Risk of recurrence and death in patients with breast cancer after delayed deep inferior epigastric perforator flap reconstruction

Abstract

BackgroundPostmastectomy reconstruction using a deep inferior epigastric perforator (DIEP) flap is increasingly being performed in patients with breast cancer. The procedure induces extensive tissue trauma, and it has been hypothesized that the release of growth factors, angiogenic agonists and immunomodulating factors may reactivate dormant micrometastasis. The aim of the present study was to estimate the risk of breast cancer recurrence in patients undergoing DIEP flap reconstruction compared with that in patients treated with mastectomy alone.MethodsEach patient who underwent delayed DIEP flap reconstruction at Karolinska University Hospital, Sweden, between 1999 and 2013, was compared with up to four controls with breast cancer who did not receive a DIEP flap. The control patients were selected using incidence density matching with respect to age, tumour and nodal status, neoadjuvant therapy and year of mastectomy. The primary endpoint was breast cancer‐specific survival. Survival analysis was carried out using Kaplan–Meier survival estimates and Cox proportional hazard regression analysis.ResultsThe analysis included 250 patients who had 254 DIEP flap reconstructions and 729 control patients. Median follow‐up was 89 and 75 months respectively (P = 0·053). Breast cancer recurrence developed in 50 patients (19·7 per cent) in the DIEP group and 174 (23·9 per cent) in the control group (P = 0·171). The 5‐year breast cancer‐specific survival rate was 92·0 per cent for patients with a DIEP flap and 87·9 per cent in controls (P = 0·032). Corresponding values for 5‐year overall survival were 91·6 and 84·7 per cent (P < 0·001). After adjustment for tumour and patient characteristics and treatment, patients without DIEP flap reconstruction had significantly lower overall but not breast cancer‐specific survival.ConclusionThe present findings do not support the hypothesis that patients with breast cancer undergoing DIEP flap reconstruction have a higher rate of breast cancer recurrence than those who have mastectomy alone.

Survival in breast cancer patients with a delayed DIEP flap breast reconstruction after adjustment for socioeconomic status and comorbidity

“…For the latter, the deep inferior epigastric perforator (DIEP) flap, consisting of adipose tissue and skin from the abdomen that is transposed to the mastectomy site as a free microsurgical transplant, is commonly performed [ 1 , 2 ]. While some reports observed a worse survival for patients undergoing large reconstructive procedures, assumedly releasing growth factors that may reactivate dormant tumour cells, our group found a significantly better overall survival in DIEP patients than in matched controls without any delayed breast reconstruction [ 3 ]. The current analysis aimed to identify underlying differences between the groups that could explain these observations.…”

“…Interaction terms were included to test for effect modification and to estimate the effect of exposure in each stratum of the modifier after investigating the main effects. Statistically significant interaction terms were tested in the 1 [3]. As shown in Table 2, the DIEP group represent a population with a higher SES, as demonstrated by a lower proportion of individuals with primary school as the highest level of education or with a low income.…”

The difference in local, regional and distant breast cancer recurrence between the immediate and delayed DIEP flap procedure; a retrospective cohort study

“…However, only 28% of the study group comprised autologous flap reconstruction, which calls this statement into question [ 11 ]. Furthermore, with mentioned hypothesis the previous described studies should have shown more recurrences in the delayed reconstruction group compared to the mastectomy alone, which they did not (Isern et al excluded) [ 13 – 15 ]. In addition, a study by Allawi et al did not find any association between surgery or accidental trauma and activation of dormant micro metastases leading to higher recurrence rates of breast cancer [ 33 ].…”

“…Previously, we mentioned there is no statistical difference in major complications between both procedures. Therefore, this particular factor will not be important in decision-making [ 13 ]. In summary, both procedures have their advantages and limitations.…”

“…Two Swedish studies described no difference in breast cancer recurrence between delayed DIEP flap reconstruction groups and mastectomy alone. A major limitation of these studies is that they included a relatively small number of DIEP flap reconstruction patients in a long period of time, 250 patients in a 14 year time period, and 225 patients in 9 years respectively [ 13 , 14 ]. A study by Geers et al assessed the effect of an (immediate or delayed) autologous breast reconstruction as compared to mastectomy alone, on distant relapse.…”