Neoadjuvant Chemotherapy for Breast Cancer Treatment and the Evidence-Based Interaction with Immediate Autologous and Implant-Based Breast Reconstruction

This article aims to determine the impact of neoadjuvant chemotherapy on immediate breast reconstruction by assessing their compatibility for oncological safety and the incidence and management of postoperative complications. A review of scientific publications published between 2009 and 2017 was undertaken. The relationship between neoadjuvant chemotherapy and immediate breast reconstruction was analyzed to compile and assess the potential interaction between the procedures. The search was limited to English language publications, but there were no limiting factors at the level of study typology. Full-text articles, including the references leading to other relevant studies, were evaluated.

Key points

  • Chemotherapy for the treatment of breast cancer dates to the 1960s. At that time it was used for locally advanced and even inoperable cancer to provide a few more months of life to the patients suffering from it.

  • Historically, patients underwent resective surgery (lumpectomy or mastectomy) followed by adjuvant therapy (chemotherapy and/or radiotherapy).

  • Later, when the adjuvant treatment was completed and sufficient time had elapsed to be considered disease-free, delayed breast reconstruction proceeded.

  • The development of more effective chemotherapy regimens has made it possible to put forth neoadjuvant chemotherapy in the case of breast tumors larger than 2 cm with or without axillary involvement.

Introduction

Although approximately 30% of oncologists think that breast reconstruction may interfere with the oncological treatment of breast cancer, there is currently sufficient scientific evidence to demonstrate that immediate breast reconstruction is a safe procedure from the oncological perspective because it does not modify the patient’s overall disease-free survival rate or interfere with subsequent oncological controls.

There are multiple benefits for the patient, from the biological to the psychosocial, including a clear improvement in body image acceptance.

The introduction of neoadjuvant chemotherapy for the treatment of breast cancer before its immediate reconstruction has been a source of controversy. Certain groups have questioned its compatibility with immediate reconstructive surgical treatment. They argue that there is a higher incidence of perioperative complications secondary to the neoadjuvant therapy before the intervention. This is also true in certain cases of delays in the implementation of coadjuvant therapy due to the presence of these postoperative complications.

The aim of this review is to examine the effect of neoadjuvant chemotherapy on immediate breast reconstruction by assessing the incidence of postoperative complications and the latency time until the onset of adjuvant therapy, and comparing it with the oncological and surgical results obtained from the combination of immediate breast reconstruction and coadjuvant therapy following surgery.

Introduction

Although approximately 30% of oncologists think that breast reconstruction may interfere with the oncological treatment of breast cancer, there is currently sufficient scientific evidence to demonstrate that immediate breast reconstruction is a safe procedure from the oncological perspective because it does not modify the patient’s overall disease-free survival rate or interfere with subsequent oncological controls.

There are multiple benefits for the patient, from the biological to the psychosocial, including a clear improvement in body image acceptance.

The introduction of neoadjuvant chemotherapy for the treatment of breast cancer before its immediate reconstruction has been a source of controversy. Certain groups have questioned its compatibility with immediate reconstructive surgical treatment. They argue that there is a higher incidence of perioperative complications secondary to the neoadjuvant therapy before the intervention. This is also true in certain cases of delays in the implementation of coadjuvant therapy due to the presence of these postoperative complications.

The aim of this review is to examine the effect of neoadjuvant chemotherapy on immediate breast reconstruction by assessing the incidence of postoperative complications and the latency time until the onset of adjuvant therapy, and comparing it with the oncological and surgical results obtained from the combination of immediate breast reconstruction and coadjuvant therapy following surgery.

Discussion

Chemotherapy for the treatment of breast cancer dates to the 1960s. It was used at that time for locally advanced and even inoperable cancer to provide a few more months of life for the patients suffering from it.

With the improved survival rates (currently, around 85% of cases ) achieved with the establishment of new chemotherapeutic lines, the need has arisen to proceed to breast reconstruction in patients who have suffered the consequences of a partial or total resection of the mammary gland.

Historically, patients underwent resective surgery (lumpectomy or mastectomy) followed by adjuvant therapy (chemotherapy and/or radiotherapy). Later, when the adjuvant treatment was completed and sufficient time had elapsed to be considered disease-free, delayed breast reconstruction proceeded. The development of more effective chemotherapy regimens has made it possible to put forth neoadjuvant chemotherapy in the case of breast tumors larger than 2 cm with or without axillary involvement. This was mainly done to increase the possibility of having conservative surgery. Neoadjuvant chemotherapy entails several cycles of chemotherapy before the definitive surgical treatment, which is usually between 4 and 6 weeks after the end of the treatment. The most commonly used programs are based on combinations of anthracyclines and taxanes. Depending on the tumor subtype, specific targeted therapies are combined with chemotherapy, as is the case for antiHER2 therapies in the case of human epidermal growth factor receptor 2 (HER2) positive tumors.

Currently, many studies demonstrate the oncological safety, as well as the aesthetic and psychological benefit, of immediate breast reconstruction after mastectomy, whether it be therapeutic or prophylactic. The relationship between breast reconstruction and postoperative adjuvant treatment has been well studied and provides data that support the compatibility and even synergy between the 2 procedures.

In contrast, there is no consistent data relative to the interaction that may exist between the introduction of a neoadjuvant therapy before surgery and the results and complications that may result from the surgical procedure performed shortly thereafter.

For this reason, different groups have initiated retrospective clinical studies to assess the incidence of neoadjuvant chemotherapy in the subsequent mammary reconstruction procedure ( Table 1 ).

Table 1
Studies assessing the relationship between chemotherapy and breast reconstruction
Author, Year of Publication Subjects Receiving NQT per Total in Cohort Type of Reconstruction Complications P Value
Autologous TE/I Minor Major
Free Pedicled
Mehrara et al, 2006 70/1195 (7.7%) 217 (18.2%) 978 (81.8) Fat necrosis (11%)
Infection or wound healing complication (9.2%)
Abdominal wall laxity or hernia (3%)
Total flap loss (0.7%)
Partial flap necrosis (2.7%)
Arterial thrombosis (0.8%)
Venous thrombosis (1.3%)
Hematoma (1.6%)
Minor complications <.01 (OR 2.1)
Major complications <.8 (OR: -)
Deutsch et al, 1999 31/31 (100%) 570 (70%) 9 (30%) Fat necrosis (22%)
Infection or wound healing complication (10%)
Abdominal hernia (6%)
Total flap loss (0%)
Partial flap necrosis (25%)
Azzawi et al, 2010 53/171 (31%) 28 (52%) 23 (44%) 2 (4%) Wound infection, slow healing, wound breakdown, fat necrosis (10%) Total flap loss (2%)
Partial flap necrosis (3%)
Hematoma (0%)
Infected implant (2%)
Minor complications .380
Major complications 1
Warren Peled et al, 2010 57/163 (35%) 1 (1%) 25 (44%) 31 (55%) Wound infection (23%)
Skin necrosis (16%)
Total flap loss (4%)
Implant or expander loss (26%)
Hematoma (9%)
Abdominal hernia (12%)
  • Minor complications:

    • Wound infection .05

    • Skin necrosis .55

  • Major complications:

    • Total flap loss .57

    • Implant or expander loss .70

    • Hematoma .04

    • Abdominal hernia .87

Forouhi et al, 1995 23/79 (30%) 11 (48%) 12 (52%) Minor seroma (17.5%)
Minor infection (10%)
Minor necrosis (2.5%)
Major seroma (2.5%)
Major infection (10%)
Major necrosis (0.5%)
Minor complications .45
Major complications .88
Hu et al, 2011 180/665 (27%) 4.5% 60.3% 35% Infection (10%)
Wound dehiscence
Hematoma (3%)
Seroma (15%)
Skin necrosis (7%)
Flap loss (1%)
Tissue expander or implant removal (0%)
  • Minor complications:

    • Infection .89

    • Wound dehiscence .41

    • Hematoma .21

    • Seroma .36

  • Major complications:

    • Skin necrosis .44

    • Flap loss .18

    • TE/implant removal .39

Abt et al, 2014 820/19,258 157 (20%) 570 (70%)
TE/I
90 (direct implant)
N = 663 patients
Surgical site complications (superficial and deep incisional surgical site infection, wound dehiscence, graft or prosthesis failure) Systemic complications (pneumonia, pulmonary embolism, renal failure, cerebrovascular accident, cardiac arrest, sepsis) Surgical site complications .82
Systemic complications .01
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Nov 21, 2017 | Posted by in Dental Materials | Comments Off on Neoadjuvant Chemotherapy for Breast Cancer Treatment and the Evidence-Based Interaction with Immediate Autologous and Implant-Based Breast Reconstruction
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