Direct-to-implant breast reconstruction after neoadjuvant chemotherapy: A safe option?

Transaxillary Single-Port Endoscopic Nipple-Sparing Mastectomy with Immediate Implant-based Breast Reconstruction in Breast Cancer Patients Receiving Neoadjuvant Chemotherapy or Not: A Comparative Study with Analysis of Surgical Complications and Patient-Reported Outcomes

BACKGROUND

In most cases, transaxillary single-port endoscopic nipple-sparing mastectomy with immediate implant-based breast reconstruction (E-NSM-IIBR) is conducted in patients with early-stage breast cancer, ensuring surgical safety while achieving improved breast aesthetics. However, whether E-NSM-IIBR is appropriate in patients undergoing neoadjuvant chemotherapy (NAC) is still unclear. The aim of this study was to report the surgical safety and patient-reported outcomes (PROs) of breast cancer patients who underwent E-NSM-IIBR with NAC in comparison to those who did not receive NAC.

METHODS

A retrospective cohort study was conducted on patients who underwent E-NSM-IIBR with or without NAC at a single center between January 2021 and July 2022. Patient demographics, postoperative complications, and PROs evaluated using the BREAST-Q version 2.0 questionnaire were compared between the two groups. Factors associated with PROs at 9 months after surgery were assessed with linear regression analysis.

RESULTS

A total of 92 patients who underwent E-NSM-IIBR were included in the study, with 27 patients receiving NAC and 65 patients not receiving NAC. There was no significant difference in the incidence of postoperative complications between the two groups. The BREAST-Q version 2.0 questionnaire was completed by 24 out of 27 patients (88.9%) in the NAC group and 59 out of 65 patients (90.8%) in the non-NAC group at 9 months after surgery. The patient-reported outcomes in various domains of the BREAST-Q did not show a significant difference between the two cohorts. The results of the multiple linear regression analysis indicated that in the both groups age (β = - 0.985, 95% CI - 1.598 to - 0.371, p = 0.003 in the NAC group; β = - 0.510, - 1.011 to - 0.009, p = 0.046 in the non-NAC group) and rippling (β = - 21.862, - 36.768 to - 6.955, p = 0.006 in the NAC group; β = - 7.787, - 15.151 to - 0.423, p = 0.039 in the non-NAC group) significantly impacted the patients' satisfaction with breasts, and PMRT was negatively associated with patients' physical well-being of chest (β = - 13.813, - 26.962 to - 0.664, p = 0.040 in the NAC group; β = - 18.574, - 30.661 to - 6.487, p = 0.003 in the non-NAC group). Our findings revealed that patients with larger implant volumes had higher scores in psychosocial well-being (β = 0.082, 0.001 to 0.162, p = 0.047), whereas implant displacement (β = - 14.937, - 28.175 to - 1.700, p=0.028) had a negative impact on patients' psychological well-being in the non-NAC group. However, our results did not demonstrate any significant influencing factors on patients' psychosocial well-being within the NAC group.

CONCLUSION

Our preliminary experiences confirm that E-NSM-IIBR is a safe option for selected patients even after NAC, with favorable patient-reported outcomes comparable with those in the primary surgery setting. The postoperative long-term outcomes of patients who undergo radiation therapy after NAC merit further investigation in the future.

LEVEL OF EVIDENCE III

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The impact of neoadjuvant chemotherapy on surgical outcomes following autologous and implant-based immediate breast reconstruction: A systematic review and meta-analysis

BACKGROUND

The impact of neoadjuvant chemotherapy (NACT) on the complication rate after implant-based and autologous breast reconstruction remains unclear. The aim of this study was to systematically review and perform a meta-analysis of previously published studies on immediate breast reconstruction (IBR) in breast cancer patients treated with NACT compared with controls.

METHODS

PubMed and EMBASE were searched to identify studies assessing the impact of NACT on major and minor complications after IBR. The primary effect measures were relative risk (RR), 95% confidence interval (95% CI), and p-value.

RESULTS

Eight studies comprising 51,731 patients were included in the meta-analysis. Of these, 5161 patients received NACT and 46,570 patients did not receive NACT. In regard to major complications, NACT did not statistically significant increase the rate of reconstructive failure (RR = 1.35, 95% CI = 0.96-1.91, p = 0.09), the rate of mastectomy skin-flap necrosis (RR = 1.39, 95% CI = 0.61-3.17, p = 0.44), or the rate of reoperation (RR = 1.09, 95% CI = 0.87-1.37, p = 0.45). Regarding minor complications, NACT did not significantly increase the rate of wound complications (RR = 1.05, 95% CI = 0.87-1.28, p = 0.62). In a subgroup analysis of implant-based breast reconstruction following NACT, single-stage direct-to-implant (DTI) had a significantly lower implant failure rate compared with two-staged tissue expander/implant (TE/I) (RR = 0.43, 95% CI = 0.26-0.71, p = 0.0011).

CONCLUSION

NACT did not increase the major or minor complication rate after IBR with either autologous tissue or implants. Thus, NACT and IBR should be considered safe procedures. The review of studies describing patients undergoing implant-based breast reconstruction following NACT could indicate that single-stage DTI was a safer procedure than two-staged TE/I. However, the association requires further evaluation.

Prepectoral vs. Submuscular Immediate Breast Reconstruction in Patients Undergoing Mastectomy after Neoadjuvant Chemotherapy: Our Early Experience

Background: Conservative mastectomy with immediate prosthetic breast reconstruction (IPBR) is an oncologically accepted technique that offers improved esthetic results and patient quality of life. Traditionally, implants have been placed in a submuscular (SM) plane beneath the pectoralis major muscle (PMM). Recently, prepectoral (PP) placement of the prosthesis has been increasingly used in order to avoid morbidities related to manipulation of the PMM. The aim of this study was to compare outcomes of SM vs. PP IPBR after conservative mastectomy in patients with histologically proven breast cancer treated with neoadjuvant chemotherapy (NAC). Methods: In this retrospective observational study, we analyzed two cohorts of patients that underwent mastectomy with IPBR after NAC in our institution from January 2018 to December 2021. Conservative mastectomy was performed in 146 of the 400 patients that underwent NAC during the study period. Patients were divided into two groups based on the positioning of implants: 56 SM versus 90 PP. Results: The two cohorts were similar for age (mean age 42 and 44 years in the SM and PP group respectively) and follow-up (33 and 20 months, respectively). Mean operative time was 56 min shorter in the PP group (300 and 244 min in the SM and PP group). No significant differences were observed in overall major complication rates. Implant loss was observed in 1.78% of patients (1/56) in the SM group and 1.11% of patients (1/90) in PP group. No differences were observed between the two groups in local or regional recurrence. Conclusions: Our preliminary experience, which represents one of the largest series of patients undergoing PP-IPBR after NAC at a single institution documented in the literature, seems to confirm that PP-IPBR after NAC is a safe, reliable and effective alternative to traditional SM-IPBR with excellent esthetic and oncological outcomes; it is easy to perform, reduces operative time and minimizes complications related to manipulation of PPM. However, this promising results need to be confirmed in prospective trials with longer follow-up.

A national analysis of outpatient mastectomy and breast reconstruction trends from 2013 through 2019

BACKGROUND

Traditionally, patients with breast reconstruction (BR) were hospitalized at least one day postoperatively. However, new trends suggest that outpatient surgery is a viable and safe alternative. This study aims to assess trends among patients with breast cancer who underwent outpatient mastectomy alone, with immediate BR (IBR) or delayed BR (DBR).

METHODS

A retrospective analysis of the 2013-2019 ACS NSQIP® database was conducted. All women who underwent outpatient mastectomy were included in this study. The cohort was divided as follows: (1) mastectomy without BR, (2) IBR, and (3) DBR. A Cochran-Armitage test and adjusted multivariable logistic regression models were performed to evaluate linear trends over time within groups, and overall and pairwise comparisons between groups across the years, respectively.

RESULTS

A total of 84,954 women were included in this study. Overall, 54.9%, 16.2%, and 28.9% underwent mastectomy without BR, IBR, and DBR, respectively. From the BR groups, the majority had implant placement. A significant difference in incidence trends between the three groups was evidenced over time (p<0.001). The greatest increase was evidenced in the IBR group and the lowest in the mastectomy without BR group.

CONCLUSION

In this cohort of patients, a significant difference in linear trends was evidenced over time within and between the three groups. Our results suggest that outpatient IBR procedures are increasing in a greater proportion compared to other surgical approaches. Further studies are required to better characterize this population and comprehend the decision-making process toward a surgical procedure within each of the three groups.

Impact of neoadjuvant chemotherapy on surgical complications in breast cancer: A systematic review and meta-analysis

BACKGROUND

The increased use of neoadjuvant chemotherapy (NACT) facilitates an increase in breast-conserving surgery and immediate breast reconstruction. While NACT is considered to have the same oncological safety as adjuvant chemotherapy, evidence on the impact of NACT on surgical outcomes following breast surgery is unclear and varies across studies. The aim of this systematic review and meta-analysis was to assess the impact of NACT on surgical complications in breast cancer patients undergoing any kind of breast surgery.

METHODS

Database searches were conducted (March 26, 2021) to identify studies assessing the impact of NACT on postoperative complications. Studies were included if they compared a group of patients treated with NACT to a control group that was not, and if they reported at least one of our defined outcomes. Primary effect measures were odds ratios (ORs) and mean difference with a 95% confidence interval. Study quality was assessed by the Newcastle-Ottawa Scale.

RESULTS

Twenty-six studies comprising 134,191 patients were included. NACT was not associated with an increased complication rate for overall complications (OR: 1.13, 95% CI: 0.86 to 1.47, p = 0.38), individual postoperative complications, nor surgery duration. There was a non-significant trend towards NACT increasing the risk of seroma, wound complications, skin or nipple necrosis, flap ischemia or loss, and implant loss. A significant difference in blood loss was found, favouring NACT (MD = -75.85, 95% CI: -107.47 to -44.23, p < 0.00001). Heterogeneity was significant between the studies (I²>50%).

CONCLUSION

Compared to a control group, NACT was not found to affect the surgical complications adversely.

Short- and long-term outcomes of immediate breast reconstruction surgery after neoadjuvant chemotherapy

PURPOSE

Immediate breast reconstruction (IBR) is a standard option for breast cancer patients, although its utility in patients with advanced breast cancer requiring neoadjuvant chemotherapy (NAC) is debatable. We assessed the short-term complications and long-term prognosis of IBR after NAC.

METHODS

We retrospectively analyzed 1135 patients with IBR and/or NAC between 2010 and 2018, 43 of whom underwent IBR after NAC.

RESULTS

Twenty-five patients underwent reconstruction with a tissue expander (TE) followed by silicon breast implantation, 5 with a latissimus dorsi muscle transfer flap, and 13 with a deep inferior epigastric perforator flap. Complete surgical resection with a free margin confirmed by a pathological assessment was achieved in all patients. The evaluation of the short-term complications indicated no cases of total flap necrosis, two cases of partial flap necrosis, and one case of wound infection. Only one case required postponement of subsequent therapy due to partial flap necrosis. A long-term evaluation indicated no local recurrence, although distant metastasis was observed in 4 cases, 3 patients died, and TE removal after post-mastectomy radiotherapy (PMRT) was performed in 2 of 11 TE cases.

CONCLUSION

IBR may be a viable option in patients with advanced breast cancer who achieve complete surgical resection after NAC.

Does chemotherapy or radiotherapy affect the postoperative complication in breast cancer patients who underwent immediate breast reconstruction with tissue expander?

BACKGROUND

Immediate breast reconstruction with tissue expander in breast cancer patients who were expected to receive adjuvant therapy, such as chemotherapy or radiotherapy, has been a topic of debate. Postoperative complications from tissue expander procedures can delay the timing of adjuvant treatment and subsequently increase the probability of recurrence. The purpose of this study was to identify the impact of chemotherapy and radiotherapy on postoperative complications in patients who underwent immediate reconstruction (IR) using tissue expander.

METHODS

We conducted a retrospective study of 1081 breast cancer patients who underwent mastectomy and IR using tissue expander insertion between 2012 and 2017 in Samsung Medical Center. The patients were divided into two groups based on complications (complication group vs. no complication group). Complication group was regarded to have surgical removal or conservative treatment based on clinical findings such as infection, capsular contracture, seroma, hematoma, rupture, malposition, tissue viability, or cosmetic problem. The complication group had 59 patients (5.5%) and the no complication group had 1022 patients (94.5%).

RESULTS

In univariate analysis, adjuvant radiotherapy and adjuvant chemotherapy were significantly associated with postoperative complications. In multivariate analysis, however, only higher pathologic N stage was significantly associated with postoperative complications (p < 0.001). Chemotherapy (p = 0.775) or radiotherapy (p = 0.825) were not risk factors for postoperative complications.

CONCLUSIONS

IR with tissue expander after mastectomy may be a treatment option even when the patients are expected to receive adjuvant chemotherapy or radiotherapy. These results will aid patients who are concerned about the complications of IR caused by chemotherapy or radiotherapy determine whether or not to have IR.

TRIAL REGISTRATION

Patients were selected and registered retrospectively, and medical records were evaluated.