Abstract
Breast-conserving surgery (BCS) outcomes are comparable to mastectomy in breast cancer treatment. However, patients with large tumours were offered mastectomy due to the resulting poor cosmetic sequelae after standard BCS. With the introduction of chest wall perforator flaps (CWPF), BCS is an option in patients with large tumour:breast ratio. The objective of our study was to evaluate the surgical outcomes of CWPFs and their impact on mastectomy rates. In order to assess the impact of CWPF on mastectomy rates, patients who underwent breast cancer surgery from January 2016 to December 2019 were included in a cohort named group A. In group A, the type of surgery performed was collected for each year from January 2016 to December 2019. Patients who underwent BCS and CWPF from July 2016 to June 2021 were included in another cohort named group B. In group B, patient-related and disease-specific details including post-operative complications were collected and analysed. In group A, following the introduction of CWPF, the mastectomy rates dropped by 10.69% and the mastectomy with reconstruction rates dropped by 23.29%. In group B, a total of 152 patients underwent CWPF reconstructions. The median tumour size was 20 mm (range = 0–80). A majority of patients were discharged within 24-h hospital stay (98.2%). Seventeen patients (11.11%) had a re-operation for margin positivity. Sixteen patients (10.46%) developed early complications and 19 patients (12.42%) developed delayed complications. CWPFs expand indications for BCS thus reducing mastectomy rates. It also has less morbidity when compared to reported mastectomy and reconstruction rates, thus making it a safe option for suitable patients.
Keywords: Breast-conserving surgery, Chest wall perforator flap, Mastectomy
Introduction
Breast-conserving surgery (BCS) has comparable or superior oncological safety when compared to mastectomy and is associated with improved cosmetic and psychological outcomes [1, 2]. Previously patients with larger tumour to breast ratios were not suitable for BCS due to poor aesthetic outcomes and hence underwent total mastectomy with or without reconstruction [3]. With the introduction of chest wall perforator flaps (CWPF), a significant proportion of these women who would have otherwise undergone mastectomy can now qualify for BCS along with volume replacement [3].
CWPF was first described by Holmstorm et al. in 1986 to assist in implant-based reconstruction after mastectomy [4]. In 2004, Hamdi et al. described various CWPF’s based on named perforators for the reconstruction of BCS defects [5]. The commonly used CWPFs are lateral intercostal artery flap (LICAP), lateral thoracic artery perforator flap (LTAP), thoracodorsal artery perforator flap (TDAP) and anterior intercostal artery perforator flap (AICAP). They have become more popular over the years due to their robust vascularity, minimal donor site morbidity, good aesthetic outcomes and improving day-case operation rates [5, 6]. However, there is minimal data on the impact of CWPFs on mastectomy rates and other forms of breast reconstruction.
We adopted the use of CWPFs from July 2016 in our institution and the objective of our study was to evaluate the surgical outcomes of CWPFs and their impact on rates of mastectomy and breast reconstruction.
Methods
All patients who underwent surgery for breast cancer from January 2016 to December 2019 were included in the study to assess the impact of CWPF on rates of mastectomy and other procedures and this cohort was named group A. Patients who underwent BCS and partial breast reconstruction with a CWPF from July 2016 to June 2021 were included in another cohort named group B. The study was registered and approved by the clinical governance department of our institute (CA12119).
In group A, the type of surgery performed was collected for each year from January 2016 to December 2019. The collection of data was done for four surgical procedures: BCS including therapeutic mammoplasty, mastectomy with reconstruction, mastectomy without reconstruction and CWPF. Data was analysed to assess the impact of CWPF on overall BCS, mastectomy and mastectomy with total breast reconstruction rates.
In group B, all patient-related and disease-specific details were obtained from the prospectively collected database. Patient demographics such as age, body mass index (BMI) and comorbidities were documented along with tumour characteristics and details of treatment received.
All patients deemed suitable for BCS and reconstruction with a CWPF were discussed in the oncoplastic multidisciplinary team (MDT) meeting, and the appropriate flap was decided based on the tumour location and availability of tissue at the donor site. A majority (> 90%) of the patients in this cohort had a A-C cup breast.
Specific outcomes recorded were margin re-excision rates, completion mastectomy rates and post-operative complications. Complications occurring up to 90 days after the procedure were labelled as early complications and those after 90 days as delayed complications. The median follow-up for this cohort was 23 months (4–61 months).
Statistical Analysis
All patient-related and disease-specific details were obtained from the electronic database of prospectively collected data. Analysis was carried out by generating means, medians and range values for quantitative factors. Simple descriptive summaries and percentages were done to analyse tumour characteristics and procedure outcomes.
Results
Group A
In 2016, a total of 612 patients underwent surgery of which 397 (65%) of them underwent BCS and 215 (35%) underwent a total mastectomy. Following the introduction of CWPF reconstruction, the mastectomy rate (including reconstruction) dropped by 10.69% (from 215 mastectomies in 2016 to 192 in 2019) and the mastectomy with reconstruction rate dropped by 23.29% (from 73 in 2016 to 56 in 2019). This change can be attributed to the use of CWPFs (from 1 in 2016 to 51 in 2019) (Table 1 and Fig. 1). In 2019, out of a total of 632 patients, 440 patients underwent BCS (70%) and 192 (30%) underwent mastectomy (an increase of 5% in BCS rates).
Table 1.
Showing number of overall surgeries done from 2016 to 2019. BCS, breast conserving surgery; TM, therapeutic mammoplasty; CWPF, chest wall perforator flap
| Year | BCS and TM (%) | BCS + CWPF (%) | Total mastectomy alone (%) | Total mastectomy + reconstruction (%) | Total |
|---|---|---|---|---|---|
| 2016 | 396 (64.71%) | 1 (0.16%) | 142 (23.2%) | 73(11.93%) | 612 |
| 2017 | 394 (61.56%) | 19 (2.97%) | 161 (25.16%) | 66(10.31%) | 640 |
| 2018 | 356 (63.80%) | 25 (4.48%) | 126 (22.58%) | 51(9.14%) | 558 |
| 2019 | 389 (61.55%) | 51 (8.07%) | 136 (21.52%) | 56(8.86%) | 632 |
Fig. 1.
Figure showing the percentage of various surgeries performed in our department from 2016 to 2019. BCS, breast-conserving surgery; TM, Therapeutic mammoplasty; CWPF, chest wall perforator flap
Among the patients who had a CWPF reconstruction, 21 (21.87%) had a median tumour size of 40 mm (range 30–60) and a median tumour weight of 88 g (range = 35–172). This group of patients would potentially have undergone mastectomy based on the relative tumour to breast size ratio according to the MDT if there was no option of CWPF reconstruction. This rate is similar to the drop in mastectomy and reconstruction rates seen over the period in this study.
Group B
A total of 152 patients underwent 153 CWPF reconstructions from July 2016 to June 2021. Out of these, 151 patients underwent unilateral and one patient had bilateral CWPF reconstruction after BCS. The median age of patients in the cohort was 56 years (range 31–81 years). The median BMI was 27 kg/m2 (19.9–45.02). Fifty-nine patients were diagnosed with cancer through the National Health Services Breast Screening Program (NHSBSP) and 92 presented to the clinic with symptoms. One patient underwent a delayed AICAP flap for a cosmetic defect after a previous WLE. Patient, tumour, surgical and adjuvant treatment details are shown in Table 2.
Table 2.
Patient, tumour, surgical and adjuvant treatment details. BMI, body mass index; ASA, American society of anesthesiology class; ER, oestrogen receptor; HER2, human epidermal growth factor receptor-2; TNBC, triple-negative breast cancer; DCIS, ductal carcinoma in situ; LICAP, lateral intercostal artery perforator flap; AICAP, anterior intercostal artery perforator flap; MICAP, medial intercostal artery perforator flap
| Patient details | Value |
|---|---|
| Median age (range) | 56 years (31–81) |
| Median BMI (range) | 27 kg/sqm (19.9–45.02) |
| Smoking status (n = 152) | |
| 1. Current smoker | 13 (8.55%) |
| 2. Non-smoker | 123 (80.92%) |
| 3. Ex-smoker | 16 (10.53%) |
| ASA status (n = 152) | |
| 1. ASA I | 8 (5.26%) |
| 2. ASA II | 137 (90.13%) |
| 3. ASA III | 7 (4.61%) |
| Tumour details | |
| Diagnosis(n = 152) | |
| 1. Screening | 59 (38.82%) |
| 2. Symptomatic | 92 (60.53%) |
| 3. Cosmetic | 1 (0.66%) |
| Laterality (n = 152) | |
| 1. Right | 66 (43.42%) |
| 2. Left | 85 (55.92%) |
| 3. Bilateral | 1 (0.66%) |
| Location of tumour (n = 152) | |
| 1. Upper outer quadrant (UOQ) | 80 (52.63%) |
| 2. Lower outer quadrant (LOQ) | 22 (14.47%) |
| 3. Lower inner quadrant (LIQ) | 20 (13.16%) |
| 4. Lower central area | 21 (13.82%) |
| 5. Multifocal (UOQ + LOQ) | 9 (5.92%) |
| Molecular subtype (n = 152) | |
| 1. ER + HER2 − | 110 (72.37%) |
| 2. ER + HER2 + | 8 (5.26%) |
| 3. ER + HER2 + | 4 (2.63%) |
| 4. TNBC | 20 (13.16%) |
| 5. Not indicated | 10 (6.58%) |
| Tumour type (n = 152) | |
| 1. Invasive cancer | 98 (64.47%) |
| 2. Invasive cancer + DCIS | 44 (28.95%) |
| 3. DCIS | 10 (6.58%) |
| Surgical details | |
| Duration of stay in hospital (n = 152) | |
| 1. Day case | 56 (36.84%) |
| 2. One day | 93 (61.18%) |
| 3. Two days | 2(1.31%) |
| 4. Three days | 1(0.66%) |
| Type of flap used (n = 153) | |
| 1. LICAP | 113 (73.85%) |
| 2. AICAP + MICAP | 40 (26.14%) |
| Median tumour size (range) | 20 mm (0–80) |
| Median specimen weight (range) | 53.5 g (17–210) |
| Re-excision | 17 (11.11%) |
| Adjuvant treatment details | |
| 1. Neoadjuvant systemic treatment | 15 (9.87%) |
| 2. Adjuvant breast radiotherapy | 144 (94.74%) |
| 3. Adjuvant systemic treatment | 57 (37.5%) |
| 4. Adjuvant anti-oestrogen treatment | 115 (75.66%) |
One hundred twelve patients underwent LICAP flap reconstruction of which one had a bilateral procedure and 40 patients underwent AICAP or MICAP flap reconstruction (based on the site of the lesion). The median tumour size in the whole cohort was 20 mm (range = 0–80). A majority of patients (98.2%) had a 24-h hospital stay after admission. Seventeen patients (11.11%) had a re-operation for margin positivity.
Sixteen patients (10.46%) developed early complications and 19 patients (12.42%) developed delayed complications (Table 3). The most common early complications were hematoma (3.27%) and wound dehiscence (3.27%). Lymphedema of the breast (10.46%) was the most common delayed complication. There were no recorded flap losses. In the early complication group, only one patient was a smoker who developed wound dehiscence and the rest all were non-smokers.
Table 3.
Details of complications during the post-operative period
| Complication | N (%) |
|---|---|
| Early complication | 16 (10.46%) |
| 1. Hematoma | 5 (3.28%) |
| 2. Seroma | 2 (1.3%) |
| 3. Wound dehiscence | 5 (3.28%) |
| 4. Red breast | 1 (0.65%) |
| 5. Early lymphedema | 2 (1.3%) |
| 6. Fat necrosis | 1 (0.65%) |
| Delayed complication | 19 (12.42%) |
| 1. Breast lymphedema | 16 (10.46%) |
| 2. Fat necrosis | 2 (1.3%) |
| 3. Chronic pain | 1 (0.65%) |
The adjuvant treatment given to this cohort is described in Table 2. Two patients had completed mastectomy as they were found to have BRCA 2 (breast cancer gene 2) mutation and PALB 2 (partner and localizer of BRCA 2) mutation, respectively. Another patient from the LICAP group with low-grade DCIS (ductal carcinoma in situ) was found to have recurrent DCIS at her first surveillance mammogram and subsequently underwent a completion mastectomy. During a median follow-up of 23 months (range 4–61 months), one patient (0.65%) developed local recurrence (recurrent DCIS) in a year and underwent mastectomy with reconstruction. Seven (4.60%) patients developed distant metastases. Five of this group were triple negative and two of them were ER (oestrogen receptor) positive and HER2 (human epidermal growth factor receptor-2) negative cancers. Of these, 3 patients had node-positive disease.
Discussion
Our study has demonstrated that following the introduction of CWPFs, mastectomy rates decreased by about 10.69% and specifically mastectomy with reconstruction rate dropped by 23.29% over a 3-year period. This finding is further supported by the data that about 21% of the cohort had a median tumour size of 40 mm (range 30–60 mm) and would have undergone mastectomy considering the relative tumour to breast ratio. Our study is one of the first to report on the impact of CWPFs on the rates of mastectomy. This is particularly relevant as these procedures increase the rates of BCS.
The findings of our study are also supported by the results from Schaverien et al. who compared the outcomes following CWPF reconstruction, volume displacement oncoplasty and mastectomy with immediate breast reconstruction (IBR). The study demonstrated that CWPF extended the indications of BCS and avoided mastectomy in that group [7]. The mean tumour size was similar in the CWPF group and mastectomy with the IBR group (31 mm ± 18.4 and 32 mm ± 21.9 respectively), whereas it was lower in the volume displacement group (22.5 mm ± 16.2; p < 0.05) [7].
The use of CWPFs extends the scope of BCS in relatively smaller breasts (A-C cup sizes) and has multiple advantages. It reduces re-excision rates when compared to simple WLE. The margin positivity rate in our study was 11.11% compared to around 20% rates reported for simple WLEs nationally, thereby reducing the morbidity of reoperations for patients. Other series on CWPFs have also reported similar rates from 10–18% [6, 8, 9]. The added advantage is that these procedures can be easily done as a day case or 24-h stay based on theatre list planning. In our series, although the day case rate was 36.84%, the rest of them were overnight stay due to logistical reasons of patients having surgery in the afternoon.
Table 4 shows the comparison between various studies on CWPFs and their outcomes and the results are comparable. The median tumour size in our study was 20 mm which was influenced by the 10% of patients in our cohort who had neoadjuvant systemic therapy and had a complete or partial pathological response.
Table 4.
Comparing outcomes of various studies reported in the literature
| Author | Our study | Soumian et al. [6] | Jae Bong Kim et al. [8] | PG Roy [9] | McCulley et al. [10] | M. Hamdi et al. [11] |
|---|---|---|---|---|---|---|
| Publication year | 2020 | 2017 |
2016 Study period: 2011–2014 |
2015 |
2004 Study period: May 2000 to May 2003 |
|
| Number of patients | 152 | 112 | 33 | 40 | 75 | 31(one patient had bilateral reconstruction) |
| CWPF used: n (%) |
LICAP: 113 AICAP + MICAP: 40 (one patient had bilateral LICAP) |
LTAP: 3 (2.68) LICAP + / − LTAP: 84 (75.00) AICAP: 14 (12.50) MICAP: 11 (9.82) |
LICAP: 19 TDAP: 14 |
LICAP and LTAP |
LTAP: 12 (17%) LTAP/LICAP: 19 (27%) LICAP: 44 (56%) |
TDAP: 18 ICAP: 3 MS-LD: 10 Parascapular flap: 1 |
| Tumour location |
Upper outer quadrant (UOQ): 80 Lower outer quadrant (LOQ): 22 Lower inner quadrant (LIQ): 20 Lower central area: 21 Multifocal (UOQ + LOQ):9 |
Upper outer: 65 (58.03) Outer central: 6 (5.36) Lower outer: 14 (12.50) Lower central: 12 (10.71) Lower inner: 14 (12.50) Multiple quadrants: 1 (0.90) |
Lower outer: 27 Upper outer + lower outer quadrants: 6 |
NA | NA | NA |
| Specimen weight: |
Median = 53.5 g Range = 17–210 |
Median = 62.50 g Range = 21–231 g |
Mean = 71.18 g SD = ± 22.86 g |
Median = 96 g Range = 35–193 g |
NA | NA |
| Margin positivity | 17 (11.11%) | 15 (13.39%) | 6 (18.18%) | 4 (10%) | NA | NA |
| Completion mastectomy | 3 (2 patients had BRCA1 and PALB 2 mutation, one had recurrence of DCIS) | 1 (persistent positive margin) | 0 | 2 (5%) | 0 | NA |
| Complications |
Early: 16 (10.46%) Hematoma: 5 Seroma: 2 Wound breakdown: 5 Red breast: 1 Early lymphedema: 2 Fat necrosis: 1 Delayed: 19 (12.42%) Lymphedema: 16 Fat necrosis: 2 Chronic pain: 1 |
Total: 8 (7.14%) Hematoma: 4 Wound dehiscence: 1 Fat necrosis: 1 Surgical site pain: 1 Seroma: 1 |
Total: 16 (48.48%) Wound disruption: 4 Skin necrosis: 8 Fat necrosis: 4 |
Total: 6 (15%) Hematoma leading to partial flap loss:1 Superficial skin necrosis: 1 Fat necrosis: 2 Minor hematoma: 1 Seroma: 1 |
One delayed LTAP had venous congestion which settled on its own |
Total: 9 (29%) Partial flap necrosis: 3 Seroma: 4 Wound dehiscence: 2 |
| Adjuvant Tx |
Neoadjuvant systemic treatment: 15 Breast radiotherapy: 144 Adjuvant systemic treatment: 57 Adjuvant anti-oestrogen treatment: 115 |
Neoadjuvant chemotherapy: 16 (14.29) Adjuvant chemotherapy: 31 (27.68) Adjuvant radiation therapy: 110 (98.21) Adjuvant endocrine therapy: 85 (75.89) Adjuvant trastuzumab: 13 (11.61) |
Radiotherapy: 33 Adjuvant chemotherapy: 21 |
NACT: 11 (31%) CT (adjuvant and NAC): 25 (71%) Adjuvant RT: 39 (1 declined) Adjuvant ET: 26 (74%) |
NA |
Pre-op RT: 2 Post-Op RT: 24 NACT: 5 ACT: 15 |
In our series, the early complication rate was 10.46% which is comparable to the rates reported in the literature [6, 8–11]. Hematoma (3.28%) and wound dehiscence (3.28%) were the most common early complication, whereas lymphedema of the breast (10.46%) was the most common delayed complications in our study. This is comparable to a systematic review which included 432 patients, which reported complications rates of 12.3% including fat necrosis (2.4%), seroma (2.1%), flap necrosis (2.1%) and infection (2.1%) [12]. The reported complication rate of simple BCS without any reconstruction also ranges from 2.1–6.5% during the early period and 9.9% in delayed settings [13–15]. In terms of total breast reconstruction, the iBRA study reported on the short-term outcome of implant-based reconstruction after mastectomy which showed that 18% of patients returned to theatre for complications and 9% had implant loss. Twenty-five percent of patients developed infections and required antibiotics [16]. The complication rates with CWPFs are significantly less compared to implant-based reconstruction and only slightly higher compared to simple BCS. In the short term, the locoregional and distant recurrence rates are very much comparable to national rates in the UK following mastectomy and simple wide local excision.
Conclusion
CWPF reduces the mastectomy rates and can potentially improve overall patient outcomes. It has significantly less morbidity when compared to mastectomy and reconstruction, thus making it a safe option in suitable patients.
Footnotes
Publisher's Note
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Kirti Katherine Kabeer and Manoj Gowda S are combined first authors and have equal contribution.
Contributor Information
Kirti Katherine Kabeer, Email: Kirti.katherine@gmail.com.
Manoj Gowda S, Email: drmanojsg@gmail.com.
Sadaf Jafferbhoy, Email: Sadaf.Jafferbhoy@uhnm.nhs.uk.
Sekhar Marla, Email: sekhar.marla@uhnm.nhs.uk.
Sankaran Narayanan, Email: Sankaran.Narayanan@uhnm.nhs.uk.
Soni Soumian, Email: soni.soumian@uhnm.nhs.uk.
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