In preinvasive and invasive breast cancer, breast-conserving surgery (BCS) has demonstrated similar survival outcomes to mastectomy, in addition to improvements in outcomes such as health-related quality of life and patient satisfaction. Chest wall perforator flap (CWPF) reconstruction can be utilized for volume replacement in oncoplastic BCS. Research indicates that CWPF reconstruction might reduce the rate of mastectomy, but there is a current lack of evidence on patient selection, surgical technique, and outcomes related to CWPF reconstruction. In this study, Karakatsanis et al1 evaluated practice patterns and outcomes of CWPF reconstruction in patients with preinvasive or invasive breast cancer.
Patients who received treatment at one of three centers with experience in CWPF reconstruction (1 in Sweden, 1 in Australia, and 1 in the United Kingdom) were included in this study. Data on breast volume, intended excision volume, and reason for offering CWPF reconstruction were required in addition to patient, tumor, pathology, and treatment data.
A nomogram was developed to identify patients who would need a mastectomy if CWPF reconstruction was unavailable. The “need for mastectomy” cohort consisted of patients who were determined to have a 75-percent or greater probability of being assessed as otherwise needing a mastectomy.
A total of 603 patients with a median age of 54 years were included for analysis. Median tumor extent was 30mm (range: 10–125mm). Median breast volume was 280mL, and median optimal resection volume (ORV) was 45mL. Calculated resection ratio (CRR) was defined as ORV divided by breast volume; the median was 16 percent. Across study sites, there were significant differences in many patient characteristics, such as age, breast volume, ORV, CRR, multifocality, and hormone receptor status.
Most patients (67.7%) were offered CWPF reconstruction to avoid mastectomy. CWPF reconstruction was offered to avoid asymmetry for those who did not want contralateral surgery in 18.1 percent of patients and to avoid wide local excision with poor cosmetic outcomes in 14.3 percent.
According to logistic regression analysis, body mass index (BMI), target area, breast volume, and CRR were associated with “need for mastectomy.” There were 301 patients (49.9%) in the “need for mastectomy” cohort. Compared to 107 patients who were offered CWPF reconstruction to avoid mastectomy but did not belong to the “need for mastectomy” cohort (<75% probability of requiring mastectomy), those who belonged to the “need for mastectomy” cohort had significantly lower median tumor volume (326mL vs. 251mL) and a significantly greater proportion of multifocal/multicentric tumors and adverse tumor locations. Median target area was 41mm and median CRR was 28.2 percent in the “need for mastectomy” cohort, compared to 25mm and 12.2 percent, respectively, for patients below the nomogram cutoff; these differences were significant.
Most patients underwent CWPF reconstruction as a day surgery, received intraoperative antibiotics, and did not have drains placed. Overall, the rate of complications was 8.6 percent, and most patients (n=32/52) experienced Clavien–Dindo Grade I complications. Axillary clearance, resection involving two or more quadrants, and operating time were significantly associated with complications in logistic regression. Ninety-six patients (15.9%) required re-excision to achieve adequate margins; there was no significant association between re-excision and belonging to the “need for mastectomy” cohort. According to logistic regression analysis, re-excision was significantly associated with study site and upfront surgery (vs. surgery following neoadjuvant systemic therapy); however, these factors were highly collinear. Only nine patients (1.5%) underwent conversion to mastectomy, which was associated with study site. Logistic regression analysis showed a correlation between BMI and conversion to mastectomy. Overall, most practice patterns, complications, and re-excision outcomes differed across study sites.
At a median postoperative follow-up of 22 months, 22 patients (3.6%) received revision surgery. A total of 529 patients were included in oncological follow-up analysis. At median 22-month oncological follow-up, distant and local recurrence were reported in 26 (4.9%) and 10 (1.9%) patients, respectively. In situ carcinoma, positive hormone receptor status, and lack of adjuvant endocrine therapy were significantly associated with local recurrence risk. Adjusted analysis showed a significant link between higher Charlson Comorbidity Index and risk of distant recurrence. Breast cancer-related mortality was reported in eight patients (1.5%), all of whom had hormone receptor positivity. There was a significant association between nodal stage and breast cancer-related mortality.
Limitations of this study included the lack of a control group and the short oncological follow-up period.
Researchers concluded that CWPF reconstruction can be an appropriate alternative to mastectomy in patients with preinvasive or invasive breast cancer. CWPF reconstruction demonstrated acceptable safety and low rates of recurrence and mortality at short-term oncological follow-up.
Reference
- Karakatsanis A, Meybodi F, Pantiora E, et al. Chest wall perforator flaps are safe and can decrease mastectomy rates in breast cancer surgery: multicentre cohort study. Br J Surg. 2024;111(11):znae266.