CLINICAL ARTICLE

Immediate Transverse Rectus Abdominis Musculocutaneous Flap Reconstruction Is Associated With Improved Cancer-Specific Survival in Locally Advanced Breast Cancer Tung-Ying Hsieh, MD,* Yun-Nan Lin, MD,* Sin-Daw Lin, MD,* Chung-Sheng Lai, MD, PhD,* Kao-Ping Chang, MD, PhD,* Su-Shin Lee, MD,* Shu-Hung Huang, MD,* Ming-Feng Hou, MD,Þ Fang-Ming Chen, MD,Þ and Fu Ou-Yang, MDÞ Background: This study of stage III (locally advanced) breast cancer patients evaluated the survival improvement conferred by immediate breast reconstruction by transverse rectus abdominis musculocutaneous (TRAM) f lap reconstruction after modified radical mastectomy (MRM) in comparison with MRM alone. Methods: This retrospective study analyzed data for all women who had received TRAM immediately after unilateral modified radical mastectomy for locally advanced breast cancer at a single institution from January 2002 to December 2009. The analysis included 192 patients divided into 2 groups: patients who had received MRM immediately followed by TRAM f lap reconstruction (MRM-TRAM group, n = 52) and patients who had received MRM alone (MRM group, n = 140). Data collection included demographic characteristics, underlying comorbidities, and cancer characteristics. Postoperative adjuvant therapies, oncologic outcomes, and survival were compared between the 2 groups. Kaplan-Meier plots, univariate log-rank test, multivariate Cox proportional hazards regression models, and t-test were used to evaluate potential predictors of cancer recurrence and patient survival. Results: In comparison with the MRM group, significant differences in the MRM-TRAM group included a younger mean age, a better overall health status, and a higher education level (all P G 0.001). Severity of breast cancer disease did not significantly differ in terms of cancer characteristics. Additionally, there were no significant differences in local recurrence (P = 0.326) and distant metastasis (P = 0.338). Immediate breast reconstruction was not associated with delays in detection of local recurrence and initiation of adjuvant therapies The 5-year breast cancer-specific survival rate was significantly higher in the MRM-TRAM group (84.6%) compared with the MRM group (61.2%) (P = 0.003). Multivariate analysis showed that TRAM f lap reconstruction is an independent predictor of survival in breast cancer patients. The MRM-TRAM group had a significantly lower hazard of death (HR, 0.235; 95% CI, 0.070Y 0.788; P = 0.019) compared with the MRM group. Conclusions: Immediate TRAM f lap reconstruction is oncologically safe and is unassociated with delayed adjuvant therapies or delayed detection of local recurrence. Patients with locally advanced breast cancer can be considered appropriate candidates for TRAM f lap reconstruction because the procedure is an independent predictor of breast cancer survival and is associated with a 76.5% decrease (HR, 0.235) in the risk of cancer death. Key Words: transverse rectus abdominis musculocutaneous flap, TRAM, survival, breast cancer (Ann Plast Surg 2014;73: S31YS36)

Received March 27, 2014, and accepted for publication, after revision, April 2, 2014. From the *Division of Plastic and Reconstructive Surgery, and †General Surgery Medicine, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan, Republic of China. Conflicts of interest and sources of funding: none declared. Reprints: Sin-Daw Lin, MD, Division of Plastic and Reconstructive Surgery, Kaohsiung Medical University Hospital, 100 Shih-Chuan 1st Road, Kaohsiung 807, Taiwan. E-mail: [email protected]. Copyright * 2014 by Lippincott Williams & Wilkins ISSN: 0148-7043/14/7301-S031 DOI: 10.1097/SAP.0000000000000251

Annals of Plastic Surgery

S

ince the first successful breast reconstruction by autologous transverse abdominal island f lap was reported in 1982 by Hartrampf et al,1 breast reconstruction has become an integral management for restoring the body self image in patients who undergo mastectomy.2Y5 Transverse rectus abdominis musculocutaneous (TRAM) f lap reconstruction has shown consistently high rates of success in terms of complications and patient satisfaction.6,7 Although recent studies suggest that postmastectomy breast reconstruction neither impairs detection of locoregional recurrence8Y11 nor delays adjuvant therapy,12,13 the effects of this procedure on the survival of breast cancer patients remain uncertain.14Y16 Another controversial issue is the conditions under which immediate breast reconstruction (IBR) after mastectomy is appropriate for treating locally advanced breast cancer (LABC). Although IBR is now considered an aesthetically acceptable and oncologically safe procedure for many early-stage breast cancer patients,17Y20 patients with LABC have been considered poor candidates for IBR because of concerns regarding the need for postmastectomy radiation and the ability of the reconstructed breast to withstand postoperative irradiation.21 Additionally, retrospective studies have evaluated the safety of IBR in terms of cancer recurrence in LABC patients,22Y24 but a literature review shows that this study is the first to compare survival between LABC patients treated with mastectomy alone and LABC patients treated with IBR immediately after mastectomy. In addition to comparing breast cancer-specific survival, breast cancer-free survival, and cancer recurrence between these 2 groups, this study compared median times until initiation of adjuvant therapies and until detection of local recurrence. The goal of the study is to evaluate whether IBR affects patient survival and cancer recurrence.

PATIENTS AND METHODS This study retrospectively reviewed the medical records of all women who had received TRAM f lap reconstruction at Kaohsiung Medical University Hospital (Kaohsiung, Taiwan) after a first course of unilateral modified radical mastectomy (MRM) for histologically confirmed locally advanced breast cancer over the 8-year period from January 2002 to December 2009. Cancer stage was defined according to the American Joint Committee on Cancer Staging Manual, Third Edition.25 The analysis was limited to women who met the criteria for stage III breast cancer, which is corresponding with LABC according to the definition of ALCC clinical staging system.26 Histologic types were categorized into the following: (1) ductal carcinoma (ICD-0-3 code 8500), (2) lobular carcinoma (ICD0-3 code 8520), and (3) medullary (ICD-0-3 code 8510, 8513). The study excluded patients with distant metastasis or multiple primary cancers and patients who had received partial mastectomy, concomitant surgery on the contralateral breast, neoadjuvant therapy before surgery, or a previous breast cancer surgery at a different institution. The 192 patients met inclusion criteria for the study were then divided into 2 treatment groups: an index group who had received TRAM f lap reconstruction immediately after MRM (MRM-TRAM

& Volume 73, Supplement 1, September 2014

www.annalsplasticsurgery.com

Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

S31

Annals of Plastic Surgery

Hsieh et al

group, n = 52) and a control group who had received MRM alone without TRAM f lap reconstruction (MRM group, n = 140). Data collection included demographic characteristics (age, marital status, household type, education level), underlying comorbidities (diabetes mellitus, hypertension, cerebrovascular accident, uremia), and disease characteristics (histology, tumor grade, cancer stage IIIA/IIIB/IIIC, estrogen receptor status, and progesterone receptor status). Both groups received the standard LABC treatment protocol at this institution, including postoperative adjuvant chemotherapy, radiotherapy, and hormone therapy. The 2 groups were then compared in terms of postoperative management (radiation therapy, chemotherapy, and hormone therapy), oncologic outcomes (local recurrence and distant metastasis), and survival (breast cancerspecific survival and breast cancer-free survival). Breast cancerspecific survival was measured from the time of diagnosis until the most recent documented occurrence of any of the following events: last follow-up, breast cancer-specific death, or death from another cause. In patients with no records of these events, survival was measured from the time of diagnosis until December 2011. Breast cancer-free survival was defined as the time from surgery until breast cancer-free status or until death. Data collection also included time intervals from operation until initiation of postoperative chemotherapy, until radiotherapy, and until detection of local recurrence.

STATISTICAL ANALYSIS Group differences in variables were evaluated using chi-square tests. The 5-year breast cancer-specific survival rate and 5-year breast cancer-free survival rate were evaluated using the Kaplan-Meier method. The local recurrence rate and distant metastasis rate were also estimated using the Kaplan-Meier method and univariate Cox proportional hazards regression model. The univariate analyses included Kaplan-Meier plots and log-rank tests to evaluate variables as potential predictors of breast cancer-specific survival and breast cancer-free survival. Significant covariates revealed by univariate analysis were further analyzed by multivariate Cox proportional hazards regression model to identify independent risk factors for breast cancer-specific death. A t test was then used to compare the 2 groups in terms of time from surgery until local recurrence or until adjuvant therapy. A P G 0.05 was considered statistically significant.

TABLE 1. Comparisons of Prognostic Factors between MRM and MRM-TRAM Groups Parameter Age Marital status

Household type

Education level

Diabetes mellitus Hypertension Cerebrovascular accident Uremia Smoke Alcohol Histologic

Grade

RESULTS In the overall study population, the mean patient age at diagnosis was 53.1 T 11.4 years (MRM-TRAM group, 46.5 T 8.3 years; MRM group, 55.5 T 11.4 years). Median follow-up time was 46 months. Table 1 compares the 2 groups in terms of demographic characteristics, clinicopathologic characteristics, oncologic outcomes, and survival outcomes. Compared with the MRM group, the MRMTRAM group was younger (P G 0.001) and more likely to be unmarried (P = 0.031). The MRM-TRAM group also had a higher education level (P = 0.001) and a lower incidence of diabetes mellitus (P = 0.036) and hypertension (P = 0.006) compared with the MRM group. However, the 2 groups did not significantly differ in terms of disease severity and subsequent adjuvant treatment. Additionally, the groups did not significantly differ in terms of cancer characteristics (histology, tumor grade, cancer stage IIIA/IIIB/IIIC, estrogen receptor status, progesterone receptor status) or percentages of patients who had received adjuvant treatment. Table 2 lists the factors identified as potential predictors of breast cancer-specific survival. The MRM-TRAM group had a higher rate of 5-year breast cancer-specific survival (84.6%) compared with the MRM group (61.2%) (P = 0.003). Other factors associated with improved survival in this model included absence of hypertension (P = 0.042), absence of uremia (P = 0.041), histologically confirmed invasive ductal carcinoma (P = 0.043), low tumor S32

www.annalsplasticsurgery.com

& Volume 73, Supplement 1, September 2014

pTNM

Estrogen receptor Progesterone receptor Radiotherapy Chemotherapy Hormone therapy

G50 950 Single Married Divorced Widowed multi-family households Living alone Illiterate Primary school High school College No Yes No Yes No

MRM MRM-TRAM Group (%) Group (%) 51 (36.4) 89 (63.6) 4 (4.7) 65 (75.6) 4 (4.7) 13 (15.1) 80 (94.1)

35 (68.6) 16 (31.4) 5 (13.2) 30 (78.9) 3 (7.9) 0 (0.0) 33 (86.8)

5 (5.9) 15 (17.4) 27 (31.4) 39 (45.3) 5 (5.8) 97 (86.6) 15 (13.4) 79 (70.5) 33 (29.5) 107 (95.5)

5 (13.2) 2 (5.4) 4 (10.8) 621(56.8) 10 (27.0) 44 (97.8) 1 (2.2) 41 (91.1) 4 (8.9) 44 (97.8)

Yes No Yes No Yes No Yes Ductal Lobular Other Well differentiated Moderately differentiated Poorly differentiated Undifferentiated IIIA IIIB IIIC Positive Negative Positive

5 (4.5) 110 (98.2) 2 (1.8) 112 (100.0) 0 (0.0) 112 (100.0) 0 (0.0) 122 (87.1) 17 (12.1) 1 (0.7) 10 (7.4)

1 (2.2) 45 (100) 0 (0.0) 45 (100.0) 0 (0.0) 44 (100.0) 0 (0.0) 48 (92.3) 3 (5.8) 1 (1.9) 1 (2.0)

77 (56.6)

30 (58.8)

49 (36.0)

20 (39.2)

0 (0.0) 82 (58.6) 23 (16.4) 35 (25.0) 58 (41.4) 82 (58.6) 72 (51.4)

0 (0.0) 33 (63.5) 6 (11.5) 13 (25.0) 19 (36.5) 33 (63.5) 23 (44.2)

Negative No Yes No Yes No Yes

68 (48.6) 57 (40.7) 83 (59.3) 14 (10.1) 125 (89.9) 51 (36.4) 89 (63.6)

29 16 35 5 47 21 31

(55.8) (31.4) (68.6) (9.6) (90.4) (40.4) (59.6)

P G0.001 0.031

0.173

0.001

0.036 0.006 0.508

0.367

0.346

0.374

0.687

0.539 0.375

0.240 0.925 0.615

grade (P = 0.005), positive estrogen receptor status (P G 0.001), and positive progesterone receptor status (P G 0.001). History of adjuvant radiotherapy (P = 0.004) or hormone therapy (P G 0.001) was also associated with better survival. * 2014 Lippincott Williams & Wilkins

Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

Annals of Plastic Surgery

& Volume 73, Supplement 1, September 2014

TABLE 2. Factors Associated with Breast Cancer-Specific Survival

Parameter TRAM

No Yes Age G50 950 Marital status Single Married Divorced Widowed Household type Multi-family households Living alone Education level Illiterate Primary school High school College Diabetes mellitus No Yes Hypertension No Yes Cerebrovascular No accident Yes Uremia No Yes Histologic Ductal Lobular Medullary Grade Well differentiated Moderately differentiated Poorly differentiated pTNM IIIA IIIB IIIC Estrogen receptor Negative Positive Progesterone Negative receptor Positive Radiotherapy No Yes Chemotherapy No Yes Hormone therapy No Yes

5-Year Breast No. Patients Cancer-Specific (%) Survival (%) 140 (72.9) 52 (27.1) 86 (45.0) 105 (55.0) 9 (7.3) 95 (77.6) 7 (5.6) 13 (10.5) 113 (91.9)

61.2 84.6 68.0 65.2 59.3 70.3 * 90.9 73.2

10 (8.1) 17 (13.8) 31 (25.2) 60 (48.8) 15 (12.2) 141 (89.8) 16 (10.2) 120 (76.4) 37 (23.6) 151 (96.2)

66.7 59.1 95.8 65.1 93.3 66.6 81.3 70.3 60.8 69.1

6 (3.8) 155 (98.7) 2 (1.3) 170 (88.5) 20 (10.4) 2 (1.0) 11 (5.9)

40.0 68.4 50.0 60.5 60.5 0.0 54.5

107 (57.2)

77.5

69 (36.9)

51.6

115 (59.9) 29 (15.1) 48 (25.0) 77 (40.1) 115 (59.9) 95 (49.5)

72.7 52.7 62.3 41.0 83.9 54.5

97 (50.5) 73 (38.0) 118 (62.0) 20 (10.4) 172 (89.6) 72 (37.5) 120 (62.5)

80.9 53.9 74.8 63.5 67.3 45.0 78.6

IBR Is Associated With Improved Survival in LABC

TABLE 3. Relative Risk of Breast Cancer-Specific Death by Prognostic Variables

P 0.003

TRAM Hypertension

0.772

Uremia

0.294

Histologic Grade

0.534

0.531

Estrogen receptor Progesterone receptor

0.802 0.042

Radiotherapy Hormone therapy

Parameter

HR

No Yes No Yes No Yes Ductal Lobular Well differentiated Moderately differentiated Poorly differentiated Negative Positive Negative Positive No Yes No Yes

1 0.235 1 1.568 1 2.220 1 1.425 1 0.755 1.342 1 0.252 1 1.163 1 0.645 1 0.938

95% CI

P

0.070Y0.788

0.019

0.759Y3.241

0.224

0.372Y13.238

0.381

0.448Y4.531 0.169Y3.376

0.548 0.313 0.713

0.306Y5.889

0.697

0.084Y0.757

0.014

0.366Y3.699

0.798

0.314Y1.327

0.234

0.378Y2.328

0.891

0.254

0.041 0.043

0.005

confidence intervals [CI], 0.070Y0.788; P = 0.019) and positive estrogen receptor status (HR, 0.252; 95% CI, 0.084Y0.757; P = 0.014). By using Kaplan-Meier method for the 192 patients analyzed in this study, stage III breast cancer patients treated at this institution had a 5-year disease-specific survival rate of 66.9%. Figures 1 and 2 compares the Kaplan-Meier survival curves for the MRM group and the MRM-TRAM group, respectively. Compared with the MRM group, the MRM-TRAM group had significantly better breast cancer-specific survival (P = 0.003) and breast cancer-free survival

0.074

G0.001 0.001

0.004 0.797 G0.001

*No statistics are computed because all cases are censored.

Table 3 shows the factors associated with survival after mastectomy for stage III breast cancer according to the multivariate Cox proportional hazards regression models. After mastectomy, significant independent predictors of breast cancer survival in the LABC patients included TRAM flap reconstruction (hazard ratio [HR], 0.235; 95% * 2014 Lippincott Williams & Wilkins

FIGURE 1. Breast cancer-specific survival (Kaplan-Meier method). 5-year breast cancer-specific survival rate: MRM: 61.2%; MRM-TRAM: 84.6%, P = 0.003. www.annalsplasticsurgery.com

Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

S33

Annals of Plastic Surgery

Hsieh et al

& Volume 73, Supplement 1, September 2014

FIGURE 2. Breast cancer-free survival (Kaplan-Meier method). 5-year breast cancer-free survival rate: MRM: 53.0%; MRM-TRAM: 73.5%, P = 0.016.

FIGURE 4. Distant metastasis (Kaplan-Meier method). 5-year distant metastasis rate: MRM: 36.4%; MRM-TRAM: 22.4%, P = 0.338, HR = 0.723, 95% CI = 0.370Y1.410.

(P = 0.016). The 5-year breast cancer-specific survival rate was higher in the MRM-TRAM group (84.6%) compared with the MRM group (61.5%) (P = 0.003). The 5-year disease-free survival rate was also higher in the MRM-TRAM group compared with the MRM group (73.5% versus 53.0%, respectively; P = 0.016). Figures 3 and 4 show the results of recurrence analyses performed by Kaplan-Meier method for both local recurrence and distant metastasis. According to the plots, the MRM group had a higher 5-year local recurrence rate (11.9%) compared with the MRM-TRAM group (4.0%) (P = 0.178) (HR, 0.367; 95% CI, 0.086Y 1.650). The 5-year distant metastasis rate was also higher in the

MRM group (36.4%) compared with the MRM-TRAM group (22.4%) (P = 0.338) (HR, 0.723; 95% CI, 0.370Y1.410). Although the local recurrence rate and distant metastasis rate tended to be lower in the MRM-TRAM group, the differences did not reach statistical significance. The mean time from operation to detection of local recurrence was shorter in the MRM-TRAM group (7.5 months) compared with the MRM group (26 months) by using t test method (P = 0.326). However, the difference was not statistically significant. The MRMTRAM patients showed no disadvantage in terms of delayed detection of local recurrence. Additionally, the MRM-TRAM patients resumed postoperative chemotherapy after a median interval of 32.3 days, which was not significantly longer than that in the MRM patients (28.6 days) (P = 0.208). The MRM-TRAM patients resumed postoperative radiotherapy after a median interval of 6.9 months, which was also not significantly longer than that in the MRM patients (6.5 months) (P = 0.375). Finally, in comparison with the MRM patients, the MRM-TRAM patients showed no significant delays in adjuvant chemotherapy and/or radiotherapy after mastectomy.

DISCUSSION

FIGURE 3. Local recurrence (Kaplan-Meier method). 5-year local recurrent rate: MRM: 11.9%; MRM-TRAM: 4.0%, P = 0.178; HR = 0.367, 95% CI = 0.086Y1.650. S34

www.annalsplasticsurgery.com

Table 1 shows that, compared with the MRM group, the MRM-TRAM group had a younger age (P G 0.001), a higher education level (P = 0.001), a lower rate of diabetes mellitus (P = 0.036), and a lower rate of hypertension (P = 0.006). However, the comparison of cancer characteristics in the 2 groups showed no significant difference in breast cancer disease severity. The younger age and better health of the MRM-TRAM group compared with the MRM group is consistent with the literature.14Y16,27 Notably, earlier studies of the SEER database have shown that MRM patients who undergo IBR tend to be in an earlier cancer stage compared with MRM patients who do not undergo IBR.14Y16 A possible explanation is that women in advanced stages of cancer tend to be advised not to undergo breast reconstruction.10,13Y16,24,28 In the present study of stage III breast cancer patients, the MRM-TRAM group and the MRM group had similar patient demographics and disease characteristics. In addition to comparing demographic characteristics, socioeconomic * 2014 Lippincott Williams & Wilkins

Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

Annals of Plastic Surgery

& Volume 73, Supplement 1, September 2014

status and cancer characteristics, this study analyzed additional data not included in the SEER database, including underlying comorbidities, hormonal therapy, and adjuvant chemotherapy. That is, this series evaluated more prognostic factors compared with previous studies. The overall 5-year breast cancer-specific survival rate was 66.9%, which is consistent with a previous population-based study of the SEER database, which reported a 5-year survival rate of 58%.29 Figure 1 and Table 2 show that the MRM-TRAM group had a significantly (P = 0.003) higher 5-year breast cancer-specific survival rate (84.6%) compared with the MRM group (61.2%). Figure 2 also shows that 5-year breast cancer-free survival rate was substantially higher in the MRM-TRAM group compared with the MRM group (73.5% and 53.0%, respectively, P = 0.016). According to multivariate analysis, IBR by TRAM flap reconstruction is an independent prognostic indicator of improved survival in LABC patients (Table 3). The cause of the association between IBR and survival is unknown.14Y16 We suggest that, compared with patients who undergo MRM alone, those who undergo IBR after MRM tend to have a higher education level (P = 0.001) and tend to be more invested in their care. Therefore, they are more likely to follow the instructions given by their physicians, which improves the overall effectiveness of their care and improves their survival. However, further research is needed to clarify the nature of this relationship. Although recent studies have concluded that IBR is oncologically safe, IBR for locally advanced breast cancer remains controversial.10,16,23,28,30Y32 Arguments against IBR include increased local recurrence rates and difficulty detecting local recurrences in the reconstructed breast mound, increased wound complication rates, and prolonged recovery from the more extensive surgery resulting in delayed initiation of postoperative systemic chemotherapy.10 Our study showed that IBR did not markedly affect the median time until adjuvant chemotherapy or until radiotherapy (P = .0208 and P = 0.375, respectively). The median time interval from mastectomy until initiation of adjuvant chemotherapy was 32.3 days, which is well within the 60- to 84-day interval permitted by large cooperative research groups for registration in randomized clinical trials.13 Additionally, the 2 groups did not significantly differ (P = 0.326) in the median time interval from operation until detection of local recurrence. That is, IBR showed no association with difficulty of detecting local recurrence or with delayed diagnosis of recurrence. Local recurrence was noted after a mean time of 7.5 months in the MRM-TRAM group, which is consistent with the range of 3.0 to 59.2 months reported in the literature.23 Additionally, Kaplan-Meier method showed no significant group differences in local recurrence (P = 0.178) or in distant metastasis (P = 0.338). In fact, the MRM-TRAM group tended to have a lower 5-year local recurrence rate (4.0%) compared with the MRM group (11.9%). An earlier study of LABC patients by Newman et al22 showed that IBR did not significantly affect local recurrence or distant metastasis rates. Another study of postmastectomy radiotherapy patients by Huang et al33 showed that TRAM flap procedures did not significantly affect the incidence of locoregional recurrence or distant metastasis. One possibility is that, because TRAM flap breast reconstruction facilitates wide resection, it may also facilitate complete removal of locally advanced breast cancer. The 4.0% 5-year local recurrence rate observed in the stage III breast cancer patients in this study compares favorably with data obtained in earlier series studies of patients with early stage breast cancers and patients with locally advanced disease treated with or without reconstruction.22,34Y37 Medina-Franco et al35 reported that local recurrence is an independent predictor of survival after skin-sparing mastectomy. The actuarial 5-year survival rate was 90% in nonlocal recurrence patients but only 50% in local recurrence patients (P = 0.03). Because there was no significant difference in local recurrence between the 2 groups, TRAM flap reconstruction did not have negative impact on survival in terms * 2014 Lippincott Williams & Wilkins

IBR Is Associated With Improved Survival in LABC

of local recurrence. These findings show that IBR is oncologically safe in LABC patients. The main limitations of this study are the relatively small number of patients analyzed as a result of the strict criteria applied for patient selection and the limitation of the analysis to patients treated at a single institution. However, the study population was derived from a consecutive series of patients treated over an 8-year period.

CONCLUSIONS After controlling for all key prognostic variables, including underlying conditions, cancer characteristics, and adjuvant therapies, this study showed that after MRM, immediate TRAM f lap reconstruction has a significant independent association with improved breast cancer-specific survival in locally advanced breast cancer. Specifically, IBR by TRAM f lap is associated with a 76.5% decrease (HR, 0.235; P G 0.001) in the risk of death in breast cancer patients. In local advanced breast cancer, TRAM f lap reconstruction does not complicate diagnosis of local recurrence and tends to lower the cancer recurrence rate. Because it improves survival and is oncologically safe, patients with locally advanced breast cancer should be considered appropriate candidates for TRAM f lap reconstruction. REFERENCES 1. Hartrampf CR, Scheflan M, Black PW. Breast reconstruction with a transverse abdominal island flap. Plast Reconstr Surg. 1982;69:216Y225. 2. Goldberg P, Stolzman M, Goldberg HM. Psychological considerations in breast reconstruction. Ann Plast Surg. 1984;13:38Y43. 3. Hartrampf CR Jr, Bennett GK. Autogenous tissue reconstruction in the mastectomy patient. A critical review of 300 patients. Ann Surg. 1987;205: 508Y519. 4. Rowland JH, Desmond KA, Meyerowitz BE, et al. Role of breast reconstructive surgery in physical and emotional outcomes among breast cancer survivors. J Natl Cancer Inst. 2000;92:1422Y1429. 5. Elder EE, Brandberg Y, Bjorklund T, et al. Quality of life and patient satisfaction in breast cancer patients after immediate breast reconstruction: a prospective study. Breast. 2005;14:201Y208. 6. Alderman AK, Wilkins EG, Lowery JC, et al. Determinants of patient satisfaction in postmastectomy breast reconstruction. Plast Reconstr Surg. 2000;106:769Y776. 7. Buck DW 2nd, Fine NA. The pedicled transverse rectus abdominis myocutaneous flap: indications, techniques, and outcomes. Plast Reconstr Surg. 2009;124:1047Y1054. 8. Sandelin K, Wickman M, Billgren AM. Oncological outcome after immediate breast reconstruction for invasive breast cancer: a long-term study. Breast. 2004;13:210Y218. 9. Vaughan A, Dietz JR, Aft R, et al. Scientific Presentation Award. Patterns of local breast cancer recurrence after skin-sparing mastectomy and immediate breast reconstruction. Am J Surg. 2007;194:438Y443. 10. Langstein HN, Cheng MH, Singletary SE, et al. Breast cancer recurrence after immediate reconstruction: patterns and significance. Plast Reconstr Surg. 2003;111:712Y720; discussion 721Y722. 11. Kroll SS, Khoo A, Singletary SE, et al. Local recurrence risk after skin-sparing and conventional mastectomy: a 6-year follow-up. Plast Reconstr Surg. 1999;104:421Y425. 12. Gouy S, Rouzier R, Missana MC, et al. Immediate reconstruction after neoadjuvant chemotherapy: effect on adjuvant treatment starting and survival. Ann Surg Oncol. 2005;12:161Y166. 13. Downes KJ, Glatt BS, Kanchwala SK, et al. Skin-sparing mastectomy and immediate reconstruction is an acceptable treatment option for patients with high-risk breast carcinoma. Cancer. 2005;103:906Y913. 14. Agarwal J, Agarwal S, Pappas L, et al. A population-based study of breast cancer-specific survival following mastectomy and immediate or early-delayed breast reconstruction. Breast J. 2012;18:226Y232. 15. Bezuhly M, Temple C, Sigurdson LJ, et al. Immediate postmastectomy reconstruction is associated with improved breast cancer-specific survival: evidence and new challenges from the Surveillance, Epidemiology, and End Results database. Cancer. 2009;115:4648Y4654.

www.annalsplasticsurgery.com

Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

S35

Annals of Plastic Surgery

Hsieh et al

16. Alderman AK, McMahon L Jr, Wilkins EG. The national utilization of immediate and early delayed breast reconstruction and the effect of sociodemographic factors. Plast Reconstr Surg. 2003;111:695Y703; discussion 704Y705. 17. Le GM, O’Malley CD, Glaser SL, et al. Breast implants following mastectomy in women with early-stage breast cancer: prevalence and impact on survival. Breast Cancer Res. 2005;7:R184YR193. 18. Brinton LA. Do breast implants after a mastectomy affect subsequent prognosis and survival? Breast Cancer Res. 2005;7:61Y63. 19. Meretoja TJ, Rasia S, von Smitten KA, et al. Late results of skin-sparing mastectomy followed by immediate breast reconstruction. Br J Surg. 2007; 94:1220Y1225. 20. Slavin SA, Schnitt SJ, Duda RB, et al. Skin-sparing mastectomy and immediate reconstruction: oncologic risks and aesthetic results in patients with early-stage breast cancer. Plast Reconstr Surg. 1998;102:49Y62. 21. Tran NV, Chang DW, Gupta A, et al. Comparison of immediate and delayed free TRAM flap breast reconstruction in patients receiving postmastectomy radiation therapy. Plast Reconstr Surg. 2001;108:78Y82. 22. Newman LA, Kuerer HM, Hunt KK, et al. Feasibility of immediate breast reconstruction for locally advanced breast cancer. Ann Surg Oncol. 1999;6: 671Y675. 23. Crisera CA, Chang EI, Da Lio AL, et al. Immediate free flap reconstruction for advanced-stage breast cancer: is it safe? Plast Reconstr Surg. 2011;128:32Y41. 24. Lim W, Ko BS, Kim HJ, et al. Oncological safety of skin sparing mastectomy followed by immediate reconstruction for locally advanced breast cancer. J Surg Oncol. 2010;102:39Y42. 25. SEER: Breast AJCC/UICC Stage. SEER Program: Comparative Staging Guide for Cancer, Major Cancer Sites, version 1.1; 2006 Available at: http:// seer.cancer.gov/manuals/historic/comp_stage1.1.pdf. Accessed October 23, 2012. 26. NCCN.org. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines)\: Breast Cancer. Version 1.2012; 2012 Available at: http://www.nccn.org/ professionals/physician_gls/pdf/breast.pdf. Accessed October 26, 2012.

S36

www.annalsplasticsurgery.com

& Volume 73, Supplement 1, September 2014

27. Card A, Crosby MA, Liu J, et al. Reduced incidence of breast cancer-related lymphedema following mastectomy and breast reconstruction versus mastectomy alone. Plast Reconstr Surg. 2012;130:1169Y1178. 28. Slavin SA, Love SM, Goldwyn RM. Recurrent breast cancer following immediate reconstruction with myocutaneous flaps. Plast Reconstr Surg. 1994;93:1191Y1204; discussion 1205Y1207. 29. Gloeckler Ries LA, Reichman ME, Lewis DR, et al. Cancer survival and incidence from the Surveillance, Epidemiology, and End Results (SEER) program. Oncologist. 2003;8:541Y552. 30. Noone RB, Frazier TG, Noone GC, et al. Recurrence of breast carcinoma following immediate reconstruction: a 13-year review. Plast Reconstr Surg. 1994;93:96Y106; discussion 107Y108. 31. Wilkins EG, Cederna PS, Lowery JC, et al. Prospective analysis of psychosocial outcomes in breast reconstruction: one-year postoperative results from the Michigan Breast Reconstruction Outcome Study. Plast Reconstr Surg. 2000;106:1014Y1025; discussion 1026Y1027. 32. Nedumpara T, Jonker L, Williams MR. Impact of immediate breast reconstruction on breast cancer recurrence and survival. Breast. 2011;20: 437Y443. 33. Huang CJ, Hou MF, Lin SD, et al. Comparison of local recurrence and distant metastases between breast cancer patients after postmastectomy radiotherapy with and without immediate TRAM flap reconstruction. Plast Reconstr Surg. 2006;118:1079Y1086; discussion 1087Y1088. 34. Toth BA, Forley BG, Calabria R. Retrospective study of the skin-sparing mastectomy in breast reconstruction. Plast Reconstr Surg. 1999;104:77Y84. 35. Medina-Franco H, Vasconez LO, Fix RJ, et al. Factors associated with local recurrence after skin-sparing mastectomy and immediate breast reconstruction for invasive breast cancer. Ann Surg. 2002;235:814Y819. 36. Styblo TM, Lewis MM, Carlson GW, et al. Immediate breast reconstruction for stage III breast cancer using transverse rectus abdominis musculocutaneous (TRAM) flap. Ann Surg Oncol. 1996;3:375Y380. 37. Godfrey PM, Godfrey NV, Romita MC. Immediate autogenous breast reconstruction in clinically advanced disease. Plast Reconstr Surg. 1995;95:1039Y1044.

* 2014 Lippincott Williams & Wilkins

Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

Immediate transverse rectus abdominis musculocutaneous flap reconstruction is associated with improved cancer-specific survival in locally advanced breast cancer.

This study of stage III (locally advanced) breast cancer patients evaluated the survival improvement conferred by immediate breast reconstruction by t...
3MB Sizes 0 Downloads 3 Views