higher with free flaps.

Risk Factors for Delays in Adjuvant Chemotherapy following Immediate Breast Reconstruction

BACKGROUND

Concerns exist that immediate breast reconstruction may delay adjuvant chemotherapy initiation, impacting oncologic outcomes. Here, the authors determine how postoperative complications impact chemotherapy timing, and identify factors associated with greater risk for delays.

METHODS

Retrospective chart review identified patients undergoing immediate breast reconstruction and adjuvant chemotherapy at a single institution from 2010 to 2015. Patients were analyzed based on occurrence of postoperative complications and time to chemotherapy.

RESULTS

A total of 182 patients (244 breast reconstructions) were included in the study; 210 (86 percent) reconstructions did not experience postoperative complications, and 34 (13.9 percent) did. Patients who experienced postoperative complications had an older mean age (53.6 years versus 48.1 years; p = 0.002) and higher rates of diabetes (23.5 percent versus 3.8 percent; p < 0.001). The complication group had delays in initiation of chemotherapy (56 versus 45 days; p = 0.017). Patients who initiated chemotherapy more than 48.5 days after reconstruction were of older mean age (55.9 years versus 50.7 years; p = 0.074) and had increased rates of diabetes (36.8 percent versus 6.7 percent; p = 0.053) and immediate autologous reconstruction (31.6 percent versus 0 percent; p = 0.027). A predictive model determined that patients with at least one of these three risk factors have a 74 percent chance of experiencing prolonged times to chemotherapy initiation.

CONCLUSIONS

Risk factors for delayed chemotherapy in the context of postoperative complications are age older than 51.7 years, diabetes, and autologous reconstruction. Reconstructive candidates who fit this profile are at highest risk and merit extra consideration.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

The impact of immediate breast reconstruction after mastectomy on time to first adjuvant treatment in women with breast cancer in a community setting

BACKGROUND

The impact of immediate breast reconstruction on the time to first adjuvant therapy is controversial.

METHODS

Retrospective study design comparing time to first treatment in women undergoing mastectomy with and without immediate reconstruction in a community cancer center.

RESULTS

Seventy-six cases fit inclusion criteria of which 44 (58%) underwent mastectomy with immediate reconstruction. Women undergoing immediate reconstruction were younger, had more bilateral mastectomies and had fewer prior breast procedures. The median time to first adjuvant therapy was longer in the immediate reconstruction group [80.5days (36-343) versus 53.5 days (18-96), p = 0.003]. Fifteen of 44 patients had the start of adjuvant treatment over 90 days after resection, 14 of whom (93%) had immediate reconstruction versus 1 (7%) who did not (p = 0.01).

CONCLUSION

In this study immediate breast reconstruction was associated with a longer time to first adjuvant treatment, with adjuvant therapies being more likely delayed over 90 days.

The iBRA-2 (immediate breast reconstruction and adjuvant therapy audit) study: protocol for a prospective national multicentre cohort study to evaluate the impact of immediate breast reconstruction on the delivery of adjuvant therapy

INTRODUCTION

Immediate breast reconstruction (IBR) is routinely offered to improve quality of life for women with breast cancer requiring a mastectomy, but there are concerns that more complex surgery may delay the delivery of adjuvant oncological treatments and compromise long-term oncological outcomes. High-quality evidence, however, is lacking. iBRA-2 is a national prospective multicentre cohort study that aims to investigate the effect of IBR on the delivery of adjuvant therapy.

METHODS AND ANALYSIS

Breast and plastic surgery centres in the UK performing mastectomy with or without (±) IBR will be invited to participate in the study through the trainee research collaborative network. All women undergoing mastectomy ± IBR for breast cancer between 1 July and 31 December 2016 will be included. Patient demographics, operative, oncological and complication data will be collected. Time from last definitive cancer surgery to first adjuvant treatment for patients undergoing mastectomy ± IBR will be compared to determine the impact that IBR has on the time of delivery of adjuvant therapy. Prospective data on 3000 patients from ∼50 centres are anticipated.

ETHICS AND DISSEMINATION

Research ethics approval is not required for this study. This has been confirmed using the online Health Research Authority decision tool. This novel study will explore whether IBR impacts the time to delivery of adjuvant therapy. The study will provide valuable information to help patients and surgeons make more informed decisions about their surgical options. Dissemination of the study protocol will be via the Mammary Fold Academic and Research Collaborative (MFAC) and the Reconstructive Surgery Trials Network (RSTN), the Association of Breast Surgery (ABS) and the British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS). Participating units will have access to their own data and collective results will be presented at relevant surgical conferences and published in appropriate peer-reviewed journals.

Breast reconstruction after neoadjuvant radio chemotherapy: review and personal technique IDEAL concept REV-EJMR-D-15-00268

Neoadjuvant radio chemotherapy and immediate reconstruction for breast cancer are still under debate. But there are recent abstracts and articles which show that neoadjuvant radio chemotherapy is feasible and could improve the clinical outcome of breast cancer patients. The aim of this review is to present the authors’ techniques and approaches with regard to neoadjuvant radiation of breast cancer patients. It seems that the concept of immediate implant delayed autologous breast reconstruction could be a safe procedure that is at least equivalent to primary autologous reconstruction.

The prognosis of breast cancer patients after mastectomy and immediate breast reconstruction: a meta-analysis

BACKGROUND

An increasing number of patients with breast cancer are being offered immediate breast reconstruction (IBR). The aim of this study was to analyze the impact of IBR on the prognosis of patients with breast cancer.

METHODS

We searched the electronic databases of Medline (Pubmed), ISI Web of Knowledge, Embase, and Google Scholar databases for studies reporting the overall recurrence, disease-free survival (DFS), and overall survival (OS) of patients after mastectomy only and mastectomy with IBR. With these data, we conducted a meta-analysis of the clinical outcomes.

RESULTS

Fourteen studies, including 3641 cases and 9462 controls, matched our criteria. Relevant information was extracted from these 14 studies. There was no significant heterogeneity (P for Q-statistic > 0.10 and I2 < 25%). Patients who underwent IBR showed no increased risk of overall recurrence of breast cancer (RR = 0.89; 95% confidence interval [CI]: 0.75, 1.04; P = 0.14). Furthermore, patients receiving IBR had similar DFS (RR = 1.04; 95%CI: 0.99, 1.08); P = 0.10) and OS (RR = 1.02; 95%CI: 0.99, 1.05; P = 0.24)) as those of control patients.

CONCLUSION

This meta-analysis provides evidence that IBR does not have an adverse effect on prognosis. These data suggest that IBR is an appropriate and safe choice for patients with breast cancer.

[Intraoperative, postoperative and long-term oncosurgical safety of therapeutic mammaplasty]

INTRODUCTION

(Pre)malignant lesion in the breast requiring mastectomy conventionally may be treated with breast conservation by using oncoplastic breast surgical techniques, which is called therapeutic mammaplasty. However, no reliable data has been published so far as regards the oncological safety of this method.

AIM

The aim of the authors was to analyse the oncological safety of therapeutic mammaplasty in a series of patients.

METHOD

99 patients were treated with therapeutic mammaplasty and data were collected in a breast surgical database prospectively. Results were analysed with respect to intraoperative, postoperative and long-term oncological safety.

RESULTS

Incomplete resection rate was 14.1%, which correlated with tumour size (p = 0.023), and multifocality (p = 0.012). Time between surgery (therapeutic mammaplasty) and chemotherapy was similar to time between conventional breast surgeries (wide excision, mastectomy, mastectomy with immediate reconstruction) and chemotherapy (mean 29-31 days; p<0.05). Overall recurrence rate was 6.1%, locoregional recurrence rate was 2% during 27 month (1-88) mean follow-up.

CONCLUSIONS

Since literature data are based on relatively short follow-up and low patient number, it is highly important that all data on therapeutic mammaplasty is collected in a prospectively maintained breast surgical database in order to determine true recurrence after long-follow-up.

Contralateral risk-reducing mastectomy in sporadic breast cancer

Recent studies have shown that the number of women undergoing risk-reducing mastectomy has increased rapidly in the USA in the past 15 years. Although a small rise in the number of bilateral risk-reducing procedures has been noted in high-risk gene mutation carriers who have never had breast cancer, this number does not account for the overall increase in procedures undertaken. In patients who have been treated for a primary cancer and are judged to be at high risk of a contralateral breast cancer, contralateral risk-reducing mastectomy is often, but not universally, indicated. However, many patients undergoing contralateral risk-reducing mastectomy might not be categorised as high risk and therefore any potential benefit from this procedure is unproven. At a time when breast-conserving surgery has become more widely used, this sharp increase in contralateral risk-reducing mastectomy is surprising. We have reviewed the literature in an attempt to establish what is driving the increase in this procedure in moderate-to-low-risk populations and to assess its justification in terms of risk-benefit analysis.

Two surgeons, one patient: the impact of surgeon-surgeon familiarity on patient outcomes following mastectomy with immediate reconstruction

BACKGROUND

Mastectomy with immediate reconstruction requires the coordination and expertise of two distinct surgeons. This often results in several different combinations of mastectomy and reconstructive surgeons, but with an unknown impact on patient outcomes. We evaluate the effect of different surgical teams on complication rates following mastectomy and immediate reconstruction.

METHODS

Retrospective review of consecutive patients that underwent mastectomy with immediate prosthetic reconstruction from 4/1998 to 10/2008 at one institution was performed. Patients of the three highest-volume mastectomy and reconstructive surgeons were stratified by their individual combination of surgeons, resulting in nine different surgical teams. Complications were categorized by end-outcome. Appropriate statistics, including multiple linear regression, were performed.

RESULTS

Clinical characteristics were similar among patients (n = 511 patients, 699 breasts) with the same mastectomy surgeon but different reconstructive surgeon. Mean follow-up was 38.4 ± 25.7 months. For each mastectomy surgeon, the choice of reconstructive surgeon did not affect complication rates. Furthermore, the combined complication rates of the three highest-volume teams (n = 384 breasts) were similar to the remaining lower-volume teams (n = 315 breasts). Patient factors, but not the individual surgeon or surgical team, were independent risk factors for complications.

DISCUSSION

Our study suggests that among high-volume surgeons, complication rates following mastectomy with immediate reconstruction are not affected by the surgeon-surgeon familiarity. The individual surgeon's expertise, and patient risk factors, may have a greater impact on outcomes than the team's experience with each other. These results validate the efficacy and safety of the surgeon distribution model currently used by many breast surgery practices.

Local breast cancer recurrence after mastectomy and immediate breast reconstruction for invasive cancer: a meta-analysis

BACKGROUND

The main priorities in the surgical treatment of patients with breast cancer are to achieve cure, local control and prevent recurrence. It is increasingly important to address quality of life and self-image with women undergoing surgical intervention for breast cancer. There is a lack of consensus as to the oncologic safety of immediate breast reconstruction (IBR). The purpose of this paper is to systematically review the literature and compare the frequency of recurrence in patients with and without IBR following mastectomy for breast cancer.

METHODS

Two independent investigators searched PubMed, Embase, and the Cochrane database using predefined search terms. After application of inclusion and exclusion criteria, 10 articles remained. Each article was assessed for quality. Relevant data was collected including recurrence rates, cancer stage, type of mastectomy and reconstruction, adjuvant treatments, and duration of follow-up.

RESULTS

Inter-rater reliability was good at 74% (95% CI: 0, 93%). There was no evidence of study heterogeneity (p for Q-statistic=0.34 and I(2)=12%). The OR ratio for recurrence of breast cancer for mastectomy with IBR as compared to mastectomy alone was 0.98 (95% CI: 0.62, 1.54).

CONCLUSION

This meta-analysis demonstrated no evidence for increased frequency of local breast cancer recurrence with IBR compared with mastectomy alone.

Does Immediate Breast Reconstruction after Mastectomy affect the Initiation of Adjuvant Chemotherapy?

Purpose

The frequency of immediate breast reconstruction (IBR) is increasing, and the types of reconstruction used are diverse. Adjuvant chemotherapy is a life-saving intervention in selected high-risk breast cancer patients. The aim of our study was to determine how IBR and type of reconstruction affect the timing of the initiation of chemotherapy.

Methods

We obtained data from female breast cancer patients treated by mastectomy with IBR (IBR group) and without IBR (mastectomy only group) who received adjuvant chemotherapy between January 1, 2008, and December 31, 2010. We retrospectively collected data including patient characteristics, disease characteristics, treatment details, and treatment outcomes from our institutional electronic patient database and medical treatment records. The reconstruction types were categorized as deep inferior epigastric perforator (DIEP) flap, latissimus dorsi (LD) flap and tissue expander/implant (TEI).

Results

In total, 595 patients were included in this study. Of these patients, 43 underwent mastectomy with IBR (IBR group) and 552 patients did not undergo reconstruction (mastectomy only group). There was significant difference in the timing of the initiation of chemotherapy between the two groups (p<0.0001). There were no cases of delays of more than 12 weeks. In the IBR group, 20 patients received TEI, 9 patients were treated by the insertion DIEP flaps, and 14 patients were treated by LD flaps. There were no significant differences in the timing of chemotherapy according to the type of reconstruction (p=0.095).

Conclusion

IBR delays the initiation of chemotherapy, but does not lead to omission or significant clinical delay in chemotherapy. Further, the type of reconstruction does not affect the timing of chemotherapy.