Immediate breast reconstruction and high-dose chemotherapy

Immediate breast reconstruction (IBR) is considered as a safe procedure nowadays, and it can be proposed in the majority of patients requiring a mastectomy. In fact, recent studies have demonstrated that immediate breast reconstruction is not detrimental also to patients with locally advanced breast cancers. However, IBR should be reevaluated in case of locally advanced breast cancer requiring high-dose chemotherapy (HDCT). The aim of this study is to evaluate both the risk of chemotherapy delay due to surgical complications and the risk of late surgical complications related to the association with HDCT. We considered 3 series of 23, 67, and 15 patients requiring a mastectomy at the European Institute of Oncology in Milan. After mastectomy, these groups respectively received an IBR and HDCT, an IBR and conventional chemotherapy, and only HDCT with no IBR.

Files of 105 patients who were admitted to our department from October 1999 to January 2002 were reviewed. Twenty-three patients underwent a mastectomy, followed by IBR and HDCT; 67 underwent a mastectomy plus IBR plus conventional CT; and, finally, 15 underwent a mastectomy alone followed by HDCT. The reconstructive techniques performed were 72 permanent prosthesis and 18 temporary expanders. We excluded all patients with IBR by flap (latissimus dorsi or pedicled rectus abdominis) to improve the homogeneity of the sample.

All patients who underwent IBR started high-dose chemotherapy without any delay; the time elapsed between surgery and HDCT is not significantly different for patients with and without IBR (54 versus 60 days, P = 0.13). The early complication rate (before CT) was 2.9% (2 patients with infection). The late complication rate (after CT) was higher for the group that underwent IBR followed by HDCT (39% versus 20%).

We did not observe any delay for the administration of high-dose chemotherapy after mastectomy with IBR surgery. The complication rate before HDCT is similar to the complication rates published in the literature. On the contrary, we observed a higher rate of infections (13% versus 0%, P = 0,014) after HDCT than after conventional CT, which can be related to the association with high-dose chemotherapy, inducing a decrease of the immune defenses. These results seems to demonstrate that the association of IBR with HDCT is not detrimental to patients from the oncological point of view, but the impact of HDCT on the reconstruction is more negative. Further studies are needed to verify if this risk exists, although lower, in the association with conventional CT. However, a careful evaluation of the risk of infections should be considered preoperatively, and perioperative contaminations should be carefully prevented.