Neoadjuvant Chemotherapy for Breast Cancer Treatment and the Evidence-Based Interaction with Immediate Autologous and Implant-Based Breast Reconstruction

Impact of neoadjuvant chemotherapy on the safety and long-term outcomes of patients undergoing immediate breast reconstruction after mastectomy

BACKGROUND

In breast cancer patients receiving neoadjuvant chemotherapy (NAC), immediate breast reconstruction (IBR) as a breast cancer treatment option remains controversial. We assessed the impact of NAC on surgical and oncological outcomes of patients undergoing IBR.

METHODS

This was a retrospective multicenter study of 4726 breast cancer cases undergoing IBR. The rate of postoperative complications and survival data were compared between IBR patients who received NAC and those who did not receive NAC. Propensity score matching analysis was performed to mitigate selection bias for survival.

RESULTS

Of the total 4726 cases, 473 (10.0%) received NAC. Out of the cases with NAC, 96 (20.3%) experienced postoperative complications, while 744 cases (17.5%) without NAC had postoperative complications. NAC did not significant increase the risk of complications after IBR (Odds ratio, 0.96; 95%CI 0.74-1.25). At the median follow-up time of 76.5 months, 36 patients in the NAC group and 147 patients in the control group developed local recurrences. The 5-year local recurrence-free survival rate was 93.1% in the NAC group and 97.1% in the control group. (P < 0.001). After matching, there was no significant difference between the two groups.

CONCLUSION

IBR after NAC is a safe procedure with an acceptable postoperative complication profile.

Effects of Neoadjuvant Chemotherapy on Autologous and Implant-Based Breast Reconstruction: A Systematic Review and Meta-Analysis of the Literature

Neoadjuvant chemotherapy (NAC) is a standard modality of treatment for breast cancer. The exposure of patients to drugs that effect the cells and processes involved in healing prior to reconstructive surgical procedures is a source of concern for reconstructive surgeons. The reported effects of NAC on autologous and tissue expander to implant-based breast reconstruction vary from study to study and have not been comprehensively reviewed on a large scale. There is also significant variation from study to study regarding which outcomes are evaluated. The primary aim of this systematic review and meta-analysis is to evaluate the effect of neoadjuvant chemotherapy (NAC) on common and significant outcomes including total complication, reconstruction loss, and SSI (Surgical Site Infection) rates in breast reconstruction. The second aim of this study is to evaluate whether NAC has differing effects on implant-based reconstruction compared with autologous flap reconstruction. A systematic review of the literature published from 1991 to 2019 in the PubMed and Scopus library database was performed to identify studies reporting outcomes of breast reconstruction in patients receiving NAC. A meta-analysis was then performed. Primary outcomes reviewed included overall complication rates, SSI rates, and total loss of reconstruction (flap necrosis or premature tissue expander or implant removal). Outcomes were analyzed using a random effects model and chi-square statistical test. Our literature search yielded 22 manuscripts with a total of 3680 patients that fit our inclusion criteria, of which 12 reported on reconstruction loss, 14 reported on SSI rates, and 10 reported on overall complication rates. There was no significant difference in overall breast reconstruction loss rate (OR 1.30, P = .35), complication rate (OR 1.21, P = .06), and rate of SSI (OR 1.28, P = .85) between NAC vs. non-NAC groups. In patients undergoing autologous flap reconstruction there were no significant differences in complication (23.4% vs. 17.7%, P = 0.076), loss of reconstruction (3.1% vs. 4.4%, P = .393), or SSI (5.3% vs. 3.4%, P = .108) rates in patients who were treated with NAC compared to those who were not. Likewise, in patients undergoing TE/implant-based reconstruction there were no significant differences in complication (19.6 vs. 24.2 P = .069), loss of reconstruction (17.4% vs. 13.3%, P = .072), or SSI (7.9% vs. 5.1%, P = .073) rates in patients who were treated with NAC compared to those who were not. NAC was not associated with any significant differences in overall complication, reconstruction loss, or SSI rates in patients receiving implant-based or autologous flap breast reconstruction. Additionally, the lack of effect of NAC on overall complication, reconstruction loss or SSI rates did not differ with or depend on the type of reconstruction.

Breast reconstruction after mastectomy

Patients requesting breast reconstruction after mastectomy is an increasing group at plastic- and breast surgery departments in Denmark. This review summarises the present surgical techniques for reconstruction with/without postoperative chemotherapy and/or radiation therapy. These surgical techniques are continuously updated. The most determining factor when selecting a reconstructive technique, is postoperative radiation therapy. Each patient is unique, and an individual assessment is made when planning surgery. The concept of a "babysitter implant" is currently being investigated in Denmark and might be an option for selected patients.

Optimizing postoperative outcomes following neoadjuvant chemotherapy and mastectomy with immediate reconstruction: A national analysis

BACKGROUND

The optimal timing between last neoadjuvant chemotherapy (NAC) session and mastectomy with immediate reconstruction (MIR) procedures has sparse data to support optimization of postoperative outcomes. Current literature suggests that timing is not a predictor of complications in patients undergoing implant-based reconstruction following NAC and other literature suggests guidelines based on tumor staging. To the best of our knowledge, this is the largest and most recent study characterizing the effect of time between NAC and mastectomy with immediate reconstruction on postoperative complications.

METHODS

Patients in the Optum Clinformatics Data Mart that underwent all billable forms of breast reconstruction following NAC were identified via CPT and ICD-10 codes. Data concerning these patient's demographics, comorbidities, oncologic treatment, and outcomes were collected by querying relevant reports of CPT, ICD-9, and ICD-10 codes. To meet inclusion criteria, patients needed to have an encounter for antineoplastic chemotherapy within 1 year of their associated reconstruction. Patients with other invasive procedures unrelated to their mastectomy-reconstruction pairing within 90 days of reconstruction were excluded. Outcomes analysis was limited to the 90-day postoperative period. The time between the last recorded chemotherapy encounter and breast reconstruction was computed. A multivariate logistic regression analysis was performed to ascertain the effects of age, race, coexisting conditions, reconstruction type (autologous or implant-based), and time between NAC and reconstruction on the likelihood of any common postoperative complication occurring. Linearity of the continuous variables with respect to the logit of the dependent variable was confirmed. Odds ratios and corresponding 95% confidence intervals were calculated.

RESULTS

From over 86 million longitudinal patient records, our study population included 139 897 4371 patient records corresponding to 13 399 3759 patients who had NAC and breast reconstruction between January 2003, October 2015, and June 2019. Increased time between last antineoplastic chemotherapy and MIR reconstruction was a statistically significant, independent predictor of decreased complication likelihood. By contrast, autologous reconstruction, hypertension, and type II diabetes mellitus, and African American, White, and Hispanic race (relative to Asian) had statistically significant associations with increased complication likelihood. Waiting an additional day between a patient's most recent chemotherapy session and MIR reconstruction reduces the odds of a complication occurring by 0.25%. This corresponds to reduction in odds of complication occurrence of approximately 7% for each month between neoadjuvant therapy and breast reconstruction.

CONCLUSION

Increased time between NAC and MIR immediate reconstruction decreases the likelihood of experiencing one or more postoperative complications. Ideal time delay between 4 and 8 weeks has been shown to provide the best benefit for future breast reconstrution outcomes. In consultation with the oncologist, this information can be used to balance postoperative complication risk with increased oncologic risk in delaying mastectomy with immediate reconstruction.

INDICATIONS FOR LIMITATIONS OF THE OMENTAL PEDICLE FLAP IN IMMEDIATE BREAST RECONSTRUCTION - SURGICAL RESULTS EVALUATION AND BREAST-Q© 2.0 SURVEY

BACKGROUND AND AIM

Immediate reconstruction with an omental flap is a recognized suitable method for a full-thickness breast reconstruction or implant coverage for well-selected cases of nipple or skin-sparing mastectomies as well as cases of skin-reducing mastectomies. The authors' aim is the evaluation of indications and limitations of this technique with an original approach and also based on the analysis of patients' global satisfaction using the BREAST-Q 2.0© survey.

MATERIALS AND METHODS

From January 2014 to March 2018, 12 women aged between 29 to 67 years old (mean age: 49 years) underwent immediate breast reconstruction alone or with a definitive implant covered by a pedicled omental flap. All of them were asked to fill out the BREAST-Q© 2.0 survey.

CONCLUSIONS

The careful analysis of the cases shows that the indications for the immediate breast reconstruction based on the omental flap with a minimal resulting donor-site morbidity are strictly linked to its limitations, which are correctly reported in the study, but in the same way, it suggests that patients who underwent implant-based immediate breast reconstruction with omental flap reported significant improvements in satisfaction and health-related quality of their life.

Comparison of Autologous Breast Reconstruction Complications by Type of Neoadjuvant Chemotherapy Regimen

BACKGROUND

Neoadjuvant chemotherapy before mastectomy helps reduce tumor burden and pathologic response in breast cancer. Limited evidence exists regarding how neoadjuvant chemotherapy impacts outcomes following microvascular breast reconstruction. This study examines the effects of neoadjuvant chemotherapy regimens and schedules on microvascular breast reconstruction complication rates and also assesses the effects of neoadjuvant chemotherapy on circulating immune cells related to wound healing.

METHODS

Patients who underwent neoadjuvant chemotherapy and microvascular breast reconstruction at Yale New Haven Hospital between 2013 and 2018 were identified. Demographic variables, oncologic history, chemotherapy regimens, and complication profiles were collected. Chemotherapy regimens were stratified by inclusion of anthracycline and order of taxane administration. Chi-square, Fisher's exact, and t tests were used for univariate analysis. Multivariate binary logistic regression was used to control for covariates.

RESULTS

One hundred patients met inclusion criteria. On multivariate analysis, the administration of taxane first in an anthracycline-containing chemotherapy sequence was associated with increased complications (OR, 3.521; p = 0.012), particularly fat necrosis (OR, 2.481; p = 0.040). In the logistic regression model evaluating the effect of the taxane-first regimen on complication rates, the area under the curve was estimated to be 0.760 (p < 0.0001), particularly fat necrosis 0.635 (p < 0.05). The dosage of chemotherapy, number of days between neoadjuvant chemotherapy completion and surgery, and number of circulating immune cells did not significantly differ among patients who experienced complications.

CONCLUSIONS

Taxane-first, anthracycline-containing neoadjuvant chemotherapy regimens were associated with increased complications, particularly fat necrosis. The increased postreconstruction complication risk must be weighed against the benefits of taxane-first regimens in improving tumor outcome.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Inframammary Fold Approach for Second-stage Operation in Expander-Implant Breast Reconstruction

BACKGROUND AND OBJECTIVES

Despite expander-based breast reconstruction being used as a reliable reconstruction method, implant removal due to wound dehiscence and infection still occurs in 0.5% to 15% of cases. This study aimed to compare the outcomes of the new inframammary fold (IMF) incision approach with previous incision in second-stage operation of expander-based 2-stage breast reconstruction.

METHODS

Patients who underwent expander-based 2-stage breast reconstruction between February 2014 and May 2019 were included. After expander inflation, patients undergoing second-stage reconstruction were divided into the previous incision and IMF incision groups and their outcomes were compared. Propensity score matching analysis was performed to compare postoperative 1-year results.

RESULTS

The previous incision and IMF incision groups comprised 79 and 31 patients, respectively. There were no intergroup differences in general demographics or intraoperative data, except for total inflation volume (426.87 ± 102.63 mL in the previous incision group and 375.48 ± 94.10 mL in the IMF incision group, P = 0.017). Wound dehiscence occurred in 12 and 0 cases in the previous and IMF incision groups, respectively (P = 0.018). Implant removal was performed due to dehiscence in 9 cases (8.18%) and 0 cases (0%) in the previous and IMF incision groups, respectively (P = 0.049). In 1-to-1 propensity score matching analysis, the IMF incision group showed better results at 1-year follow-up (odds ratio: 0, 95% confidence interval: 0-1.09; P = 0.063).

CONCLUSIONS

The IMF approach is a safe method for replacing the expander with an implant, with lower incidence of wound dehiscence and implant explantation.

Management of the Axilla and the Breast After Neoadjuvant Chemotherapy in Patients with Breast Cancer: A Systematic Review

Breast cancer is the most common cancer in women worldwide. Breast cancer is traditionally treated with surgery, plus adjuvant systemic therapy and radiotherapy as required. Neoadjuvant chemotherapy (NACT) for the treatment of breast cancer is used for locally advanced operable breast cancer to reduce the tumor size, to perform breast conserving surgery, and to perform a limited axillary approach. Adjuvant chemotherapy for the treatment of inflammatory breast cancer and even in inoperable breast cancer is used to increase overall survival time and to delay disease progression while relieving symptoms. NACT for breast cancer is a new strategy that was introduced toward the end of the 20^th century and is increasingly used in the treatment of breast cancer. At present, NACT is increasingly being used to reduce the need for axillary dissection and to convert patients with large tumors to candidates for breast conservation therapy in both locally advanced and operable breast cancers. Breast conserving procedures are currently more preferred by surgeons and axillary dissection is being replaced by sentinel lymph node biopsy after chemotherapy. One of the targets of neoadjuvant systemic therapy is to try to perform a less aggressive surgery by breast conservation, mainly for cosmetic reasons and avoiding axillary dissection mainly for arm mobility, pain, and lymphedema risk. The other target of neoadjuvant systemic therapy is to see the response of the tumor to chemotherapy and determine the treatment accordingly. Neoadjuvant systemic therapy increases the rate of complete pathological response by clearing the breast and axilla from tumor cells before surgery. In this review, we examine the key points of using the NACT in breast cancer, considering radiological imaging methods, surgical management, and reconstruction after NACT.

Intratumoral injection of gels containing losartan microspheres and (PLG-g-mPEG)-cisplatin nanoparticles improves drug penetration, retention and anti-tumor activity

Intratumoral injection of chemotherapy agents may be employed in the treatment of cancers. However, its anti-tumor efficacy is significantly impeded by collagen fibers in the tumor which decrease drug penetration into the tumor tissues. To improve the penetration, collagen inhibiting drug exposure is required. In this study, microspheres were fabricated by the modified double emulsion-solvent evaporation method as the drug delivery system of losartan potassium (LP MSs), with 5% gelatin as the inner phase. The collagen inhibiting experiment analyzed by Sirius Red stains demonstrated that LP MSs may effectively inhibit collagen I synthesis in B16 tumors. In addition, 15% F127 was used as the solvent to fix the formulations at the injection site, with poly (α-l-glutamate) grafted polyethylene glycol mono methyl ether (PLG-g-mPEG)-cisplatin loaded nanoparticles (CDDP NPs) as the model drug. The in vivo live imaging system showed that formulations dissolved in 15% F127 had 54.91% CDDP NPs retained in tumors at the end of 10 days, in comparison with 19.72% for those solved in water, suggesting strong intratumoral retention property of the in situ gel. In addition, confocal laser scanning microscope (CLSM) and Energy-Dispersive Analysis of X-ray spectroscopy combined with scanning electron microscope (SEM-EDAX) tests showed that LP MSs can effectively enhance the distribution and penetration of CDDP NPs within tumors. Furthermore, tumors i.t. treated with LP MSs/CDDP NPs gel could be significantly halted, or even reduced to 200 mm³, comparing with a volume of about 12000 mm³ incontrol group at the end of the anti-tumor effect experiment. These results provided important guiding principles for prolonged and localized drug delivery system of intratumoral collagen inhibitor. The improvements of intratumoral penetration method made in this study provided practical significance for the treatment of cancer, especially for mass tumors.

Oncoplastic breast reconstruction with omental flap: A retrospective study and systematic review

The increasing frequency of early breast cancer cases has driven an increasing number of patients to choose immediate reconstruction with an autologous flap. Omentum-flap-based breast reconstruction is a unique strategy that is highly suitable for repairing moderate tissue defects. However, all available evidence comes from individual reports with small numbers of cases, and the overall effectiveness and safety of the procedure have yet to be reported. Here, we reported 7 cases of laparoscopically harvested omental free flap breast reconstruction and performed a systematic review to assess the applicability and safety of this approach. The data were gathered from MEDLINE, Ovid, Google Scholar and the China Knowledge Resource Integrated Database. In total, we combined 15 articles (410 cases) for analysis. The data revealed that almost all patients (87.6%) were reported to have undergone laparoscopy instead of laparotomy; pedicle flaps were used in 90.9% of the cases, while only 5 (37 cases) used free flaps for reconstruction; and 96.6% (396/410) of all reconstruction procedures were immediate. Almost all of these cases had a small tumour burden (T0/Tis/T1 59.8%; T2 36.8%), and the distribution of tumour location was similar among the four quadrants. The cosmetic outcomes were desirable in most cases (83.9%). There were 41 complications identified in the dataset: partial graft necrosis accounted for the largest percentage (41.5%) of all events, followed by skin necrosis (19.5%), haematoma (12.2%) and wound infection (9.8%). During the follow-up period, which had a short median duration, 2 cases of tumour recurrence were reported. Overall, our systematic review found that omentum-flap-based breast reconstruction could achieve a satisfactory aesthetic outcome, especially for small breasts and tissue replacement after breast-conserving surgery, and the safety of the procedure was also acceptable.