Breast Cancer Local Recurrence after TRAM Reconstruction: Incidence and Treatment
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Michael A. Howard, MD, Kristen Polo, BA, David A. Hidalgo, MD, Peter G. Cordeiro,
MD, Babak J. Mehrara, MD, and Joseph J. Disa, MD
Introduction
Skin sparing mastectomy and TRAM flap reconstruction are accepted modalities in the
treatment of breast cancer(1); however the management of local recurrence of breast cancer after
TRAM flap breast reconstruction is not standardized.(2-4) The purpose of this study was to
examine the incidence of local recurrence of breast cancer after TRAM flap breast
reconstruction and evaluate treatment modalities.
Methods
A retrospective review was conducted of all breast reconstruction patients at Memorial SloanKettering Cancer Center. All patients who underwent free or pedicled TRAM reconstruction
were identified. A subset of patients who experienced local breast cancer recurrence was further
identified. The medical records and prospectively maintained reconstructive database were
reviewed for demographic data, medical history, surgical procedures, and clinical outcome. Only
patients with ≥ one year of postoperative follow up were included in this series.
Results
Between 1987 and 2002, 419 TRAM flap breast reconstructions were identified in 395 patients.
The mean follow up for this group of patients was 4.9 years (range 1-14.7). There were 218
pedicled TRAMs, 142 free TRAMs, and 59 supercharged TRAM flaps. Thirty four of 395
patients (9%) underwent complete skin sparing mastectomy (CSSM) utilizing a periareolar
mastectomy incision only. Mean follow up in the CSSM group was 2.7 years (range 1-7 years).
Local recurrence occurred in 4% of the total population (16 of 395 patients). The site of
recurrence was the mastectomy skin flap (8) and chest wall (8). Tumor stage at initial diagnosis
in patients with local recurrence was as follows: DCIS (1), Stage I (3), IIA (6), IIB (3), IIIA (2),
and unknown (1). Six patients had prior breast conservation surgery treated with lumpectomy
and radiation therapy, while 14 patients had chemotherapy prior to the recurrence (either postlumpectomy or post-mastectomy). Mean time to local recurrence was 1.6 years (range 0.2-7.0).
There were no local recurrences seen in patients with CSSM. Treatment of local recurrence
included excision of recurrence in 75% (12 of 16), chemotherapy in 63% (10 of 16), radiation
therapy in 50% (8 of 16), and bone marrow transplant 13% (2 of 16). Only three patients (19%)
required removal of the entire TRAM flap to manage local breast cancer recurrence. Fifty six
percent (9 of 16) of patients with local recurrence died of disease, a mean of 1.2 years after the
development of recurrence.
Conclusions
In this series, long term follow up demonstrated a local recurrence rate after TRAM flap breast
reconstruction similar to that reported in the literature. Local recurrence was effectively
managed with surgical excision of the involved tissues, chemotherapy and/or radiation therapy.
Removal of the entire TRAM flap was only necessary in the setting of multifocal recurrence or
involvement of the flap pedicle with disease. The risk of local recurrence was not increased in
the setting of CSSM.
Table 1: Site of Local Breast Cancer Recurrence (n=16)
Site
Mastectomy flap
Chest wall
Incidence (n=16)
50%
50%
Table 2: Treatment modalities utilized for local breast cancer recurrence
Modality
Surgical excision
(TRAM Removal)
Chemotherapy
Radiation therapy
Bone marrow transplant
Incidence % (n=16)
75
(19)
63
50
13
Reference List
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mastectomy and immediate breast reconstruction: a prospective cohort study
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Annals of Surgical Oncology 9: 462-466, 2002.
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treatment after local breast cancer relapse. [Review] [7 refs]. Recent Results in
Cancer Research 127: 109-112, 1993.
3. Langstein, H. N., Cheng, M. H., Singletary, S. E. et al. Breast cancer recurrence after
immediate reconstruction: patterns and significance. Plastic & Reconstructive
Surgery 111: 712-720, 2003.
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immediate reconstruction with myocutaneous flaps. Plastic & Reconstructive
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