Complications and Pattern of Failure Following Immediate Breast Reconstruction after Breast Cancer Surgery: A Retrospective Analysis over Nine Years

Abstract

Post-operative radiotherapy (RT) has been reported to increase the complications following immediate breast reconstruction (IBR) for breast cancer (BC) patients. ESTRO guideline in 2019 has published the recommendation for CTV-chest wall definition in retro-pectoral IBR-implant reconstruction (IBR-i), which excludes the implant on the dorsal border in patients with no risk factors. The guideline aims to decrease the RT-related complications without compromising the oncological outcomes. The present study aims to explore risk factors related with complications after IBR and the pattern of local-regional recurrence (LRR) to view the potential benefit of delineation recommendation and oncological safety of CTV border. Consecutive BC patients treated with IBR in single center from Jan.2009 to Dec.2018 were retrospectively analyzed. Reconstruction failure (RF) is defined as any unplanned implantation/replacement/adjustment of implants, or complete loss/necrosis of autologous flaps. Severe capsular contracture (CC) is defined as requiring capsulotomy or capsulectomy. Univariate and multivariate analysis were performed using logistic regression analysis. In total, 265 patients undergoing 274 IBR were reviewed, including 262 breasts receiving retro-pectoral IBR-i with or without latissimus dorsi flaps and 12 autologous flaps only. The median age was 40 years. A total of 55 breasts received RT and CTV was defined to include entire implants or flaps. In total, RF events occurred in 15 (5.5%) breasts and the most common cause (60%) of RF was implant exposure and/or infection. Univariate analysis showed that adjuvant chemotherapy (CT) and BMI were both significant risk factors for RF while RT was not (OR 0.995, 95% CI 0.271-3.656, p = 0.994). Multivariate analysis showed that only adjuvant CT was the significant risk factor for RF (OR 6.283, 95% CI 1.332-29.643, p = 0.02). CC was evaluated in 262 breasts with IBR-i. Severe CC occurred in 11 patients, with 7 in the RT group. Multivariate analysis showed that RT was the only significant risk factor for developing severe CC (OR 4.000, 95% CI 1.017-15.738, p = 0.047). After a median follow-up of 44 months, 6 LRR events were observed, including 2 in chest-wall, 1 in nipple-areolar and 3 in axilla. No recurrence in pectoral muscles, ribs or intercostal muscles was observed. None of recurrence occurred outside the border of ESTRO CTV-chest wall recommendation. The 5-year recurrence from survival (RFS), local-regional RFS and overall survival were 93.0%, 98.2% and 98.7%, respectively. IBR after BC surgery yields a low rate of RF and severe CC. Adjuvant CT was associated with increased risk of RF. Post-operative RT remains a risk factor for severe CC. Pattern of LRR in our study supports the oncological safety of ESTRO delineation guideline. Further study is needed to confirm if the new delineation will help to decrease the RT-related complications in patients with IBR.