Association Between Postoperative Complications After Immediate Alloplastic Breast Reconstruction and Oncologic Outcome

Postoperative Complications Result in Poor Oncological Outcomes: What Is the Evidence?

The majority of patients with solid tumors undergo a curative resection of their tumor burden. However, the reported rate of postoperative complications varies widely, ranging from 10% to 70%. This narrative review aims to determine the impact of postoperative complications on recurrence and overall survival rates following elective cancer surgeries, thereby providing valuable insights into perioperative cancer care. A systematic electronic search of published studies and meta-analyses from January 2000 to August 2023 was conducted to examine the effect of postoperative complications on long-term survival after cancer surgeries. This comprehensive search identified fifty-one eligible studies and nine meta-analyses for review. Recurrence-free survival (RFS) and overall survival (OS) rates were extracted from the selected studies. Additionally, other oncological outcomes, such as recurrence and cancer-specific survival rates, were noted when RFS and OS were not reported as primary outcomes. Pooled hazard ratios and 95% confidence intervals were recorded from the meta-analyses, ensuring the robustness of the data. The analysis revealed that long-term cancer outcomes progressively worsen, from patients with no postoperative complications to those with minor postoperative complications (Clavien-Dindo grade ≤ II) and further to those with major postoperative complications (Clavien-Dindo grade III-IV), irrespective of cancer type. This study underscores the detrimental effect of postoperative complications on long-term oncological outcomes, particularly after thoracoabdominal surgeries. Importantly, we found a significant gap in the data regarding postoperative complications in surface and soft tissue surgical procedures, highlighting the need for further research in this area.

Oncologic Safety of One-Stage Implant-Based Breast Reconstruction in Breast Cancer Patients With Positive Sentinel Lymph Nodes: A Single-Center Retrospective Study Using Propensity Score Matching

OBJECTIVE

The purpose of this study is to evaluate the oncologic safety of one-stage implant-based breast reconstruction (OIBR) following mastectomy in breast cancer patients with positive sentinel lymph nodes (SLNs).

METHODS

We collected clinical and pathological data from breast cancer patients with positive SLNs who underwent OIBR or not after mastectomy between January 2015 and December 2018. A total of 194 patients were included, with 130 patients undergoing mastectomy alone (MA) and 64 patients receiving OIBR after mastectomy. The clinical and pathological features, as well as the postoperative oncologic outcomes, of the 2 groups were retrospectively analyzed. Propensity score matching (PSM) was employed to mitigate the effects of data bias and confounding factors.

RESULTS

The median follow-up time was 66 months for the OIBR group and 64 months for the MA group after PSM. The majority of reconstructive surgeries use an approach of prosthetic implantation (52.0%). This is followed by prosthetic implantation combined with a latissimus dorsi (LD) flap (32.0%), and acellular dermal matrix (ADM)-assisted implant placement (16.0%). During the follow-up period, a local recurrence was observed in 1 case, regional recurrence in 3 cases, and distant metastasis leading to death in 3 cases among the OIBR group patients. No significant difference was found between the OIBR and MA groups in disease-free survival (DFS) (P = .66), distant metastasis-free survival (DMFS) (P = .91), locoregional recurrence-free survival (LRRFS) (P = .44), and overall survival (OS) (P = .57).

CONCLUSION

OIBR is a safe option for breast cancer patients with positive SLNs and does not negatively impact cancer recurrence or overall survival.

Oncological results in women with wound complications following mastectomy and immediate breast reconstruction: A meta‐analysis

We performed a meta-analysis to evaluate the oncological results in women with wound complications following mastectomy and immediate breast reconstruction. A systematic literature search up to August 2022 was performed and 1618 subjects with mastectomy and immediate breast reconstruction at the baseline of the studies; 443 of them were with wound complications, and 1175 were with no wound complications as a control. Odds ratio (OR) and mean difference (MD) with 95% confidence intervals (CIs) were calculated to assess the oncological results in women with wound complications following mastectomy and immediate breast reconstruction using dichotomous or contentious methods with a random or fixed-effect model. The wound complications had a significantly longer length of time to adjuvant therapy (MD, 9.44; 95% CI, 4.07-14.82, P < .001) compared with no wound complications in subjects with mastectomy and immediate breast reconstruction. However, no significant difference was found between wound complications and no wound complications in subjects with mastectomy and immediate breast reconstruction in breast cancer recurrence (OR, 1.96; 95% CI, 0.95-4.06, P = .07), death rates (OR, 1.95; 95% CI, 0.89-4.27, P = .09), and kind of immediate breast reconstruction (OR, 1.01; 95% CI, 0.53-1.92, P = .98). The wound complications had a significantly longer length of time to adjuvant, however, no significant difference was found in breast cancer recurrence, death rates, and kind of immediate breast reconstruction. The analysis of outcomes should be done with caution even though no low sample size was found in the meta-analysis but a low number of studies was found in certain comparisons.

Major surgical postoperative complications and survival in breast cancer: Swedish population-based register study in 57 152 women

BACKGROUND

Postoperative complications may activate prometastatic systemic pathways through tissue damage, wound healing, infection, and inflammation. Postoperative complications are associated with inferior survival in several types of cancer. The aim was to determine the association between postoperative complications and survival in breast cancer.

METHODS

This population-based cohort included women operated for T1-3 N0-3 M0 invasive breast cancer in Sweden from 2008 to 2017. Only major surgical postoperative complications leading to readmission and/or reoperation within 30 days were considered. Main outcomes were overall survival (OS) and breast cancer-specific survival (BCSS). Prospectively collected nationwide register data were used. Multivariable Cox models were adjusted for clinical and socioeconomic confounders and co-morbidity.

RESULTS

Among 57 152 women, major surgical postoperative complications were registered for 1854 patients. Median follow-up was 6.22 (0.09-11.70) years. Overall, 9163 patients died, and 3472 died from breast cancer. Major surgical postoperative complications were more common after mastectomy with or without immediate reconstruction (7.3 and 4.3 per cent respectively) than after breast-conserving surgery (2.3 per cent). Unadjusted 5-year OS and BCSS rates were 82.6 (95 per cent c.i. 80.8 to 84.5) and 92.1 (90.8 to 93.5) per cent respectively for women with a major surgical postoperative complication, and 88.8 (88.6 to 89.1) and 95.0 (94.8 to 95.2) per cent for those without a complication (P < 0.001). After adjustment, all-cause and breast cancer mortality rates remained higher after a major surgical postoperative complication (OS: HR 1.32, 95 per cent c.i. 1.15 to 1.51; BCSS: HR 1.31, 1.04 to 1.65). After stratification for type of breast surgery, this association remained significant only for women who had mastectomy without reconstruction (OS: HR 1.41, 1.20 to 1.66; BCSS: HR 1.36, 1.03 to 1.79).

CONCLUSION

Major surgical postoperative complications are associated with inferior survival, especially after mastectomy. These results underline the importance of surgical de-escalation.

Oncoplastic breast consortium recommendations for mastectomy and whole breast reconstruction in the setting of post-mastectomy radiation therapy

Aim

Demand for nipple- and skin- sparing mastectomy (NSM/SSM) with immediate breast reconstruction (BR) has increased at the same time as indications for post-mastectomy radiation therapy (PMRT) have broadened. The aim of the Oncoplastic Breast Consortium initiative was to address relevant questions arising with this clinically challenging scenario.

Methods

A large global panel of oncologic, oncoplastic and reconstructive breast surgeons, patient advocates and radiation oncologists developed recommendations for clinical practice in an iterative process based on the principles of Delphi methodology.

Results

The panel agreed that surgical technique for NSM/SSM should not be formally modified when PMRT is planned with preference for autologous over implant-based BR due to lower risk of long-term complications and support for immediate and delayed-immediate reconstructive approaches. Nevertheless, it was strongly believed that PMRT is not an absolute contraindication for implant-based or other types of BR, but no specific recommendations regarding implant positioning, use of mesh or timing were made due to absence of high-quality evidence. The panel endorsed use of patient-reported outcomes in clinical practice. It was acknowledged that the shape and size of reconstructed breasts can hinder radiotherapy planning and attention to details of PMRT techniques is important in determining aesthetic outcomes after immediate BR.

Conclusions

The panel endorsed the need for prospective, ideally randomised phase III studies and for surgical and radiation oncology teams to work together for determination of optimal sequencing and techniques for PMRT for each patient in the context of BR

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Autologous breast reconstruction is increasingly preferred over implants in the setting of radiation therapy.

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Use of patient-reported outcomes is endorsed.

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Shape and size of reconstructed breasts can hinder radiotherapy planning.

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There is a need for randomised phase III trials.

The Failed Breast Implant in Postmastectomy Reconstruction: A Systematic Literature Review of Complications of Implant-Based Breast Reconstruction

BACKGROUND

Breast cancer is the most diagnosed malignant neoplasia of female patients worldwide in 2019. Survival has increased making it necessary to offer breast reconstructive procedures to improve quality of life and self-esteem. Implant-based breast reconstruction is the most common approach, making it necessary to quantify the associated complications.

METHODS

A systematic literature review of the PubMed, Cochrane, and Web of Science databases was performed. A total of 9608 citations were identified, and 44 studies met the inclusion criteria.

RESULTS

Studies included reported the incidence of complications either per patient or per breast leading consequently to 2 complication rates depending on the type of reporting. A total of 14.3% of patient-related and 28.8% of breast-related complications while undergoing implant-based reconstruction were reported.Among total complications reported, 72.6% of patient-related and 48.5% of breast-related complications were classified as major complications.A total of 37.6% of patients respectively 15.1% of breasts required prosthesis explantation due to severe complications. Depending on reporting, 9.7% of patients and 4% of breasts required autologous flap reconstruction due to reconstructive failure.

CONCLUSIONS

High complication and failure rates are associated with implant-based breast reconstruction. Lacking randomized controlled trials, the choice between implant-based and autologous breast reconstruction has to be made individually for each patient.

Immediate breast reconstruction in locally advanced breast cancer: is it safe?

PURPOSE

Immediate breast reconstruction (IBR) following mastectomy remains controversial for locally advanced breast cancer over concerns regarding recurrence and complications which may delay adjuvant therapies. This study aimed to compare the oncologic outcomes and surgical safety of IBR following mastectomy with mastectomy alone (MA) for locally advanced breast cancer.

METHODS

All patients treated at the Providence Breast Center between 2012 and 2017 for biopsy-proven locally advanced breast cancer, AJCC (8th edition) clinical stages (IIB-IIIC), were included. Primary outcomes were overall survival (OS), disease-specific survival (DSS), and disease-free survival (DFS). Secondary outcomes included recurrence rate, adjuvant therapy use, and reoperation.

RESULTS

267 patients (112 IBR, 155 MA) were included. On average, IBR patients were younger (48.82 years vs 61.42 years, P < 0.001). Median study follow-up was 50.7 months. OS was higher among IBR patients (86.6% vs 73.5%, P < 0.05). However, no significant differences were found in DSS (87.5% vs 84.5%, P = 0.34), DFS (79.5% vs 78.7%, P = 0.55), local recurrence (0% vs 1.9%, P = 0.194), adjuvant therapy use (95.5% vs 91.6%, P = 0.155), or reoperation (1.8% vs 1.3%, P = 0.559).

CONCLUSION

IBR is a safe option for patients with locally advanced breast cancer and does not negatively impact survival, cancer recurrence rates, and use of adjuvant therapy.

Association of postoperative infection and oncological outcome after breast cancer surgery

Background

Surgical-site infection (SSI) is a well known complication after breast cancer surgery and has been reported to be associated with cancer recurrence. The aim of this study was to investigate the association between SSI and breast cancer recurrence, adjusting for several known confounders. The secondary aim was to assess a possible association between any postoperative infection and breast cancer recurrence.

Method

This retrospective cohort study included all patients who underwent breast cancer surgery from January 2009 to December 2010 in the Uppsala region of Sweden. Data collected included patient, treatment and tumour characteristics, infection rates and outcome. Association between postoperative infection and oncological outcome was examined using Kaplan–Meier curves and Cox regression analysis.

Results

Some 492 patients (439 with invasive breast cancer) with a median follow-up of 8.4 years were included. Mean(s.d.) age was 62(13) years. Sixty-two (14.1 per cent) of those with invasive breast cancer had an SSI and 43 (9.8 per cent) had another postoperative infection. Some 26 patients had local recurrence; 55 had systemic recurrence. Systemic recurrence was significantly increased after SSI with simple analysis (log rank test, P = 0.035) but this was not observed on adjusted analysis. However, tumour size and lymph node status remained significant predictors for breast cancer recurrence on multiple regression. Other postoperative infections were not associated with recurrence.

Conclusion

Neither SSI nor other postoperative infections were associated with worse oncological outcome in this study. Rather, other factors that relate to both SSI and recurrence may be responsible for the association seen in previous studies.

The Impact of Postoperative Wound Complications on Oncological Outcomes Following Immediate Breast Reconstruction for Breast Cancer: A Meta-analysis

The association between immediate breast reconstruction (IBR)-related wound complications and breast cancer recurrence (BCR) remains uncertain. This study aimed to investigate the oncological outcomes in patients with wound complications following mastectomy and IBR. A comprehensive search was undertaken for all studies describing complications in patients with breast cancer following IBR. Studies were included if they reported on complications and investigated their relationship with BCR. A meta-analysis was performed using a random-effects model, with data presented as odds ratios and 95% confidence intervals. A total of 1418 patients from five studies were included in the final analysis. The mean age of patients included was 47.2 years. A total of 382 (26.9%) patients had postoperative complications following a majority of implant-based IBR (929/1418). A total of 158 (11.1%) recurrences, which included 63 locoregional and 106 distant recurrences, was noted at a mean follow-up of 66 months. Although there was an increase in recurrence rates in the complication group (n = 66/382; 17.3% vs. n = 92/1036; 8.9%), there was no significant association between complications and BCR (17.3% vs. 8.9%; P = .18) or mortality (3.6% vs. 2.3%; P = .15). Time to adjuvant therapy was significantly increased in patients with complications (mean difference, 8.69 days; range, 1.18-16.21 days; P = .02; I² = 0.02). This meta-analysis demonstrated a higher incidence of wound complications following IBR and a statistically significant increased time to adjuvant therapy. However, this did not translate into adverse oncological outcomes in patients with breast cancer undergoing IBR.

The effect of postoperative complications on survival and recurrence after surgery for breast cancer: A systematic review and meta-analysis

BACKGROUND

This systematic review investigated the impact of complications on long term outcomes for patients with primary invasive operable breast cancer.

METHODS

A systematic review was performed using appropriate keywords, and meta-analysis using a random effects model completed.

RESULTS

Ten retrospective cohort studies, including 37,657 patients were included. Five studies identified a relationship between wound complications, infection and pyrexia and recurrence or recurrence-free survival. Risk of recurrence, 1-year and 5-year recurrence-free survival and overall survival were related to complications, particularly for patients with poor Nottingham Prognostic Index. Five studies failed to demonstrate a relationship between complications and prognosis. Complication was found to significantly affect 5-year recurrence-free survival (HR 1.48 95 % CI 1.02-2.14, p = 0.04) but not recurrence (HR 2.39, 95 %CI 0.94-6.07, p = 0.07), with a high degree of heterogeneity amongst analysed studies (I2 = 95 %).

DISCUSSION

Further research is needed to quantify the effects of postoperative complication on prognosis following surgery for breast cancer.

The relationship between post-surgery infection and breast cancer recurrence

Breast cancer is the second most prevalent form of cancer in women worldwide, with surgery remaining the standard treatment. The adverse impact of the surgery remains controversial. It has been suggested that systemic factors during the postoperative period may increase the risk of recurrence, specifically surgical site infection (SSI). The aim of this review was to critically appraise current published literature regarding the influence of SSIs, after primary breast cancer surgery, on breast cancer recurrence, and to delve into potential links between these. This systematic review adopted two approaches: to identify the incidence rates and risk factors related to SSI after primary breast cancer surgery; and, secondly, to examine breast cancer recurrence following SSI occurrence. Ninety-nine studies with 484,605 patients were eligible in the SSI-focused searches, and 53 studies with 17,569 patients for recurrence-focused. There was a 13.07% mean incidence of SSI. Six-hundred and thirty-eight Gram-positive and 442 Gram-negative isolates were identified, with methicillin-susceptible Staphylococcus aureus and Escherichia coli most commonly identified. There were 2077 cases of recurrence (11.8%), with 563 cases of local recurrence, 1186 cases of distant and 25 cases which recurred both locally and distantly. Five studies investigated the association between SSI and breast cancer recurrence with three concluding that an association did exist. In conclusion, there is association between SSI and adverse cancer outcomes, but the cellular link between them remains elusive. Confounding factors of retrospective study design, surgery type and SSI definition make results challenging to compare and interpret. A standardized prospective study with appropriate statistical power is justified.

Influence of complications following total mastectomy and immediate reconstruction on breast cancer recurrence

Background

Immediate breast reconstruction is safe from an oncological perspective, but the relatively high rate of postoperative complications raises oncological concerns. The present study aimed to evaluate the potential influence of postoperative complications after immediate breast reconstruction on breast cancer recurrence and survival.

Methods

Patients with breast cancer who had total mastectomy and immediate reconstruction between 2008 and 2013 were followed for at least 5 years. The impact of postoperative complications on oncological outcomes was assessed using multivariable Cox regression analyses.

Results

In total, 438 patients with a median follow-up of 82 months were analysed. Five-year local recurrence-free, disease-free and overall survival rates were 95·4, 93·1 and 98·4 per cent respectively. Postoperative complications developed in the operated breast in 120 patients (27·4 per cent) and at other sites (flap donor) in 30 patients (6·8 per cent). Development of breast complications was associated with significantly increased rate of recurrence compared with no complications (16·7 versus 5·9 per cent; P = 0·002). In multivariable analysis, patients with breast complications had significantly worse disease-free survival than those with no complications (hazard ratio (HR) 2·25; P = 0·015). This remained significant in patients who received adjuvant therapy without delay (8 weeks or less after surgery) (HR 2·45; P = 0·034).

Conclusion

Development of postoperative complications in the breast can have a negative impact on survival and recurrence after immediate reconstruction.

Patient-Reported Satisfaction after Prophylactic Operations of the Breast

Background

Prophylactic mastectomies in carriers of mutations in BRCA1 or BRCA2 are becoming increasingly more accepted. We investigated the outcome after prophylactic mastectomy, especially regarding satisfaction with the procedure, in a monocenter study.

Methods

BRCA1/2 mutation carriers and non-carriers with elevated pedigree-based cancer risk were followed prospectively in a structured surveillance program between 2000 and 2017. A retrospective telephone survey was conducted among all patients with documented prophylactic mastectomy. Complications and satisfaction with the decision for prophylactic mastectomy were recorded.

Results

39 patients who opted for a prophylactic mastectomy (38 BRCA1/2 mutation carriers and 1 non-carrier) were interviewed. Mostly nipple-sparing mastectomy with reconstruction was performed (87%). Half of the patients (22/39; 56.4%) had a history of unilateral breast cancer. The median time since prophylactic mastectomy was 5.6 years. While 61.5% did not report any complications, flap loss was seen in 15% (3/20) and moderate limitations in everyday life were present in 20% (7/35). An improvement in quality of life was noticed by 82% after prophylactic mastectomy and no patient expressed regret with regard to the decision.

Conclusions

Prophylactic mastectomy is a procedure with risk for long-term complications in some cases. Our results confirm high satisfaction with the decision and improved quality of life.