Breast Cancer Res Treat (2015) 152:9–15 DOI 10.1007/s10549-015-3449-5
REVIEW
Systematic review of effects of pregnancy on breast and abdominal contour after TRAM/DIEP breast reconstruction in breast cancer survivors Sadaf Alipour1 · Amirhossein Eskandari2
Received: 9 April 2015 / Accepted: 25 May 2015 / Published online: 6 June 2015 © Springer Science+Business Media New York 2015
Abstract Transverse rectus abdominis myocutaneous (TRAM) and its derivatives are the most commonly performed autologous breast reconstruction procedures. These procedures were not recommended in the past for those who planned for subsequent childbearing because of the transposition of portions of the abdominal wall during the procedure into the anatomic position of the breast, implying possible adverse effects over the contour of these manipulated areas during pregnancy and delivery. We conducted a systematic review to assess the literature on esthetic or functional consequences of childbearing over the breast and abdomen after these procedures in patients that were affected by breast cancer. A comprehensive literature search in databases and citation indexes was conducted from February 2014 to April 2015. Any paper on pregnancy after breast reconstruction by TRAM or its derivatives and modifications, written in English or French, were included. The search results underwent a first screening to exclude duplicate and irrelevant papers. Full texts were then reviewed as to the criteria for inclusion, and data were extracted into data extraction forms from eligible papers. The initial search yielded 5132 articles. After screening and review, overall 17 papers met all criteria for inclusion in this review. Our work revealed that uneventful pregnancy and delivery can be anticipated in breast cancer survivors who had undergone breast reconstruction via TRAM or its derivatives with minor negative effects on either the breast or the abdomen. & Sadaf Alipour [email protected] 1
Department of Surgery, Arash Women’s Hospital, Tehran University of Medical Sciences, Tehran, Iran
2
Ministry of Health and Medical Education, Tehran, Iran
Keywords Abdominal contour · Breast cancer · Breast reconstruction · Pregnancy · Transverse rectus abdominis myocutaneous (TRAM) · Muscle flap · Deep inferior epigastric artery perforator (DIEP) flap
Introduction Breast cancer is the most common female cancer and the second most common cause of cancer mortality among women world-wide [1]. Mastectomy remains one of the major surgeries for this malignancy [2, 3], but this procedure disturbs the body self-image of the women [4–6]. Breast reconstruction attempts to reverse this negative course and thus, has a positive influence on the psychological health after mastectomy [7–9]. Among the methods of autologous breast reconstruction, transverse rectus abdominis myocutaneous (TRAM) and deep inferior epigastric artery perforators (DIEP) flap are the most commonly performed procedures [10–12]. In the pedicled TRAM procedure, based on the selected technique, all or part of the contralateral, ipsilateral, or bilateral rectus abdominis muscle(s), together with the overlying adipose tissue and skin, are transposed over the underlying superior epigastric artery/arteries into the breast position through a subcutaneous tunnel. In free graft techniques, instead of transposing tissues subcutaneously, the flap vessels are anastomosed to an arterial branch in the new site. A similar procedure is undertaken in the DIEP operation using the deep inferior epigastric artery instead of the superior branch; in this procedure, the rectus muscle may be left intact. In all cases, the flap is then remodeled to look like the absent breast [12–14]. Muscle-sparing techniques may help in protecting lateral motor innervation to the rectus abdominis. For closure of the defect in the
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anterior abdominal fascia, repair is performed primarily by suturing the external oblique fascia to the rectus sheath or the linea alba. Alternatively, closure may be achieved by using a synthetic mesh [15]. In all these cases, one of the surgeon’s concerns in addition to the viability of the flap is the integrity of the abdominal wall. Due to the increasing age of marriage and pregnancy in the world [16], and the decreasing age of breast cancer presentation in some areas [17], many women who undergo breast cancer treatment are still single or have not completed their childbearing plans [16, 18]. Therefore, many breast cancer survivors may wish to become pregnant, and this may happen after breast reconstruction. Because a portion of the abdominal wall fascia, with or without the rectus muscle, is removed, and because the transported tissue is repositioned in the anatomic position of the breasts, potential adverse effects over the contour of the abdomen as well as the reconstructed breasts are presumed during pregnancy and delivery. For these reasons, TRAM flap surgery has not been recommended in the past for women who were planning to have children [19]. We undertook this systematic review to assess the potential esthetic or functional consequences of childbearing on the breast and abdomen after TRAM flap reconstruction.
Methods Review question What are the effects of pregnancy on the abdomen and breasts after autologous breast reconstruction via TRAM or DIEP procedures? Search strategy We developed a structured protocol and followed it. From February to May 2014, a comprehensive literature search in the following databases and citation indexes was carried out: Ovid Medline, Medline In-Process, and Other NonIndexed Citations; Scopus; Pubmed from 1970 to 2014; Evidence-Based Medicine Reviews (EBMR) including Cochrane Database of Systematic Reviews (DSR), the American College of Physicians (ACP) Journal Club, Database of Abstracts of Reviews of Effects (DARE), Cochrane Central Register of Controlled Trials (CCTR), Cochrane Methodology Register (CMR), Health Technology Assessment (HTA), National Health Service Economic Evaluation Database (NHSEED) from 1970 to 2014 (50–200 first results based on relevance to the search subject), and Google Scholar from 1970 to 2014 in 200 first results (due to complete irrelevancy of further results). Thereafter, from May to August 2014, references of
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selected papers were assessed for any additional related work not returned via the initial search; the last review of the literature was performed from March to April 2015, before submitting the paper. Our search comprised the following key words: (pregnancy or childbearing) AND (breast) AND (tram OR diep OR reconstruction OR rectus abdominis OR autologous OR flap OR deep inferior epigastric) in article title, abstract, and keywords. Criteria for inclusion of studies Any paper on pregnancy after breast reconstruction by TRAM technique or its derivatives and modifications, written in English or French, including case reports, case series, reviews, or any type of study, were included. If the full text of the article was unavailable, but the abstract was consistent, it was included as well. Criteria for exclusion of studies No exclusion criteria were considered. Study selection Studies were selected in two steps. First, the titles and abstracts of all papers identified by the search were screened and those irrelevant to the review, as well as duplicate papers, were excluded. Full texts of potentially relevant articles were then assessed and reviewed by the first author as to the criteria for inclusion. Data extraction Data were extracted systematically from eligible papers by the two authors using data extraction forms (Fig. 1) designed for this review.
Results Despite selecting a sensitive search strategy and a wide range of keywords for defining the surgery, only a few case reports and case studies could be identified. The initial search yielded 5132 articles. After the first screening of titles and abstracts, 5084 papers were excluded (including duplicates). In the second screen, 14 out of 48 manuscripts met the criteria for inclusion in this review, and 3 others were found from the reference lists of selected articles. Therefore, 17 papers, comprising 15 full texts and 2 abstracts, were included in our work (Fig. 2). The earliest article had been published in 1986 [20] and the latest in 2013 [21]. Due to the type and heterogeneity of the
Breast Cancer Res Treat (2015) 152:9–15
Fig. 1 Data extraction form
existing studies, we present a narrative synthesis of the studies, and given the diversity of data recorded in the papers, relevant information of all included studies is summarized in Table 1.
Discussion The issue of pregnancy after breast cancer has always been one of the concerns in medicine because of the significant role of female sex hormones in breast cancer and considerable hormonal rises during pregnancy. Despite earlier advice of physicians against childbearing in breast cancer survivors, pregnancy has always occurred in this group through the history; the results of most studies so far have been in favor of safety in these women [35]. In addition to the probable consequences of pregnancy over the disease
11
itself, patients who have undergone reconstruction via autologous tissue transferred from the lower abdomen face the problem of abdominal wall laxity as well as probable changes in the reconstructed breast contour following pregnancy; the former may lead to defects in fascia as well as malfunctioning abdominal musculature in the delivery process. Techniques that partially or completely spare rectus muscle and fascia (medial or lateral portions) are more favorable in women of childbearing age. In addition, bipedicled techniques (using both sides of the rectus and its vascular pedicle for reconstruction of one breast) or bilateral pedicled TRAM (using both rectus muscles and superior epigastric vessels for bilateral breast reconstruction) are expected to harm the abdominal function more seriously. The earliest reports of pregnancy after TRAM reconstruction in breast cancer survivors note an attenuated abdominal wall during cesarean section or enlargement and medial displacement of the remaining rectus muscle as a probable compensation to the absence of the other, and conclude that this event should not be an indication for abortion in women who have undergone the procedure [20, 23]. Accordingly and based on common sense, a oneyear waiting period from reconstruction to pregnancy has been recommended to allow for adequate healing of structures [24, 28]. In this systematic review, papers dealing with pregnancy after breast reconstruction via TRAM or DIEP procedures are reviewed. Among the six cases reported by Chen et al., two were affected by Poland syndrome and did not have breast cancer, and Kroll only mentioned that several women following TRAM had successful pregnancies. As a result, the overall number of cases in our work cannot be calculated, but we can say that more than 30 breast cancer survivors who had undergone the above surgeries had achieved pregnancy. One patient gave birth to twins, and three women experienced two pregnancies after breast reconstruction; therefore, more than 34 cases of pregnancy after post-mastectomy TRAM are represented. Regarding the type of procedure used for reconstruction, more than 27 women had undergone TRAM flap surgery, five of which were bilateral (overall more than 32 TRAM), and DIEP technique was used in four cases. Information regarding surgical technique was not complete in the papers, but some can be guessed. For example, where it is not explained in a report if TRAM was pedicled or free, it is most probable that a pedicled flap was used because a free flap microvascular anastomosis is generally expected to be pointed out. Hence, only one of the reported cases had undergone a free TRAM flap and the others were pedicled flaps. Two pedicles were used in four of the TRAM cases (bipedicled).
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Fig. 2 Search strategy and results
There were only minor abdominal complications following pregnancy in these cases. Reportable cases were in women in whom the pedicled TRAM had been performed, including two small hernias after pregnancy occurring 12 and 18 months subsequent to reconstruction [20, 28], and thinned abdominal fascia in one patient (who had subsequently undergone surgical repair for this failure) [25]. A prolonged stage 2 of labor was attributed to the lack of rectus muscle in a case of twin pregnancy 10 months after immediate bilateral TRAM with complete muscle harvest and fascia repair by prolene mesh [29]. The main muscle that supports pregnancy and the delivery course is the uterus, whereas abdominal muscles are recognized as secondary only in assisting the process [19, 29]. Complications are not expected to occur in the reconstructed breast because it is not under hormonal influence during pregnancy. Therefore, breast outcomes are not mentioned in most articles, and it can be deduced that no
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adverse effect occurred in breasts for these cases. Nevertheless, the breast reconstructed by TRAM increases in size with pregnancy, which may be due to a general increase in fatty tissues [33]. Asymmetric breasts after pregnancy and lactation are due to changes occurring in the normal breast [19, 20]. Regarding the recommended time lag needed from reconstruction to pregnancy, a waiting period has been recommended, although pregnancies have occurred well before 1 year with no negative consequence for the abdomen or breasts. As to the preferred technique for autologous breast reconstruction in breast cancer patients wishing to become pregnant in the future, the scarcity of cases and rarity of complications does not allow for a distinction among different techniques; the very low complication rate argues against a priority of any technique [24, 29]. Theory is in favor of muscle sparing (free), partial muscle preservation, or DIEP procedures [30].
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Table 1 Summary of studies about pregnancy after post-mastectomy TRAM/DIEP breast reconstruction
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Table 1 continued
* Unknown data, NVD normal vaginal delivery, CS cesarean section, m month(s), y year(s), CPD cephalopelvic disproportion a
Two of the women underwent TRAM because of Poland syndrome, but because operation techniques and pregnancy outcomes were not defined separately for cases of breast cancer in the paper, all six are mentioned here
b
The one with mesh repair had undergone bipedicled TRAM and subsequently had two pregnancies
c
Two were already pregnant at the time of procedure. In four cases, the pregnancy was undiagnosed because they were under neoadjuvant chemotherapy
d e f
In his book, Kroll reports his experiences with TRAM and its outcomes, including successful pregnancies in several of them May be an adverse effect due to the lack of rectus on Valsalva in stage 2 Bilateral mastectomy and immediate reconstruction were performed a year after cancer treatment (lumpectomy)
Conclusion This review reveals that a successful pregnancy and labor can be expected after breast reconstruction using a TRAM procedure or its derivatives, with minor consequences for either
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the breast or the abdomen. Obstetricians are advised to treat subsequent pregnancy as normal after an oncologic consult. Conflict of interest Authors declare that they have no conflict of interest.
Breast Cancer Res Treat (2015) 152:9–15
References 1. Hunt Kk NL, Copeland III EM, Bland KL (2010) The breast. In: Brunicardi FC, Andersen DK, Billiar TR, Dunn DL, Hunter JG, Matthews JB, Pollock RE (eds) Schwartz’s principles of surgery, 9th edn. McGraw-Hill,New York, pp. 424–426 2. Schroeder M, Sugg S, Brooks J, Thomas A (2013) Abstract P218-12: surgical management of breast cancer: Breast conserving surgery or mastectomy in the 2010 SEER registries by hormone receptor and HER2 status. Cancer Res 73:P2-18-12-P12-18-12 3. Najafi M, Ebrahimi M, Kaviani A, Hashemi E, Montazeri A (2005) Breast conserving surgery versus mastectomy: cancer practice by general surgeons in Iran. BMC Cancer 5:35 4. Esmaili R, Saiidi JA, Majd HA, Esmaieli M (2010) A survey of the body image of mastectomies women referring to imam khomeini and imam hussein hospitals in tehran, iran. Indian J Psychol Med 32:34–37 5. Waljee JF, Ubel PA, Atisha DM, Hu ES, Alderman AK (2011) The choice for breast cancer surgery: can women accurately predict postoperative quality of life and disease-related stigma? Ann Surg Oncol 18:2477–2482 6. Marı´n-Gutzke M, Sa´nchez-Olaso A (2010) Reconstructive surgery in young women with breast cancer. Breast Cancer Res Treat 123:67–74 7. Nano MT, Gill PG, Kollias J, Bochner MA, Malycha P, Winefield HR (2005) Psychological impact and cosmetic outcome of surgical breast cancer strategies. ANZ J Surg 75:940–947 8. Shi HY, Uen YH, Yen LC, Culbertson R, Juan CH, Hou MF (2011) Two-year quality of life after breast cancer surgery: a comparison of three surgical procedures. Eur J Surg Oncol 37:695–702 9. Collins KK, Liu Y, Schootman M, Aft R, Yan Y, Dean G et al (2011) Effects of breast cancer surgery and surgical side effects on body image over time. Breast Cancer Res Treat 126:167–176 10. Alipour S, Omranipour R, Akrami R (2013) Obesity should not prevent from TRAM flap breast reconstruction in developing countries. Indian J Surg 2013:1–4 11. Kanchwala SK, Bucky LP (2008) Optimizing pedicled transverse rectus abdominis muscle flap breast reconstruction. Cancer J 14:236–240 12. Gil Zeligson M, Michael Koretz M, Eldad Silberstein M (2011) Uneventful pregnancy and delivery after tram flap reconstruction following bilateral mastectomies. Isr Med Assoc J 13(6):381–383 13. Chang DW (2012) Breast reconstruction with microvascular MSTRAM and DIEP flaps. Arch Plast Surg 39:3–10 14. Tan S, Lim J, Yek J, Ong WC, Hing CH, Lim TC (2013) The deep inferior epigastric perforator and pedicled transverse rectus abdominis myocutaneous flap in breast reconstruction: a comparative study. Arch Plast Surg 40:187–191 15. Nahabedian MY, Manson PN (2002) Contour abnormalities of the abdomen after transverse rectus abdominis muscle flap breast reconstruction: a multifactorial analysis. Plast Reconstr Surg 109:81–87 Discussion 88–90 16. Pagani O, Partridge A, Korde L, Badve S, Bartlett J, Albain K et al (2011) Pregnancy after breast cancer: if you wish, ma’am. Breast Cancer Res Treat 129:309–317 17. Merlo DF, Ceppi M, Filiberti R, Bocchini V, Znaor A, Gamulin M et al (2012) Breast cancer incidence trends in European women aged 20–39 years at diagnosis. Breast Cancer Res Treat 134:363–370
15 18. de Bree E, Makrigiannakis A, Askoxylakis J, Melissas J, Tsiftsis DD (2010) Pregnancy after breast cancer. A comprehensive review. J Surg Oncol 101:534–542 19. Wagner LH, Ruth-Sahd LA (2000) Pregnancy after a TRAM flap procedure: principles of nursing care. J Obstet Gynecol Neonatal Nurs 29:363–368 20. Lawrence WT, McDonald HD (1986) Pregnancy after breast reconstruction with a transverse rectus abdominis musculocutaneous flap. Ann Plast Surg 16:354–355 21. Patel KM, Basci D, Nahabedian MY (2013) Multiple pregnancies following deep inferior epigastric perforator (DIEP) flap breast reconstruction. J Plast Reconstr Aesthet Surg 66:434–436 22. Grotting JC, Urist MM, Maddox WA, Vasconez LO (1989) Conventional TRAM flap versus free microsurgical TRAM flap for immediate breast reconstruction. Plast Reconstr Surg 83:828– 841 Discussion 842-824 23. Viterbo R, Luca L, Me´lega JM (1989) Pregnancy after breast reconstruction with the transverse rectus abdominis musculocutaneous flap. A case report. Plast Reconstr Surg 84:178 24. Chen L, Hartrampf CR Jr, Bennett GK (1993) Successful pregnancies following TRAM flap surgery. Plast Reconstr Surg 91:69–71 25. Mizgala CL, Hartrampf CR Jr, Bennett GK (1994) Assessment of the abdominal wall after pedicled TRAM flap surgery: 5-to 7-year follow-up of 150 consecutive patients. Plast Reconstr Surg 93:988–1002 26. Carramaschi FR, Ramos ML, Pinotti JA, Ferreira MC (1998) Pregnancy Following Breast Reconstruction with TRAM Flaps. Breast J 4:258–260 27. Kroll SS (2000) Follow-Up of TRAM Flap Breast Reconstruction Patients. Breast Reconstruction with Autologous Tissue 347-363 28. Parodi PC, Osti M, Longhi P, Rampino E, Anania G, Riberti C (2001) Pregnancy and tram-flap breast reconstruction after mastectomy: a case report. Scand J Plast Reconstr Surg Hand Surg 35:211–215 29. Johnson MR, Barney LM, King JC (2002) Vaginal delivery of monozygotic twins after bilateral pedicle TRAM breast reconstruction. Plast Reconstr Surg 109:1653–1654 30. Ong WC, Lim J, Lim TC (2004) Successful pregnancy after breast reconstruction with the deep inferior epigastric perforator flap. Plast Reconstr Surg 114:1968–1970 31. Collin TW, Coady MS (2006) Is pregnancy contraindicated following free TRAM breast reconstruction? J Plast Reconstr Aesthet Surg 59:556–559 32. Stevens P, Villagra´n R, Klenner A (2008) Embarazo y parto vaginal en primigesta posterior a reconstruccio´n mamaria con colgajo TRAM. Revista chilena de cirugı´a 60:344–347 33. Bhat W, Akhtar S, Akali A (2010) Pregnancy in the early stages following DIEP flap breast reconstruction–a review and case report. J Plast Reconstr Aesthet Surg 63:e782–e784 34. Lin Y-N, Lin S-D, Lai C-S, Chang K-P, Hou M-F (2012) Is it safe for an Asian woman to be pregnant after TRAM flap surgery for breast reconstruction? A case report. 臺灣整形外科醫學會雜誌 21:343–350 35. Alipour S, Eskandari A (2013) Perspectives of maternity after breast cancer. Androl Gynecol 2:1–5
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REVIEW
Systematic review of effects of pregnancy on breast and abdominal contour after TRAM/DIEP breast reconstruction in breast cancer survivors Sadaf Alipour1 · Amirhossein Eskandari2
Received: 9 April 2015 / Accepted: 25 May 2015 / Published online: 6 June 2015 © Springer Science+Business Media New York 2015
Abstract Transverse rectus abdominis myocutaneous (TRAM) and its derivatives are the most commonly performed autologous breast reconstruction procedures. These procedures were not recommended in the past for those who planned for subsequent childbearing because of the transposition of portions of the abdominal wall during the procedure into the anatomic position of the breast, implying possible adverse effects over the contour of these manipulated areas during pregnancy and delivery. We conducted a systematic review to assess the literature on esthetic or functional consequences of childbearing over the breast and abdomen after these procedures in patients that were affected by breast cancer. A comprehensive literature search in databases and citation indexes was conducted from February 2014 to April 2015. Any paper on pregnancy after breast reconstruction by TRAM or its derivatives and modifications, written in English or French, were included. The search results underwent a first screening to exclude duplicate and irrelevant papers. Full texts were then reviewed as to the criteria for inclusion, and data were extracted into data extraction forms from eligible papers. The initial search yielded 5132 articles. After screening and review, overall 17 papers met all criteria for inclusion in this review. Our work revealed that uneventful pregnancy and delivery can be anticipated in breast cancer survivors who had undergone breast reconstruction via TRAM or its derivatives with minor negative effects on either the breast or the abdomen. & Sadaf Alipour [email protected] 1
Department of Surgery, Arash Women’s Hospital, Tehran University of Medical Sciences, Tehran, Iran
2
Ministry of Health and Medical Education, Tehran, Iran
Keywords Abdominal contour · Breast cancer · Breast reconstruction · Pregnancy · Transverse rectus abdominis myocutaneous (TRAM) · Muscle flap · Deep inferior epigastric artery perforator (DIEP) flap
Introduction Breast cancer is the most common female cancer and the second most common cause of cancer mortality among women world-wide [1]. Mastectomy remains one of the major surgeries for this malignancy [2, 3], but this procedure disturbs the body self-image of the women [4–6]. Breast reconstruction attempts to reverse this negative course and thus, has a positive influence on the psychological health after mastectomy [7–9]. Among the methods of autologous breast reconstruction, transverse rectus abdominis myocutaneous (TRAM) and deep inferior epigastric artery perforators (DIEP) flap are the most commonly performed procedures [10–12]. In the pedicled TRAM procedure, based on the selected technique, all or part of the contralateral, ipsilateral, or bilateral rectus abdominis muscle(s), together with the overlying adipose tissue and skin, are transposed over the underlying superior epigastric artery/arteries into the breast position through a subcutaneous tunnel. In free graft techniques, instead of transposing tissues subcutaneously, the flap vessels are anastomosed to an arterial branch in the new site. A similar procedure is undertaken in the DIEP operation using the deep inferior epigastric artery instead of the superior branch; in this procedure, the rectus muscle may be left intact. In all cases, the flap is then remodeled to look like the absent breast [12–14]. Muscle-sparing techniques may help in protecting lateral motor innervation to the rectus abdominis. For closure of the defect in the
123
10
anterior abdominal fascia, repair is performed primarily by suturing the external oblique fascia to the rectus sheath or the linea alba. Alternatively, closure may be achieved by using a synthetic mesh [15]. In all these cases, one of the surgeon’s concerns in addition to the viability of the flap is the integrity of the abdominal wall. Due to the increasing age of marriage and pregnancy in the world [16], and the decreasing age of breast cancer presentation in some areas [17], many women who undergo breast cancer treatment are still single or have not completed their childbearing plans [16, 18]. Therefore, many breast cancer survivors may wish to become pregnant, and this may happen after breast reconstruction. Because a portion of the abdominal wall fascia, with or without the rectus muscle, is removed, and because the transported tissue is repositioned in the anatomic position of the breasts, potential adverse effects over the contour of the abdomen as well as the reconstructed breasts are presumed during pregnancy and delivery. For these reasons, TRAM flap surgery has not been recommended in the past for women who were planning to have children [19]. We undertook this systematic review to assess the potential esthetic or functional consequences of childbearing on the breast and abdomen after TRAM flap reconstruction.
Methods Review question What are the effects of pregnancy on the abdomen and breasts after autologous breast reconstruction via TRAM or DIEP procedures? Search strategy We developed a structured protocol and followed it. From February to May 2014, a comprehensive literature search in the following databases and citation indexes was carried out: Ovid Medline, Medline In-Process, and Other NonIndexed Citations; Scopus; Pubmed from 1970 to 2014; Evidence-Based Medicine Reviews (EBMR) including Cochrane Database of Systematic Reviews (DSR), the American College of Physicians (ACP) Journal Club, Database of Abstracts of Reviews of Effects (DARE), Cochrane Central Register of Controlled Trials (CCTR), Cochrane Methodology Register (CMR), Health Technology Assessment (HTA), National Health Service Economic Evaluation Database (NHSEED) from 1970 to 2014 (50–200 first results based on relevance to the search subject), and Google Scholar from 1970 to 2014 in 200 first results (due to complete irrelevancy of further results). Thereafter, from May to August 2014, references of
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selected papers were assessed for any additional related work not returned via the initial search; the last review of the literature was performed from March to April 2015, before submitting the paper. Our search comprised the following key words: (pregnancy or childbearing) AND (breast) AND (tram OR diep OR reconstruction OR rectus abdominis OR autologous OR flap OR deep inferior epigastric) in article title, abstract, and keywords. Criteria for inclusion of studies Any paper on pregnancy after breast reconstruction by TRAM technique or its derivatives and modifications, written in English or French, including case reports, case series, reviews, or any type of study, were included. If the full text of the article was unavailable, but the abstract was consistent, it was included as well. Criteria for exclusion of studies No exclusion criteria were considered. Study selection Studies were selected in two steps. First, the titles and abstracts of all papers identified by the search were screened and those irrelevant to the review, as well as duplicate papers, were excluded. Full texts of potentially relevant articles were then assessed and reviewed by the first author as to the criteria for inclusion. Data extraction Data were extracted systematically from eligible papers by the two authors using data extraction forms (Fig. 1) designed for this review.
Results Despite selecting a sensitive search strategy and a wide range of keywords for defining the surgery, only a few case reports and case studies could be identified. The initial search yielded 5132 articles. After the first screening of titles and abstracts, 5084 papers were excluded (including duplicates). In the second screen, 14 out of 48 manuscripts met the criteria for inclusion in this review, and 3 others were found from the reference lists of selected articles. Therefore, 17 papers, comprising 15 full texts and 2 abstracts, were included in our work (Fig. 2). The earliest article had been published in 1986 [20] and the latest in 2013 [21]. Due to the type and heterogeneity of the
Breast Cancer Res Treat (2015) 152:9–15
Fig. 1 Data extraction form
existing studies, we present a narrative synthesis of the studies, and given the diversity of data recorded in the papers, relevant information of all included studies is summarized in Table 1.
Discussion The issue of pregnancy after breast cancer has always been one of the concerns in medicine because of the significant role of female sex hormones in breast cancer and considerable hormonal rises during pregnancy. Despite earlier advice of physicians against childbearing in breast cancer survivors, pregnancy has always occurred in this group through the history; the results of most studies so far have been in favor of safety in these women [35]. In addition to the probable consequences of pregnancy over the disease
11
itself, patients who have undergone reconstruction via autologous tissue transferred from the lower abdomen face the problem of abdominal wall laxity as well as probable changes in the reconstructed breast contour following pregnancy; the former may lead to defects in fascia as well as malfunctioning abdominal musculature in the delivery process. Techniques that partially or completely spare rectus muscle and fascia (medial or lateral portions) are more favorable in women of childbearing age. In addition, bipedicled techniques (using both sides of the rectus and its vascular pedicle for reconstruction of one breast) or bilateral pedicled TRAM (using both rectus muscles and superior epigastric vessels for bilateral breast reconstruction) are expected to harm the abdominal function more seriously. The earliest reports of pregnancy after TRAM reconstruction in breast cancer survivors note an attenuated abdominal wall during cesarean section or enlargement and medial displacement of the remaining rectus muscle as a probable compensation to the absence of the other, and conclude that this event should not be an indication for abortion in women who have undergone the procedure [20, 23]. Accordingly and based on common sense, a oneyear waiting period from reconstruction to pregnancy has been recommended to allow for adequate healing of structures [24, 28]. In this systematic review, papers dealing with pregnancy after breast reconstruction via TRAM or DIEP procedures are reviewed. Among the six cases reported by Chen et al., two were affected by Poland syndrome and did not have breast cancer, and Kroll only mentioned that several women following TRAM had successful pregnancies. As a result, the overall number of cases in our work cannot be calculated, but we can say that more than 30 breast cancer survivors who had undergone the above surgeries had achieved pregnancy. One patient gave birth to twins, and three women experienced two pregnancies after breast reconstruction; therefore, more than 34 cases of pregnancy after post-mastectomy TRAM are represented. Regarding the type of procedure used for reconstruction, more than 27 women had undergone TRAM flap surgery, five of which were bilateral (overall more than 32 TRAM), and DIEP technique was used in four cases. Information regarding surgical technique was not complete in the papers, but some can be guessed. For example, where it is not explained in a report if TRAM was pedicled or free, it is most probable that a pedicled flap was used because a free flap microvascular anastomosis is generally expected to be pointed out. Hence, only one of the reported cases had undergone a free TRAM flap and the others were pedicled flaps. Two pedicles were used in four of the TRAM cases (bipedicled).
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Fig. 2 Search strategy and results
There were only minor abdominal complications following pregnancy in these cases. Reportable cases were in women in whom the pedicled TRAM had been performed, including two small hernias after pregnancy occurring 12 and 18 months subsequent to reconstruction [20, 28], and thinned abdominal fascia in one patient (who had subsequently undergone surgical repair for this failure) [25]. A prolonged stage 2 of labor was attributed to the lack of rectus muscle in a case of twin pregnancy 10 months after immediate bilateral TRAM with complete muscle harvest and fascia repair by prolene mesh [29]. The main muscle that supports pregnancy and the delivery course is the uterus, whereas abdominal muscles are recognized as secondary only in assisting the process [19, 29]. Complications are not expected to occur in the reconstructed breast because it is not under hormonal influence during pregnancy. Therefore, breast outcomes are not mentioned in most articles, and it can be deduced that no
123
adverse effect occurred in breasts for these cases. Nevertheless, the breast reconstructed by TRAM increases in size with pregnancy, which may be due to a general increase in fatty tissues [33]. Asymmetric breasts after pregnancy and lactation are due to changes occurring in the normal breast [19, 20]. Regarding the recommended time lag needed from reconstruction to pregnancy, a waiting period has been recommended, although pregnancies have occurred well before 1 year with no negative consequence for the abdomen or breasts. As to the preferred technique for autologous breast reconstruction in breast cancer patients wishing to become pregnant in the future, the scarcity of cases and rarity of complications does not allow for a distinction among different techniques; the very low complication rate argues against a priority of any technique [24, 29]. Theory is in favor of muscle sparing (free), partial muscle preservation, or DIEP procedures [30].
Breast Cancer Res Treat (2015) 152:9–15
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Table 1 Summary of studies about pregnancy after post-mastectomy TRAM/DIEP breast reconstruction
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Table 1 continued
* Unknown data, NVD normal vaginal delivery, CS cesarean section, m month(s), y year(s), CPD cephalopelvic disproportion a
Two of the women underwent TRAM because of Poland syndrome, but because operation techniques and pregnancy outcomes were not defined separately for cases of breast cancer in the paper, all six are mentioned here
b
The one with mesh repair had undergone bipedicled TRAM and subsequently had two pregnancies
c
Two were already pregnant at the time of procedure. In four cases, the pregnancy was undiagnosed because they were under neoadjuvant chemotherapy
d e f
In his book, Kroll reports his experiences with TRAM and its outcomes, including successful pregnancies in several of them May be an adverse effect due to the lack of rectus on Valsalva in stage 2 Bilateral mastectomy and immediate reconstruction were performed a year after cancer treatment (lumpectomy)
Conclusion This review reveals that a successful pregnancy and labor can be expected after breast reconstruction using a TRAM procedure or its derivatives, with minor consequences for either
123
the breast or the abdomen. Obstetricians are advised to treat subsequent pregnancy as normal after an oncologic consult. Conflict of interest Authors declare that they have no conflict of interest.
Breast Cancer Res Treat (2015) 152:9–15
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