The Association between Surgical Closure Type and Acute Infection, Local Recurrence, and Disease Surveillance in Patients Undergoing Breast Conserving Therapy For Early Stage Breast Cancer

Abstract

Purpose/Objective: In patients undergoing breast-conserving therapy (BCT), surgical closure technique has been largely influenced by expected cosmetic outcome. However, the common practice of promoting postoperative fluid collection raises concerns about potential bacterial colonization, tumor cell migration, and impaired post-BCT surveillance. This study investigates the effect of full-thickness versus superficial closure of the breast parenchyma on the likelihood of subsequent infection and local recurrence. Materials/Methods: From 1985 through 2004, 577 women with 599 stage T0-2N0-1 breast cancers underwent BCT at our institution. Medical records were reviewed to determine surgical closure technique, incidence of post-operative infection, local recurrence (LR), and ipsilateral breast tumor recurrence (IBTR). Three surgeons performed the majority of operations. Re-excision of the tumor bed was performed in patients with close or positive margins when feasible. In all patients, radiation treatment was planned using computed tomography (CT) scans. The tumor bed target included postoperative fluid collections, tumor bed clips, and postoperative tissue changes. Acute infection was diagnosed on a clinical basis within three months of surgery. Results: Median observed follow-up was 6.4 years from the completion of radiotherapy. Surgical closure technique was determined in 514 patients. Acute infections occurred in 27/229 (11.8%) breasts known to have superficial closure compared with 15/285 (5.3%) with full-thickness closure (p=0.0091). In stage T1–2 patients, the overall 10-year actuarial rates of IBTR and LR were 5% and 3%. In this group of patients with invasive cancer, there was no difference between superficial and full-thickness closure in the rate of either IBTR 5.6% (11/195) vs. 3.5% (8/230) or LR 3.6% (7/195) vs. 1.7% (4/230). In Stage T0-T2 patients, local recurrences following superficial closure were less likely to be initially detected on mammography 29% (2/7) vs. 100% (10/10) p=0.0034 compared to local recurrences following full-thickness closure. In addition, when locally recurrent tumors were identified in mastectomy specimens of stage T0-T2 patients, 80% (4/5) of recurrent tumors after superficial closures were >1 cm compared with no (0/9) (p=0.0050) recurrent tumors after full-thickness closures. A Cox multivariate analysis was performed examining factors potentially associated with IBTR and LR including: surgical closure type, age, infection, obesity, tumor bed radiation dose, hormonal therapy, and surgical margin status. Only close (<2 mm) or positive margins were significant risk factors for both IBTR and LR (p = 0.0147 and 0.0177). Acute infection was also a significant risk factor for LR alone (p = 0.0034). Conclusions: In the University of Florida BCT experience, women with superficial closures after partial mastectomy had an increased risk of infection, which itself was associated with a higher risk of local recurrence. Additionally, local recurrences after superficial closure may be more difficult to detect on surveillance imaging, permitting the development of larger recurrent tumors.