Title: The Safety, Efficacy, and Reconstructive Arena of Radical Ablation in Patients
with Locally Advanced Breast Cancer
Authors:
Elisabeth K. Beahm, M.D., Mossi Salibian, M.D., Henry Kuerer, M.D.,
Robert L. Walton, M.D.
Introduction: Historically, locoregional recurrence and chest wall involvement in breast cancer
have been considered harbingers of distant metastasis and poor prognosis. The use of
neoadjuvant chemotherapy has resulted in selected patients with advanced disease,
previously deemed “inoperable”, to be referred for radical resection requiring reconstruction. 1-4
Purpose: To define the safety, efficacy, and reconstructive arena of radical ablation in
patients with locally advanced breast neoplasms.
Methods: Data for 92 patients with advanced breast cancer treated by surgical resection and
reconstruction from1988-2000 were compiled retrospectively. Inclusion criteria included clinical
tumor size of 5 cm or greater, primary or recurrent with chest wall invasion requiring flap
reconstruction with a minimum 6-month postoperative follow-up. Patient demographics and
outcomes including survival, local and/or distant metastases, reconstructive strategies, and
complications were evaluated.
1.0
1.0
0.9
0.9
0.8
0.8
Cumulative Proportion Surviving
Cumulative Proportion Surviving
Results: All patients were female with T4 tumors, either Stage IIIb (N=80) or Stage IV (N=13).
Mean age was 53 years (Range(R) = 28-86) with an average of 28 months follow-up (R= 6144). All patients received adjuvant/neoadjuvant chemotherapy. Two-thirds of the patients had
primary locally advanced breast cancer (LABC N=55), and one-third had recurrent disease
(RC N=37). Median survival was 40.48 months, with a median disease free survival of 17.75
months. Survival of LABC was not statistically different from RC (28.5 versus 22.1 months,
p=0.318).
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0.0
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0.0
0
20
40
60
80
100
120
Survival Time (Months)
Figure 1: Actuarial Overall Survival
Following Reconstruction.
0
20
40
60
80
100
Disease-free Survival Time (Months)
Figure 2: Actuarial Disease-Free
Survival After Reconstruction.
120
Cumulative Proportion Surviving
1.0
0.9
0.8
0.7
0.6
LABC
0.5
0.4
0.3
CW
P = 0.202
0.2
0.1
0.0
0
20
40
60
80
100
120
Time (Months)
LABC: Locally Advanced Breast Cancer Group
CW: Chest Wall Recurrence Group
Figure 3: Actuarial Overall Survival.
Mean tumor size was 6.8 cm (R= 5.0-8.5) with a resultant defect size of 264 cm2 (R= 70-900)
necessitating 116 flaps in 92 patients to achieve wound closure. Twenty patients required
more than one flap. The latissimus dorsi and rectus abdominus myocutaneous flaps were the
most commonly utilized. Pedicled flaps were more common than free flaps. Prosthetic
materials were utilized in 33 patients (mesh N=25; methylmethacrylate N=8). There were no
perioperative deaths. Hospital stay averaged 7.0 days (R= 2-34). Complications included:
Flap loss (total N=4; partial N=6) cellulitis (N=10) seroma (N=13) respiratory compromise
and/or systemic infection (N=29).
Conclusions: In the largest series to date, we have demonstrated that radical ablation and
reconstruction in large locally advanced or recurrent breast cancers can be safely carried out
with an acceptable risk even if multiple flaps are required for closure. Overall survival with this
regime is favorable to historic controls. Some patients may experience a long disease free
interval and a few, long-term survival. While rarely curative, this surgery appears to decrease
morbidity by palliation in the final stages of terminal disease and therefore appears warranted
selected cases.
Figure 4: 50 year old female with locally advanced breast cancer underwent full
thickness chest wall resection including the sternum and 6 ribs, reconstructed with
mesh, methylmethacrylate, bilateral free TRAM and pedicled latissimus dorsi flaps.
References:
1. Singletary, S.E., Hortobagyi, G.N., and Kroll, S.S. Surgical and medical management of
local-regional treatment failures in advanced primary breast cancer. Surg Oncol Clin North
Am 4:671, 1995.
2. Hortobagyi, G.N., Ames, F.C., Buzdar, A.U., et al. Management of stage III primary breast
cancer with primary chemotherapy, surgery and radiation therapy. Cancer 62:2507, 1988.
3. Buzdar, A.U., McNeese, M.D., Hortobagyi, G.N., et al. Is chemotherapy effective in
reducing the local failure rate in patients with operable breast cancer? Cancer 65:394,
1990.
4. Downey, R.J., Rusch, V., Jsu, F.I., et al. Chest wall resection for locally recurrent breast
cancer: is it worthwhile? J Thorac Cardiovasc Surg 119:420, 2000.