Local Recurrence of Breast Cancer Following Mastectomy,Mastectomy with Immediate Reconstruction, and Mastectomy with Delayed Reconstruction

ABSTRACT

Introduction: The incidence of local recurrence of breast cancer in women who underwent mastectomy with or without reconstruction was examined.

Methods: All female mastectomy patients were followed in a 10-year retrospective review. Groups consisted of patients who had mastectomy, mastectomy with immediate reconstruction, or delayed reconstruction. Reconstruction was performed using prostheses, latissimus dorsi myocutaneous flaps with/without implants, or transverse rectus abdominus myocutaneous flaps. Charts were reviewed for local breast cancer recurrence. Statistical analysis was performed using Pearsonís chi-square and ANOVA.

Results: Of the 1444 mastectomies performed, 1262 (87%) breasts were not reconstructed, 182 (13%) were reconstructed, 158 (87%) were immediately reconstructed, and 24 (13%) were reconstructed later. There were no recurrences in delayed reconstruction group, 2 (1.3%) recurrences in immediate reconstruction group, and 9 (0.7%) recurrences in mastectomy without reconstruction group (p = 0.746).

Conclusion: There is no relationship between local recurrence of breast cancer after mastectomy and reconstruction.

INTRODUCTION

 

Breast cancer is the most common cancer among women in the United States. Over a lifespan of 85 years, approximately 1 in 8 women may be expected to develop breast cancer [1]. It is the third leading cause of death by cancer in the United States, exceeded only by lung and colorectal malignancies [1].

Surgical treatment options for breast cancer include partial mastectomy with axillary dissection and radiation therapy or modified radial mastectomy. Mastectomy has long been the gold standard for treatment of breast cancer and is still performed frequently. Indications for mastectomy include multi-focality, diffuse disease, recurrent disease, and large tumor in a relatively small breast [2]. Some women simply prefer mastectomy to breast conservation because it obviates the need for radiation therapy and removes the entire diseased breast [3].

††††††††††† The obvious disadvantage of mastectomy is the postoperative cosmetic deformity. With the advancement of reconstructive surgical technique over the past 20 years, breast reconstruction after mastectomy has undergone tremendous growth in popularity and practice [4]. The concept of mastectomy with immediate reconstruction is a compelling one. At one setting, the breast cancer is removed and the breast is reconstructed, restoring body image immediately. This has a profound positive effect on the patient psychologically and emotionally [5-8].Unfortunately, immediate reconstruction may not be routinely offered to patients who require mastectomy. Physicians who do not offer reconstruction cite concerns that the mastectomy might be compromised in an effort to conserve skin flaps for reconstruction. Other concerns include possible delays in the detection and treatment of local recurrence that may have a negative impact on survival [9-11]. In recent years, various studies have examined the safety of immediate reconstruction [12-23]. Kroll et al. [17] found no increased risk of local recurrence in patients with early stage breast cancer who had mastectomy with immediate reconstruction. Slavin et al. [24] reported that myocutaneous flap breast reconstruction with rectus abdominis or latissimus dorsi flaps did not affect the detection and treatment of local recurrence of breast cancer. This study examines the incidence of local recurrence of breast cancer in women who were followed over time after undergoing mastectomy, mastectomy with immediate reconstruction, and mastectomy with delayed reconstruction.

 

METHODS

A 10-year retrospective review was performed using the Tumor Registry data at Lehigh Valley Hospital, a tertiary care facility in Allentown, Pennsylvania. The tumor registry is a hospital database that tracks all individuals who have a diagnosis of cancer, including breast cancer. All female patients who underwent mastectomy for breast cancer between 1988 and 1997 were included. The general surgeons at our institution performed all mastectomies. As a result, a single cohort of patients was followed longitudinally from time of diagnosis andtumor registry entrancethrough the end of the study period. Male patients and patients who underwent prophylactic mastectomies were excluded from this study.

Patient groups consisted of those who had mastectomy without reconstruction, mastectomy with immediate reconstruction, or mastectomy with delayed reconstruction. Reconstruction was performed using prostheses, latissimus dorsi myocutaneous flaps with or without implants, or transverse rectus abdominus myocutaneous flaps. Patient charts and tumor registry data were reviewed for local recurrence of breast cancer. Local recurrence is defined as recurrence within the soft tissues of the ipsilateral anterior chest, i.e., the skin, subcutaneous tissue, or underlying muscle. This zone includes a region bounded by the sternum medially, the clavicle superiorly, the posterior axillary line laterally, and the costal margin inferiorly [25].

Follow-up ranged from 1 to 9 years. Statistical analysis of recurrence rates was performed using Pearsonís chi-square analysis. Analysis of variance (ANOVA) was used to determine whether there was a difference in the stage of breast cancer and whether or not the patient underwent reconstruction. ANOVA was also used to analyze the difference in age among the three groups.

 

RESULTS

During this 10-year period, 1444 mastectomies were performed and 182 (13%) breasts were reconstructed. Of these, 158 (87%) were immediately reconstructed, and 24 (13%) were reconstructed at a later date. Patient age at the time of mastectomy was found to be statistically significant. Women who underwent mastectomy without reconstruction were older than those who underwent mastectomy with either immediate or delayed reconstruction (p < 0.001). The mean age of patients who had mastectomy without reconstruction was 66 years (range 29-97), the mean age of the patients who underwent mastectomy with immediate reconstruction was 48 years (range 27-74), and the mean age of those who underwent mastectomy with delayed reconstruction was 50 years (range 29-78) (Table 1).

The mean follow-up time was 6.28 years (range 1-11 years). There were no local recurrences in the delayed reconstruction group, 2 (1.3%) local recurrences in the immediate reconstruction group, and 9 (0.7%) local recurrences in the mastectomy without reconstruction group (Table 1). This difference was not statistically significant (p = 0.746).

When recurrence rates were evaluated in relation to stage of disease, no statistical significance was observed (Table 2). Furthermore, when the extremes of stages were removed (i.e., stage 0 and stage IV), the recurrence rates remained the same. In this scenario, ANOVAdetermined that the stage of disease was not related to local recurrence (p = 0.5).

The ANOVA showed a statistically significant difference in the number of patients who underwent reconstruction when compared to those who deferred reconstruction when the stage of disease variable was analyzed (Table 3). It was found that patients who did not undergo reconstruction had a higher stage of disease on average than those who did undergo reconstruction.

 

DISCUSSION

Breast reconstruction following mastectomy is an accepted procedure that is not only offered to patients who have undergone mastectomy, but is also actively sought by patients [26]. Immediate breast reconstruction offers improved aesthetic results as well as psychological benefits to patients. Women undergoing immediate reconstruction have been shown to have better self-image, less depression, and less psychosocial morbidity during this understandably difficult time of cancer diagnosis and treatment. They have also been found to have less impairment in their sense of femininity and sexual attractiveness [5-8]. It is important, however, to ensure that patients receive the appropriate oncological care in the management of their disease.

Our results support the theory that reconstruction, immediate or otherwise, do not adversely affect the detection of local recurrence in this study population. Local recurrence, as previously defined, may occur any time after initial treatment, most likely within the first 2 years. The peak incidence occurs in the second year after which the annual rate steadily declines. However, there have been reports in the literature of local recurrence occurring 15, 25, and 30 years after mastectomy. Some presumed mechanisms for local recurrence include: 1) incomplete removal of the primary tumor or its local extensions; 2) transection of tumor with surgical implantation in the wound; 3) retrograde embolization of tumor through transected lymphatics; and 4) implantation of circulatory tumor cells as a part of general dissemination [25].

Our study did not identify a statistical difference in recurrence rates for patients diagnosed with any stage of breast cancer. Even when extreme stages of disease were removed, which left a population of patients who were reasonable candidates for reconstruction, recurrence rates remained the same. It could be hypothesized that there is no correlation between higher stage of disease and rate of local recurrence. Therefore, detection of local recurrence is not adversely affected when mastectomy with immediate reconstruction is the treatment of choice.

Studies have also shown that chemotherapy and radiation therapy are not significantly delayed in patients undergoing immediate reconstruction [27]. Furthermore, distant recurrence rates and survival are similar for patients who have had mastectomy without reconstruction and those who have had immediate breast reconstruction [3, 21, 28, 29].

This study also demonstrated a statistically significant difference in the age of patients who underwent breast reconstruction when compared to thosepatients who did not have breast reconstruction. Generally, patients who underwent mastectomy without reconstruction were older. These findings correlate with the studies of Anderson et al. [30], Polednak [31], and Rowland et al. [32].

Selection bias may have confounded this study. No recurrences were identified in the delayed reconstruction group. This may be due to the fact that women who initially deferred reconstruction and subsequently suffered a local recurrence after mastectomy would not be candidates for delayed reconstruction.

Our study adds to the growing volume of literature that supports immediate breast reconstruction following mastectomy. There appears to be no relationship between local recurrence of breast cancer after mastectomy and immediate breast reconstruction. Reconstructive surgery should be offered to appropriate patients who are facing mastectomy for breast cancer [2, 6, 8, 13-15, 17, 19, 21-23, 30, 33].

 

CONCLUSION

There appears to be no relationship between local recurrence of breast cancer after mastectomy combined with reconstructive surgery of the breast. Breast reconstruction performed immediately following mastectomy is generally a safe procedure from an oncologic standpoint in the appropriate patient population.

 

REFERENCES

1.      Greenlee RT, Hill-Harmon MB, Murray T, Thun M. Cancer Statistics, 2001. CA Cancer J Clin 2001;51:15-36

2.      Morrow M, Schmidt RA, Bucci C. Breast conservation for mammographically occult carcinoma. Ann Surg 1998;227:502-6

3.      Eberlein TJ, Crespo LD, Smith BL, et al. Prospective evaluation of immediate reconstruction after mastectomy. Ann Surg 1993;218:29-36

4.      Goldwyn RM. Breast reconstruction after mastectomy. N Engl J Med 1987;317:1711-1714

5.      Bensimon RH, Bergmeyer JM. Improved aesthetics in breast reconstruction: modified mastectomy incision and immediate autologous tissue reconstruction. Ann Plast Surg 1995;34:229-235

6.      Holley DT, Toursarkissian B, Vasconez HC, et al. The ramifications of immediate reconstruction in the management of breast cancer. Am Surg 1995;61:60-65

7.      Jozwik M, Rouanet P, Sobierajski J, et al. Immediate breast reconstruction revisited. Ann Chirurg Gynaecol 1995;84:11-16

8.      Schain WS. Breast reconstruction: update of psychosocial and pragmatic concerns. Cancer 1991;68:1170-1187

9.      Handel N, Silverstein M J, Waisman E, et al. Reasons why mastectomy patients do not have breast reconstruction. Plast Reconstr Surg 1990;86:1118-1125

10. Paulson RL, Chang FC, Helmer SD. Kansas surgeonsí attitudes toward immediate breast reconstruction: a statewide survey. Am J Surg 1994;168:543-546

11. Spyrou GE, Titley OG, Cerqueiro J, et al. A survey of general surgeonsí attitudes towards breast reconstruction after mastectomy. Ann Royal Coll Surg Engl 1998;80:178-183

12. Carlson GW, Bostwick J 3rd, Styblo TM, et al. Skin-sparing mastectomy. Oncologic and reconstructive considerations. Ann Surg 1997;225:570-578

13. Corral CJ, Mustoe TA. Controversy in breast reconstruction. Surg Clin North Am 1996;76:309-326

14. Elliott LF, Eskenazi L, Beegle PH Jr, et al. Immediate TRAM flap breast reconstruction: 128 consecutive cases. Plast Reconstr Surg 1993;92:217-227

15. Fung KW, Lau Y, Nyunt, K, et al. Immediate breast reconstruction in Chinese women using the transverse rectus abdominis myocutaneous (TRAM) flap. Aust N Z J Surg 1996;66:452-456

16. 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;104:421-425

17. Kroll SS, Schusterman MA, Tadjalli HE, et al. Risk of recurrence after treatment of early breast cancer with skin-sparing mastectomy. Ann Surg Oncol 1997;4:193-197

18. Newman LA, Kuerer HM, HuntKK, et al. Presentation, treatment, and outcome of local recurrence after skin-sparing mastectomy and immediate breast reconstruction. Ann Surg Oncol 1998;5:620-626

19. Noone RB, Frazier TG, Noone GC, et al. Recurrence of breast carcinoma following immediate reconstruction: a 13-year review. Plast Reconstr Surg 1994;93:96-108

20. Simmons RM, Fish SK, Gayle L, et al. Local and distant recurrence rates in skin-sparing mastectomies compared with non-skin-sparing mastectomies. Ann Surg Oncol 1999;6:676-681

21. 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;102:49-62

22. Sultan MR, Smith ML, Estabrook A, et al. Immediate breast reconstruction in patients with locally advanced disease. Ann Plast Surg 1997;38:345-351

23. Toth BA, Forley BG, Calabria R. Retrospective study of the skin-sparing mastectomy in breast reconstruction. Plast Reconstr Surg 1999;104:77-84

24. Slavin SA, Love SM, Goldwyn RM. Recurrent breast cancer following immediate reconstruction with myocutaneous flaps. Plast Reconstr Surg 1994;93:1191-1207

25. Donegan WL. Local and regional recurrence. In: Donegan WL and Spratt JS, eds. Cancer of the Breast. Philadelphia: W.B. Saunders, 1995

26. Bostwick J 3rd. Breast reconstruction following mastectomy. Ca: Ca J Clin 1995;45:289-304

27. Frazier TG, Noone RB. An objective analysis of immediate simultaneous reconstruction in the treatment of primary breast cancer. Cancer 1985;55:1202-5

28. Hunt KK, Baldwin BJ, Strom EA, et al. Feasibility of postmastectomy radiation therapy after TRAM flap breast reconstruction. Ann Surg Oncol 1997;4:377-384

29. 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;3:375-380

30. Anderson SG, Rodin J, Ariyan S. Treatment considerations in Postmastectomy reconstruction: their relative importance and relationship to patient satisfaction. Ann Plast Surg 1994;33:263-271

31. Polednek AP. Geographic variation in postmastectomy breast reconstruction rates. Plast Reconstr Surg 2000;106:298-301

32. Rowland JH, Dioso J, Holland JC, et al. Breast reconstruction after mastectomy: who seeks it, who refuses? Plast Reconstr Surg 1995;95:812-823

33. Godfrey PM, Godfrey NV, Romita MC. Immediate autogenous breast reconstruction in clinically advanced disease. Plast Reconstr Surg 1995;95:1039-1044

 

 

 

Table 1.Patient Demographics

Treatment†††† ††††††††††† ††††††††††† No. †††† ††††††††††† ††††††††††† Age†††† ††††††††††† ††††††††††† Recurrence

Mastectomy

 

Range (mean)

 

Without reconstruction

1262 (87%)

29-97 (65.8)

9 (0.7%)

With reconstruction

182 (13%)

 

 

†††† Immediate

158 (87%)

27-74 (48.0)

2 (1.3%)

†††† Delayed

24 (13%)

29-78 (49.9)

0

Total

1444

 

11 (0.8%)

P values

 

††††††† < .001*

0.746

*Scheffe post-hoc ANOVA defining significance between patients who did not have reconstruction when compared to patients who underwent either immediate or delayed reconstruction.†††††††††††††††††††† ††††††††††††††††††††††† †††††††††††††††††††††††

 

 

 

Table 2. Stage vs. Recurrence

Stage

Recurrence

No recurrence

Total

Stage undefined

2 (1.7%)

117 (98.3%)

119 (100.0%)

Stage 0

 

129 (100.0%)

129 (100.0%)

Stage 1

3 (0.6%)

518 (99.4%)

521 (100.0%)

Stage 2A

2 (0.7%)

279 (99.3%)

281 (100.0%)

Stage 2B

1 (0.6%)

171 (99.4%)

172 (100.0%)

Stage 3A

 

54 (100.0%)

54 (100.0%)

Stage 3B

1 (0.9%)

113 (99.1%)

114 (100.0%)

Stage 4

2 (3.7%)

52 (96.3%)

54 (100.0%)

Total

11 (0.8%)

1433 (99.2%)

1444 (100.0%)

Pearsonís chi-square value = 9.258 . p = 0.235. Eight cells (50%) have expected count < 5. The minimum expected count is 0.41.

 

 

 

 

Table 3. Stage vs. Treatment Group

††††††††††† ††††††††††† Reconstruction Group†††††††††††

Stage

Immediate

reconstruction

Delayed reconstruction

No reconstruction

Total

Stage undefined

18 (15.1%)

2 (1.7%)

99 (83.2%)

119 (100.0%)

Stage 0

31 (24.0%)

 

98 (76.0%)

129 (100.0%)

Stage 1

55 (10.6%)

6 (1.2%)

460 (88.3%)

521 (100.0%)

Stage 2A

30 (10.7%)

6 (2.1%)

245 (87.2%)

281 (100.0%)

Stage 2B

18 (10.5%)

8 (4.7%)

146 (84.9%)

172 (100.0%)

Stage 3A

 

2 (3.7%)

52 (96.3%)

54 (100.0%)

Stage 3B

4 (3.5%)

 

110 (96.5%)

114 (100.0%)

Stage 4

2 (3.7%)

1 (1.9%)

51 (94.4%)

54 (100.0%)

††††††††††† Pearsonís chi-square value = 55.870 . p < 0.001. Seven cells (29.2%) have expected count < 5. The minimum expected count is 0.93.

†††††††††††

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