Patterns of treatment failure - Reconstruction of large non metastatic locally advanced breast cancer with free flaps.

SDCC 

Introduction-
Locally advanced breast cancer(LABC) is heterogeneous ranging from local involvement of skin to peau-d'orange, and/or extensive lymphadenopathy. In India, 40% present as LABC. Neoadjuvant chemotherapy (NACT) is standard but 10-15% don't respond. Surgery necessitates extensive resection and reconstructions. The reconstruction of extended breast skin defects resulting from complex-mastectomies (multiple procedures) can pose a surgical challenge for reconstructive plastic surgeons. Herein, we present our institution's experience in tackling such extremely complex post-mastectomy defects. We evaluated their long-term outcomes.
Methods-
A prospective series of non-metastatic BC patients who underwent large resection and reconstruction between 2016-2021 was retrospectively assessed.
Results-
Of 63, 44 were LABCs, 6 oligo-metastatic, 10 local recurrences and 3 oligo-recurrences. Median age was 45 years. All had cT,cN2-3 disease. Standard NACT was administered in 56 (88.8%), 1 received endocrine therapy. Of these, 41% progressed, 42% had partial response and 16% stable disease. Six patients were operated first for ulcero-proliferative disease. Median clinical and pathological tumor size was 10cm(1-20cm) and 7.2 cm(0-20cm) respectively. 43% were TN, 35% HR+ and 22% HER2+. Reconstruction method was LDflap-29, FALT-26 and free-TRAM/DIEP-8. Morbidity was seen in 9/63(14.2%) patients. At median 18 months, 43(68.3%) recurred-5, 26 and 12 local, distant and both respectively. Free flaps [anterolateral thigh flap (ALT) variants, deep inferior epigastric perforator flap (DIEP) and tensor fascia lata flap (TFL)] were used in 34 patients whereas pedicle-flap based reconstruction [latissimus dorsi flap (LDF) and vertical rectus abdominis muscle (VRAM) flap] were performed in 29 patients. The following ALT variants were used for reconstruction: ALT only (n=19), ALT+TFL (n=4), ALT+ vastus lateralis (VL), (n=4) and ALT+ anteromedial thigh (n=1). The mean longitudinal and transverse dimensions of the included flaps were 23.211 ± 7.197 cm and 8 cm [IQR, 12-15] respectively. The mean flap area was 162.5 cm2 [IQR, 258.2 - 445.2]. The overall complication rate in this cohort was 25.6%. Hemoglobin (p= 0.002) and albumin (p=0.005) levels were associated with increased incidence of flap excision and debridement. On Cox-regression, TN-status(HR-2.44,1.02-5.8,0.043) and non-receipt of post-operative radiation therapy(HR- 2.68,1.28- 5.58,0.008) predicted recurrence. 20/63 progressed before radiation. Time-to-recurrence was 5 and 9.8 months for locoregional and distant metastases. The DFS and OS at 3 and 5 years was 26.4% (25.07-39.73) and 38.6% (23.9-53.3) and 21.1% (19.69-35.21) and 35.4% (20.7-50.1) respectively.
Conclusion-
Curative resection with negative margin is desired in non-metastatic breast cancers, caution is needed in those who progress on chemotherapy and need large resection and reconstruction. Surgery needs to be backed by post-operative radiotherapy and further systemic therapy. Oncoplastic reconstruction with a combination of free and pedicled flaps are feasible options for reconstruction of extended breast skin defects resulting from multiple mastectomy procedures.

Breast

PSTM 2024