Surgical Management of Locally Advanced Breast Cancer: Recommendations of the Brazilian Society of Surgical Oncology

A B S T R A C T

The Brazilian Society of Oncological Surgery organized a group of oncological surgeons to discuss surgical aspects associated with locally advanced breast carcinoma. This article reviews the indications, the different surgeries (especially those associated with thoracoabdominal or myocutaneous flaps), and associated complications. It discusses special conditions such as invasion of the chest wall and interscapular thoracic disarticulation. It makes recommendations based on the literature regarding clinical findings, tumor conditions, response to neoadjuvant therapy, choice of flaps in surgery, and tumor biology.

Keywords

Breast neoplasm, surgical flaps, myocutaneous flaps, peroperative complication, locally advanced tumors

Introduction

In 2020, a group of breast studies was conducted within the Brazilian Society of Oncological Surgery. The mission was to seek a consensus regarding breast cancer surgery in Brazil. After discussions of potential topics, the group considered a frequent common in Brazil, i.e., a locally advanced mammary carcinoma (LABC), given its frequency and relevance in our environment. We observed the rarity of publications on the subject and chose to conduct a succinct review of the main surgical treatments performed by breast surgeons involved in treating LABC. The group pointed conditions related to this condition as the basis of the recommendations. A literature review was conducted, the text was organized and in the resectability and recommendations sections, points were discussed and organized in the form of a group consensus with the aim of generating recommendations for the surgeons involved in the treatment of patients with LABC.

In Brazil and other developing countries, LABC is a frequent problem that is influenced by limitations in its early diagnosis and treatment flow [1]. The treatment of LABC is not simple, and it involves discussions regarding neoadjuvant treatment, indications of resectability, mastectomy, and options for chest wall closure.

LABC usually presents as advanced breast cancer that is potentially curable with surgery, radiotherapy, and systemic therapy; however, some patients present with primarily inoperable tumors, even without metastatic disease, and other patients with metastatic LABC require palliative or hygienic surgery. There is no definition that encompasses all clinical findings, but there is a consensus that LABC includes extensive invasive disease with varying degrees of involvement of the skin and chest wall and/or profuse regional adenopathy [2-4]. LABC includes tumors larger than 5 cm (T3), tumors of any diameter with involvement of the skin or chest wall (T4) and/or extensive lymph node involvement (N2 or N3), and stages IIB and III can be considered [5]. Inflammatory breast cancer (IBC) is a subtype of LABC, but it is usually studied separately due to its more severe biological behaviour.

In staging, chest, upper abdomen, and bone scintigraphy or PET-CT scans should be performed if available, although the latter is better for recognizing metastatic disease in this subgroup of patients [6]. In the presence of doubts regarding the potential metastatic disease, controls should be performed, and even then, some patients, even those with metastatic disease, will require hygienic surgery for local control due to ulceration, bleeding, or pain [7]. Breast evaluation most often involves mammography associated with ultrasound; for breast imaging, however, MRI can be considered for surgical planning after neoadjuvant chemotherapy because of high correlation with pathological results [8].

To increase resectability, neoadjuvant chemotherapy is the standard treatment for LABC and shows an overall survival rate equivalent to that of adjuvant treatment, with the advantage of increasing conservative treatment rates and the ability to select the patients with a better likelihood of survival, i.e., those who achieve a complete pathological response (CPR) [9, 10].

Many patients will obtain CPR, defined as the absence of residual tumor in the breast and lymph nodes, which is observed in 3-30% of cases and is considered the greatest predictor of disease-free and overall survival [9, 10]. The rates of CPR vary according to the subtype of disease and access to new drugs. Triple-negative and HER2 tumors have higher CPR rates; rates can be as high as 66% in HER2-positive tumors with double blocking [11-14]. At present, studies have shown increased survival in patients with triple-negative and HER2+ tumors without a complete pathological response who have access to adjuvant treatment with Xeloda (Create-X Trial) and TDM1 (Kathy Trial) [15, 16]. However, a percentage of patients will not respond to neoadjuvant treatment, and about 3% will present disease progression; therefore, it is necessary to be aware of surgical solutions for these patients. Similarly, neoadjuvant treatment should be monitored, and if disease progression occurs after two cycles of treatment, changes in therapy should be considered, and surgical treatment should be considered within a multidisciplinary context.

Surgery should be performed 3-4 weeks on average after the last application of chemotherapy, at which time the myelotoxicity of neoadjuvant chemotherapy has passed and spinal function has been reestablished, allowing safe conditions for surgical resection [17]. Complete resection is required, with free margins that meet the same criteria for free margins in initial tumors. Skin tattooing, metal clip placement clip, noting the area in the medical records, and resection of only the remaining area are discussed in the literature [18]. Additionally, the literature reflects the uncertainty regarding whether to resect the entire original tumor bed or only the residual tumor before systemic treatment; although there is a tendency toward oncological resection of the residual tumor area (and not the original tumor area), but there are no prospective and controlled studies validating this approach [19].

In LABC patients who respond to neoadjuvant chemotherapy, the omission of axillary lymphadenectomy, with the performance of sentinel lymph node research in good responders, has debatable value, although it can be performed in well-selected cases [20]. The presence of ulceration is associated with increased infectious phenomena, and many patients will have to undergo chemotherapy to increase resectability [21]. During surgery, steps should be taken to avoid infectious complications when resecting the lesion, such as covering the ulcerated area and providing therapeutic antibiotic therapy [22, 23]. To increase resectability in borderline situations, i.e., in cases of failure after neoadjuvant chemotherapy, some patients may undergo neoadjuvant radiotherapy [24, 25]. In patients with metastatic disease, the primary indication is based on the presence of ulceration, bleeding, or pain, with consideration of the molecular subtype, the presence of oligometastatic disease, and the metastasis site, or specific subgroups [7, 26]. A review of uncontrolled studies suggests a potential benefit of surgery, but this is not observed in prospective studies with initial randomization or the randomization of good responders [7, 26-30].

Resectability

In patients with LABC, surgical resection should promote local control, even in cases of metastatic disease. There is no sense in performing resection in cases of residual local disease, given the need for complementary treatment. Thus, when evaluating resection, surgical complications, potential morbidity, and associated mortality should be considered. Extensive soft tissue lesions will require myocutaneous or fasciocutaneous flaps for the closure of the defect, and lesions fixed to deep planes may indicate extension to the chest wall and the involvement of the rib cage. Thus, the main resectability criteria are as follows:

i. Adequate clinical condition for extensive surgery;
ii. Potential clinical benefit, determined by local control, with the aim of improving or palliating symptoms;
iii. Planned neoadjuvant sequencing strategies aimed at increasing resectability and adjuvant strategies aimed at increasing local control;
iv. Conditions for the resection of the entire lesion or primary closure of the area may require a team of professionals with knowledge of tumor resection, reconstruction of the skin defect, and/or chest wall reconstruction;
v. In the presence of extension to the axilla and extensive axillary skin resection, extensive flaps should be considered to allow arm mobility, eventually including the use of double flaps or microsurgical flaps;
vi. The presence of surgical complications is not an unresectability criterion in and of itself; however, the surgeon must have knowledge of multiple techniques to select the most appropriate flap and to intervene early in cases of surgical complications and tumors with adverse biological characteristics.

In contrast, tumors with the following criteria are considered unresectable (Figure 1):

i. Lesions with a large extension to the thoracic wall, for which closure of the skin defect would be impossible even with multiple myocutaneous flaps;
ii. Lesions with a large extension to bony parts, for which closure of the chest wall is not feasible;
iii. Lesions with direct involvement of the axillary nerve vasculature plexus, for which resection, even with interscapular thoracic disarticulation, has no curative purpose;
iv. Extensive lesions affecting resection areas that cannot be covered with double or microsurgical flaps;
v. Relative contraindications include tumors, even resectable ones, with aggressive tumor biology evidenced by rapid progression during previous chemotherapy; in such cases, a surgical complication could cause delays in subsequent therapy that allow an early local recurrence.

Figure 1: Conditions associated with unresectability. a & b) Extensive disease affecting soft tissues and extensive areas of the rib cage and sternum in a patient with pleural metastasis; c) bilateral disease with right lateral skin extension that creates a donor area for primary coverage; d) extension to the left upper limb and back.

Patchworks

A solution used in the past consisted of resecting the tumor and leaving a bloody area that can heal secondarily or with skin grafts [31]. It is advised to close all skin defects with flaps, although the association of skin grafts is reported in the literature [32, 33]. The main problem with skin grafts is that it increases the time for wound complete healing which makes, increasing the time to start another treatment [34].

The main types of flaps used to close tissue defects resulting from mastectomy for the treatment of locally advanced cancer are fasciocutaneous, dermofat, and myocutaneous [35-38]. In the absence of randomized studies in these repair methods, the choice of flap depends on the extent of tissue loss, the clinical condition of the patient, the need for concomitant chest wall resection based on the experience of the surgical team, and the material resources available [36].

Thoracoabdominal Flaps

Historically, these flaps were classified as dermofat and fasciocutaneous flaps, but this classification has been revised [36, 37]. These flaps are used to close small and medium defects. Their main advantage is the ease of use, but they can be associated with a higher rate of necrosis, greater than myocutaneous flaps. Lateral flaps have a lower rate of necrosis [36, 37].

Thoracoabdominal flaps are described in case series, are easy to perform, do not require the involvement of reconstructive surgeons, and have a higher rate of necrosis than myocutaneous flaps, with variations in the complication rate according to the type of flap [36]. Table 1 reviews previous group publications and update in literature related to the flaps for breast cancer, or VRAM flap in oncologic procedures [34, 36, 38-47]. The main complication is necrosis, with no separation according to the type of necrosis (tip necrosis or more extensive), the treatment performed (expectant or reapproach), the rate of reapproach in the operating room, or the time to the start of the next treatment; these issues should be addressed in future studies. We highlight a flap described and used for major defects, the ipsilateral, thoracoabdominal horizontal, dermofat flap (ITADE; Figure 2a), which allows the closure of areas of moderate extent where myocutaneous flaps would generally be used [36].

Table 1: Series with thoracoabdominal and myocutaenous flaps used in primary closure after mastectomy.

Flap/ Author

Number of cases

Cases with necrosis

Necrosis

Rate

Thoracoabdominal Flap

 

 

 

Deo (2018) [38]

72

8

11.1% total; 8.3% superficial; 2.7% Major

Min [34]

41

17

42.5%

 

 

 

4,9% extensive necrosis

Baroudi

34

10

29.4%

Buratani

30

0

0

Vieira/ ITADE [36]

23

9

34.8% tip necrosis

4.1% extensive necrosis

Deo (2003) [35]

22

2

9.1%

Das

20

1

5%

Persichetti

18

4

22.2%

Kubo/ Romboid [63]

14

2

14.3%

Park-TE (medial pedicle)

10

6

60.0%

Park-TA (lateral pedicle)

9

2

22.2%

Martela

8

0

0

Tai

5

1

20.0%

Lim

3

0

0

 

 

 

 

Myocutaneos Flap

 

 

 

Le Boudec/ LD [42]

101

3

3%

Apffelstaedt/ LD [43]

83

14

(7 major)

16.8%

8,4% major

Salmon/ LD

40

2

5.0%

Munhoz/ LD

25

2

8.0%

Woo/ LD

12

0

0%

Amelung

12

4

25%

Micali/ LD

8

3

37.5%

 

 

 

 

Lee/ EOMF [40]

75

9

12.0%

Bogossian/ EOMF

20

1

5%

Gesson-Paute/ EOMF

9

0

0%

Cordoba/ EOMF

13

1

7.7%

Vieira/ MEOMF [39]

17

12

70.5%

 

 

 

 

Charanek/ VRAM [45]

55

2

3.6%

Lin/ TRAM [44]

16

1

6.3%

Mir/ TRAM-VRAM [41]*

60

8

13.3%

 

 

 

 

Mirza/ VRAM[46]**

58

10

17.2%

Daigeler/ VRAM[47]**

78

10

12.8%

Adapted from Vieira et al. [36]. New publications included [34, 38-43].

LD: Latissimus Dorsi; EOMF: External Oblique Myocutaneous Flap; MEOMF: Modified EOMF; ITADE: Ipsilateral Thoracoabdominal Dermofat flap.

*Reconstruction for breast reconstruction for LABC; **Oncologic patients.


Myocutaneous Flaps

In the reconstruction of postmastectomy defects, there are several options, but basically, three flaps are generally used: the latissimus dorsi myocutaneous flap, the myocutaneous flap of the rectus abdominis, the myocutaneous flap of the oblique abdominal muscle, and potential combinations [2, 39, 40, 44, 48-50]. These flaps are used when the postmastectomy defect area is more extensive and can usually be performed by breast specialists, oncological surgeons and plastic surgeons; in general, they are associated with a lower rate of flap necrosis [36, 39]. Conversely, microsurgical flaps are a good option for the reconstruction of defects after mastectomy; however, they require a team with a high level of training in microsurgery [51]. A myocutaneous flap of the latissimus dorsi muscle (Figure 2b) can be used to close large defects after mastectomy for locally advanced breast cancer. It has a low rate of necrosis, and a large skin donation area can be used, but eventually, a second skin graft is need [2, 42, 43]. The limitation for its use is neoplastic infiltration of the vascular pedicle due to axillary disease.

Figure 2: Flaps used for cutaneous synthesis after LABC mastectomy. a) ITADE flap; b) myocutaneous flap of the latissimus dorsi muscle; c) myocutaneous flap of the abdominal oblique muscle; d) transverse myocutaneous flap of the rectus abdominis muscle.

Myocutaneous flaps of the rectus abdominis muscle can be transverse (TRAM) or vertical (VRAM; Figure 2d). VRAM flaps is a versatile flap for reconstruction of oncology defects, with few series associated it with breast carcinoma reconstruction for LABC or closure of the chest wall [41, 45-47]. Evaluating series using this flap exclusively for primary closure for oncologic patients the VRAM rate of necrosis was 11.5%, although it was lower when used exclusively for breast cancer patients (3.6%) [45-47]. Comparing these flaps, TRAM offers better cosmetic results than VRAM flap, which may be considered after abdominoplasties [41-52]. These flaps require the involvement of trained surgeons and are associated with complications that impact the patient’s quality of life: abdominal incisional hernia, navel necrosis, infection, flap necrosis, and abdominal wall fragility with bulging areas, even in the absence of incisional hernia [44, 48, 49].

The external oblique abdominal myocutaneous flap (EOMF; Figure 2c) have the advantages of fast execution and acceptable complication rates, and they do not require a change in the patient’s position during surgery; however, they have a partial and tip necrosis [40]. One publication described a technical modification that allowed the resection of more extensive areas and although it was associated with high rates of necrosis, but the difference in relation to the classical surgery was the non-use of the anterior aponeurosis of abdominal rectus and the greater size of resection [39]. In cases of extensive resections in which the defect cannot be closed with a single flap, it may be necessary to combine flaps, for example, by combining a latissimus dorsi flap with a VRAM [50]. Although these situations are infrequent, if they are necessary, detailed planning should be performed by a team highly trained in all reconstruction techniques.

Reviewing breast cancer patients (Table 1), excluding possible double publication and publications used for general oncologic patients, the general rate of necrosis, for breast cancer patients, was lower in myocutaneous flaps (11.3%) than thoracoabdominal flaps (20.2%), as previously published [35, 36, 46, 47]. No difference was noted in relation to the rate of necrosis between latissimus dorsi (9.9%), classic EOMF (9.5%) and TRAM/VRAM (8.4%) flaps, although more studies are necessary to increase the global casuistry; all the studies were retrospectively carried out and a great variability was observed in relation to the necrosis rate by author.

Recommendations

The main problem affecting surgery involving flaps is the recovery time required before the next treatment (radiotherapy or chemotherapy) can take place, since many of these tumors show aggressive behaviour and early local recurrence, even with free margins. Necrosis will increase the time until adjuvant therapy, increasing the risk of early recurrence. Thus, when choosing a flap, the potential for top necrosis, which can increase the time of local healing, should be evaluated, since extensive necrosis is an infrequent complication. Similarly, when evaluating the reconstruction of the chest wall, especially with the use of prosthetic materials, flaps with a low necrosis index should be considered, since necrosis can contribute to chest exposure and secondary infection [36].

The choice of flap should be based on tumor extension, the possibility of primary closure, local complications, and tumor biology, factors that determine the benefits of surgical treatment (Figure 3). Generally, in areas with small postmastectomy defects, the upper and lower subcutaneous cellular tissue is detached for closure. Conversely, in small- to medium-sized areas, the use of a thoracoabdominal flap is an option that should be considered according to the surgeon’s experience. We advise avoiding skin grafts. Different types of thoracoabdominal flaps are described in the literature, and the surgeon should be aware of the different options (Table 1). Myocutaneous flaps have a lower rate of necrosis than thoracoabdominal flaps. The ITADE flap, despite having a higher rate of necrosis than other thoracoabdominal flaps, allows coverage of extensive areas without the use of myocutaneous flaps [36].

Figure 3: Necrosis. a) Tip necrosis; b) extensive, requiring surgery. Extensive tumor occupying the axillary cavity; c) preoperative; d) double latissimus dorsi and abdominal oblique flap; e) axillary dehiscence; f) early recurrence: bilateral tumor and double flap; g) ITADE on the right, latissimus dorsi flap on the left; h) dehiscence and early recurrence.

In cases of large defects, the options include myocutaneous flaps such as latissimus dorsi, oblique abdominal muscle, and rectus abdominis muscle flaps. The indications and contraindications of each, as well as the extent of the area to be covered, should be considered. The latissimus dorsi flap is the best because of its flexibility and low complication rate, but its use is limited by the size of the defect and invasion of the thoracodorsal pedicle. The decision to maintain the thoracodorsal pedicle when it is invaded should be based on the patient’s clinical condition and curability criteria, even when secondary local radiotherapy will be performed [36].

VRAM and TRAM flaps provide an excellent donor area and can be considered in patients with a high body mass index. TRAM flaps are associated with a higher rate of necrosis, especially when they are monopediculated. The VRAM, which is minimally described in the literature, is a good flap with the disadvantage that it leaves an abdominal scar, a fact that is a background consideration in cases of advanced tumors [45, 53]. Abdominal oblique muscle flaps allow the closure of large defects; when they are made, the anterior fascia of the rectus abdominis should be used, since studies that have used this tissue show a lower rate of necrosis. The literature presents the use of the anterior fascia of the rectum as an option, and a comparison of studies indicates that its use is associated with a lower rate of necrosis [39]. Despite the lack of prospective studies, we recommend the inclusion of the anterior fascia of the rectus abdominis as a good option.

In the presence of bilateral disease, each side is considered individually, and for closure, reverse abdominoplasty and the use of double flaps may be considered. As previously mentioned, a double flap can also be used when the initial plan proves to be ineffective for covering the area, when there is a need to use flaps without tension at the axillary level, and when the use of skin grafts is not desired. In cases of primary tumor or recurrence in the axillary cavity, the presence of a fold determines the need for more extensive flaps. In such cases, a latissimus dorsi flap is an acceptable option, but potential tumor infiltration of the flap and a microscopical residual disease in the pedicle, should be considered. A VRAM flap should be considered as a primary or second flap [36, 39, 53].

The very thin patient presents a challenge, given the limited donor skin available. In these cases, when a myocutaneous flap is considered, an oblique flap is not a good option [39]. Microsurgical flaps can be used given the presence of surgeons with experience with this technique; however, the rate of failure and partial or total loss of these flaps should be considered. Additionally, when considering concomitant chest wall resection, considerations should include comorbidities as well as pulmonary function, risk of associated infection (especially in the mediastinum), and potential curative nature. In terms of options for local coverage, flaps with a low necrosis index should be considered [54].

Special Conditions

In LABC, chest wall resection is not the rule. In general, the resection of these tumors occurs in selected cases, namely, patients with good clinical conditions and in situations of localized tumor disease, local recurrence, or single localized metastatic bone disease. In the evaluation of resection, complete resection of macroscopic disease (R0 resection) should be used to obtain free margins. When choosing the flap, viable flaps with low complication and necrosis rates should be considered, since in many cases, the chest wall will be replaced by synthetic mesh, where the presence of local complications can be disastrous [55]. The objective is to maintain thoracic stability and minimize dead space, allowing adequate coverage, shape, and function [56, 57].

When resection of the costal arches is necessary, the following considerations generally apply [58]: i) Resection of up to 3 ribs: no reconstruction of the chest wall itself, and a myocutaneous flap can cover the defect and isolate the pleural cavity from the subcutaneous tissue; ii) resection of 4 or more costal arches: in such cases, an unstable thorax may occur, and coverage with myocutaneous flaps may require the reestablishment of the chest wall with meshes, methyl methacrylate, and titanium metal rods. The mortality rate is up to 8.5% in patients who require extensive resections [59]. Another situation that should be discussed in LABC is interscapulothoracic disarticulation surgery. This surgery is usually used in cases of extensive breast tumors, axillary recurrence, brachial plexus infiltration, or sarcoma associated with lymphedema, in which the only curative situation is the loss of the upper limb [60, 61]. Palliative situations are also described in the literature, but their aim is hygienic control and improved quality of life [62].

Perspectives

The literature is open to the development and publication of new surgical techniques, but it is necessary to improve the knowledge regarding the described techniques, complications, and patient evolution. The differences observed in the literature may reflect a retrospective characteristic of the studies and the absence of rigid criteria for the measurement of the necrosis. Regarding the surgical treatment of LABC it is important to evaluate conditions related to the tumor, flap technique, postoperative complications, and generally, the literature focus on these conditions. But it is also important to evaluate conditions related to follow-up, as local recurrence (influenced by margin and molecular subtype); and patient conditions like the quality of life and the possibility of future breast reconstruction. Table 2 shows possible indicators to be reported in future studies.

Table 2: Important conditions to be evaluated associated to surgical management of LABC.

General

Category

Variables

 

Tumor

Tumor size

-

 

Tumor condition

Primary, recurrence; breast, axillary cavum

 

Size of resection

-

 

Type of resection

R0, R1, R2

 

Ulceration

Absent, present

 

Time of surgery

Up front; after neoadjuvant therapy (chemotherapy +/- radiotherapy)

 

Response to previous therapies

Stable disease; disease progression

 

Intention to treat

Curative, palliative

 

Metastasis

Absent; Oligometastatic; symptomatic

 

Histology

Histology; molecular subtype

Flap technique

Classical description; variation

-

 

Irrigation based

Thoracoabdominal or myocutaneous

 

Thoracoabdominal

Irrigation based/ random; lateral, medial

 

Myocutaneous

Type

 

Skin grafts

Absent; association with flaps

 

Size of the flap

-

 

Time of the surgical procedure

-

 

Hospitalization stay

-

 

Antibiotics

-

Complication

Absent or present

 

 

Infection

Primary, secondary to necrosis

 

Necrosis

Extension (tip, extensive)

 

 

Depth (epidermolysis, total skin necrosis)

 

Treatment of necrosis

Surgical revision, additional procedures: Expectant, local debridement, surgery with general anaesthesia

 

Dehiscence

-

 

Surgical healing time

Local control; beginning of the next adjuvant treatment

Patient

Patient

Age, BM, Smoking, Diabetes

 

Postoperative survival

Comorbidities; Mortality (chest wall resection)

 

Quality of life

-

 

Secondary breast reconstruction

-

Follow up

Local recurrence

-

 

Local free survival

-

 

Overall survival

-


Conclusion

In the surgical indication for LABC, the patient's clinical condition, the tumor biology, the response to the established therapy, the presence of distant disease, the need for adjuvant therapy, local hygienic control, and the risk of necrosis should be considered. The pros and cons should be evaluated by the multidisciplinary team and discussed with the patient. The breast surgeon must have the knowledge of the different surgical options of choice for surgical treatment of LABC, a fact that will reflect in the resectability, or the necessity or not of another reconstructive surgeon.

Acknowledgment

The authors thank the president of the Brazilian Society of Surgical Oncology, Alexandre Ferreira Oliveira, for the idea and the creation of the study groups.

Article Info

Article Type
Review Article
Publication history
Received: Mon 15, Nov 2021
Accepted: Wed 01, Dec 2021
Published: Wed 22, Dec 2021
Copyright
© 2021 Rene Aloisio da Costa Vieira. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Hosting by Science Repository.
DOI: 10.31487/j.JSO.2021.03.03

Author Info

Corresponding Author
Rene Aloisio da Costa Vieira
Grupo de Estudos da Mama, Sociedade Brasileira de Cirurgia Oncologica, Brazil

Figures & Tables

Table 1: Series with thoracoabdominal and myocutaenous flaps used in primary closure after mastectomy.

Flap/ Author

Number of cases

Cases with necrosis

Necrosis

Rate

Thoracoabdominal Flap

 

 

 

Deo (2018) [38]

72

8

11.1% total; 8.3% superficial; 2.7% Major

Min [34]

41

17

42.5%

 

 

 

4,9% extensive necrosis

Baroudi

34

10

29.4%

Buratani

30

0

0

Vieira/ ITADE [36]

23

9

34.8% tip necrosis

4.1% extensive necrosis

Deo (2003) [35]

22

2

9.1%

Das

20

1

5%

Persichetti

18

4

22.2%

Kubo/ Romboid [63]

14

2

14.3%

Park-TE (medial pedicle)

10

6

60.0%

Park-TA (lateral pedicle)

9

2

22.2%

Martela

8

0

0

Tai

5

1

20.0%

Lim

3

0

0

 

 

 

 

Myocutaneos Flap

 

 

 

Le Boudec/ LD [42]

101

3

3%

Apffelstaedt/ LD [43]

83

14

(7 major)

16.8%

8,4% major

Salmon/ LD

40

2

5.0%

Munhoz/ LD

25

2

8.0%

Woo/ LD

12

0

0%

Amelung

12

4

25%

Micali/ LD

8

3

37.5%

 

 

 

 

Lee/ EOMF [40]

75

9

12.0%

Bogossian/ EOMF

20

1

5%

Gesson-Paute/ EOMF

9

0

0%

Cordoba/ EOMF

13

1

7.7%

Vieira/ MEOMF [39]

17

12

70.5%

 

 

 

 

Charanek/ VRAM [45]

55

2

3.6%

Lin/ TRAM [44]

16

1

6.3%

Mir/ TRAM-VRAM [41]*

60

8

13.3%

 

 

 

 

Mirza/ VRAM[46]**

58

10

17.2%

Daigeler/ VRAM[47]**

78

10

12.8%

Adapted from Vieira et al. [36]. New publications included [34, 38-43].

LD: Latissimus Dorsi; EOMF: External Oblique Myocutaneous Flap; MEOMF: Modified EOMF; ITADE: Ipsilateral Thoracoabdominal Dermofat flap.

*Reconstruction for breast reconstruction for LABC; **Oncologic patients.


Table 2: Important conditions to be evaluated associated to surgical management of LABC.

General

Category

Variables

 

Tumor

Tumor size

-

 

Tumor condition

Primary, recurrence; breast, axillary cavum

 

Size of resection

-

 

Type of resection

R0, R1, R2

 

Ulceration

Absent, present

 

Time of surgery

Up front; after neoadjuvant therapy (chemotherapy +/- radiotherapy)

 

Response to previous therapies

Stable disease; disease progression

 

Intention to treat

Curative, palliative

 

Metastasis

Absent; Oligometastatic; symptomatic

 

Histology

Histology; molecular subtype

Flap technique

Classical description; variation

-

 

Irrigation based

Thoracoabdominal or myocutaneous

 

Thoracoabdominal

Irrigation based/ random; lateral, medial

 

Myocutaneous

Type

 

Skin grafts

Absent; association with flaps

 

Size of the flap

-

 

Time of the surgical procedure

-

 

Hospitalization stay

-

 

Antibiotics

-

Complication

Absent or present

 

 

Infection

Primary, secondary to necrosis

 

Necrosis

Extension (tip, extensive)

 

 

Depth (epidermolysis, total skin necrosis)

 

Treatment of necrosis

Surgical revision, additional procedures: Expectant, local debridement, surgery with general anaesthesia

 

Dehiscence

-

 

Surgical healing time

Local control; beginning of the next adjuvant treatment

Patient

Patient

Age, BM, Smoking, Diabetes

 

Postoperative survival

Comorbidities; Mortality (chest wall resection)

 

Quality of life

-

 

Secondary breast reconstruction

-

Follow up

Local recurrence

-

 

Local free survival

-

 

Overall survival

-


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Figure 1: Conditions associated with unresectability. a & b) Extensive disease affecting soft tissues and extensive areas of the rib cage and sternum in a patient with pleural metastasis; c) bilateral disease with right lateral skin extension that creates a donor area for primary coverage; d) extension to the left upper limb and back.


Science Repository

Figure 2: Flaps used for cutaneous synthesis after LABC mastectomy. a) ITADE flap; b) myocutaneous flap of the latissimus dorsi muscle; c) myocutaneous flap of the abdominal oblique muscle; d) transverse myocutaneous flap of the rectus abdominis muscle.


Science Repository

Figure 3: Necrosis. a) Tip necrosis; b) extensive, requiring surgery. Extensive tumor occupying the axillary cavity; c) preoperative; d) double latissimus dorsi and abdominal oblique flap; e) axillary dehiscence; f) early recurrence: bilateral tumor and double flap; g) ITADE on the right, latissimus dorsi flap on the left; h) dehiscence and early recurrence.


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References


1.     Vieira RAC, Biller G, Uemura G, Ruiz CA, Curado MP (2017) Breast cancer screening in developing countries. Clinics (Sao Paulo) 72: 244-253. [Crossref]

2.     Munhoz AM, Montag E, Arruda E, Okada A, Brasil JA et al. (2011) Immediate locally advanced breast cancer and chest wall reconstruction: surgical planning and reconstruction strategies with extended V-Y latissimus dorsi myocutaneous flap. Plast Reconstr Surg 127 :2186-2197. [Crossref]

3.     Micali E, Carramaschi FR (2001) Extended V-Y latissimus dorsi musculocutaneous flap for anterior chest wall reconstruction. Plast Reconstr Surg 107: 1382-1390. [Crossref]

4.     Baroudi R, Pinotti JA, Keppke EM (1978) A transverse thoracoabdominal skin flap for closure after radical mastectomy. Plast Reconstr Surg 61: 547-554. [Crossref]

5.     Amin MB, Edge SB, Greene FL (2017) AJCC (American Joint Committee on Cancer) Cancer Staging Manual. Vol 1. 8th edition ed. Chicago: Springer.

6.     Ko H, Baghdadi Y, Love C, Sparano JA (2020) Clinical Utility of 18F-FDG PET/CT in Staging Localized Breast Cancer Before Initiating Preoperative Systemic Therapy. J Natl Compr Canc Netw 18: 1240-1246. [Crossref]

7.     Harris E, Barry M, Kell MR (2013) Meta-analysis to determine if surgical resection of the primary tumour in the setting of stage IV breast cancer impacts on survival. Ann Surg Oncol 20: 2828-2834. [Crossref]

8.     Zhang X, Wang D, Liu Z, Wang Z, Li Q et al. (2020) The diagnostic accuracy of magnetic resonance imaging in predicting pathologic complete response after neoadjuvant chemotherapy in patients with different molecular subtypes of breast cancer. Quant Imaging Med Surg 10: 197-210. [Crossref]

9.     Kong X, Moran MS, Zhang N, Haffty B, Yang Q (2011) Meta-analysis confirms achieving pathological complete response after neoadjuvant chemotherapy predicts favourable prognosis for breast cancer patients. Eur J cancer 47: 2084-2090. [Crossref]

10.  Mauri D, Pavlidis N, Ioannidis JP (2005) Neoadjuvant versus adjuvant systemic treatment in breast cancer: a meta-analysis. J Natl Cancer Inst 97: 188-194. [Crossref]

11.  Wang D, Feng J, Xu B (2019) A meta-analysis of platinum-based neoadjuvant chemotherapy versus standard neoadjuvant chemotherapy for triple-negative breast cancer. Future Oncol 15: 2779-2790. [Crossref]

12.  Wuerstlein R, Harbeck N (2017) Neoadjuvant Therapy for HER2-positive Breast Cancer. Rev Recent Clin Trials 12: 81-92. [Crossref]

13.  Gianni L, Pienkowski T, Im YH, Roman L, Tseng LM et al. (2012) Efficacy and safety of neoadjuvant pertuzumab and trastuzumab in women with locally advanced, inflammatory, or early HER2-positive breast cancer (NeoSphere): a randomised multicentre, open-label, phase 2 trial. Lancet Oncol 13: 25-32. [Crossref]

14.  Schneeweiss A, Chia S, Hickish T, Harvey V, Eniu A et al. (2013) Pertuzumab plus trastuzumab in combination with standard neoadjuvant anthracycline-containing and anthracycline-free chemotherapy regimens in patients with HER2-positive early breast cancer: a randomized phase II cardiac safety study (TRYPHAENA). Ann Oncol 24: 2278-2284. [Crossref]

15.  Masuda N, Lee SJ, Ohtani S, Im YH, Lee ES et al. (2017) Adjuvant Capecitabine for Breast Cancer after Preoperative Chemotherapy. N Engl J Med 376: 2147-2159. [Crossref]

16.  von Minckwitz G, Huang CS, Mano MS, Loibl S, Mamounas EP et al. (2019) Trastuzumab Emtansine for Residual Invasive HER2-Positive Breast Cancer. N Engl J Med 380: 617-628. [Crossref]

17.  Sutton TL, Schlitt A, Gardiner SK, Johnson N, Garreau JR (2020) Time to surgery following neoadjuvant chemotherapy for breast cancer impacts residual cancer burden, recurrence, and survival. J Surg Oncol 122: 1761-1769. [Crossref]

18.  Zucca Matthes AG, Uemura G, Kerr L, Silva Matthes AC, D Michelli RA et al. (2012) Feasibility of oncoplastic techniques in the surgical management of locally advanced breast cancer. Int J Surg 10: 500-505. [Crossref]

19.  Curigliano G, Burstein HJ, Winer EP, Gnant M, Dubsky P et al. (2017) De-escalating and escalating treatments for early-stage breast cancer: the St. Gallen International Expert Consensus Conference on the Primary Therapy of Early Breast Cancer 2017. Ann Oncol 28: 1700-1712. [Crossref]

20.  Mocellin S, Goldin E, Marchet A, Nitti D (2016) Sentinel node biopsy performance after neoadjuvant chemotherapy in locally advanced breast cancer: A systematic review and meta-analysis. Int J Cancer 138: 472-480. [Crossref]

21.  Meher S, Mishra TS, Sasmal PK, Rath S, Sharma R (2016) An Ulcerated Giant Malignant Phyllodes Tumour Presenting in Septic Shock. J Clin Diagn Res 10: PJ01-PJ02. [Crossref]

22.  Aloisio da Costa Vieira R, Zucca Mathes AG, Michelli RA, Fabri Pereira Ribeiro GH, Luiz Haikel R et al. (2012) Necrotizing soft tissue infection of the breast: case report and literature review. Surg Infect (Larchmt) 13: 270-275. [Crossref]

23.  Vieira RAC, Oliveira Junior I (2021) Ulcerative-vegetative Locally Advanced Breast Carcinoma Mimicking Flower Image. Mastology 31: e20200079.

24.  Coelho RC, Da Silva FML, Do Carmo IML, Bonaccorsi BV, Hahn SM et al. (2017) Is there a role for salvage radiotherapy in locally advanced breast cancer refractory to neoadjuvant chemotherapy? Breast 31: 192-196. [Crossref]

25.  Sousa C, Cruz M, Neto A, Pereira K, Peixoto M et al. (2020) Neoadjuvant radiotherapy in the approach of locally advanced breast cancer. ESMO Open 4: e000640. [Crossref]

26.  Soran A, Ozmen V, Ozbas S, Karanlik H, Muslumanoglu M et al. (2018) Randomized Trial Comparing Resection of Primary Tumor with No Surgery in Stage IV Breast Cancer at Presentation: Protocol MF07-01. Ann Surg Oncol 25: 3141-3149. [Crossref]

27.  Gera R, Chehade H, Wazir U, Tayeh S, Kasem A et al. (2020) Locoregional therapy of the primary tumour in de novo stage IV breast cancer in 216 066 patients: A meta-analysis. Sci Rep 10: 2952. [Crossref]

28.  Fitzal F, Bjelic Radisic V, Knauer M, Steger G, Hubalek M et al. (2019) Impact of Breast Surgery in Primary Metastasized Breast Cancer: Outcomes of the Prospective Randomized Phase III ABCSG-28 POSYTIVE Trial. Ann Surg 269: 1163-1169. [Crossref]

29.  Badwe R, Hawaldar R, Nair N, Kaushik R, Parmar V et al. (2015) Locoregional treatment versus no treatment of the primary tumour in metastatic breast cancer: an open-label randomised controlled trial. Lancet Oncol 16: 1380-1388. [Crossref]

30.  Soran A, Ozbas S, Dogan L, Sezgin E, Özmen V et al. (2020) Loco-Regional Treatment for Intact Primary Tumor in Patient with De Novo Metastatic Breast Cancer; Comments and Concerns of ECOG-ACRIN 2108 Trial. Eur J Breast Health 16: 158-159. [Crossref]

31.  Parkash S, Srinivasan R, Ananthakrishnan N (1981) Primary closure of excisional defects of the breast with local flaps: a problem in the treatment of advanced carcinoma of the breast in developing countries. Br J Plast Surg 34: 291-294. [Crossref]

32.  Moon SH, Jung JH, Lee J, Kim WW, Park HY et al. (2019) Complete remission of giant malignant phyllodes tumor with lung metastasis: A case report. Medicine (Baltimore) 98: e15762. [Crossref]

33.  Sakamoto N, Nashimoto M, Nakagawa M, Haruyama Y, Koshida Y et al. (2021) Skin grafting utilizing a skin of lateral thoracic area for chest wall reconstruction in patient who underwent mastectomy for locally advanced breast cancer. Breast cancer 28: 533-537. [Crossref]

34.  Min K, Choi EJ, Lee YH, Eom JS, Son BH et al. (2019) Single vertical incision thoracoabdominal flap for chest wall reconstruction following mastectomy of locally advanced breast cancer. Ann Surg Treat Res 97: 168-175. [Crossref]

35.  Deo SV, Purkayastha J, Shukla NK, Asthana S (2003) Myocutaneous versus thoraco-abdominal flap cover for soft tissue defects following surgery for locally advanced and recurrent breast cancer. J Surg Oncol 83: 31-35. [Crossref]

36.  Vieira R, da Silva KMT, de Oliveira Junior I, de Lima MA (2017) ITADE flap after mastectomy for locally advanced breast cancer: A good choice for mid-sized defects of the chest wall, based on a systematic review of thoracoabdominal flaps. J Surg Oncol 115: 949-958. [Crossref]

37.  Vieira RAC, Boni R, Silva VD (2019) Reply: ITADE flap after mastectomy for locally advanced breast cancer: A good choice for mid-sized defects of the chest wall based on a systematic review of thoracoabdominal flaps. J Surg Oncol 119: 1182-1183. [Crossref]

38.  Suryanarayana Deo SV, Mishra A, Shukla NK, Sandeep B (2019) Thoracoabdominal Flap: a Simple Flap for Covering Large Post-mastectomy Soft Tissue Defects in Locally Advanced Breast Cancer. Indian J Surg Oncol 10: 494-498. [Crossref]

39.  da Costa Vieira RA, de Oliveira Junior I, Branquinho LI, Haikel RL, Ching AW (2020) Modified External Oblique Myocutaneous Flap for Repair of Postmastectomy Defects in Locally Advanced Breast Tumors: A Cohort Series Associated with a Systematic Review of Literature. Ann Surg Oncol 28: 3356-3364. [Crossref]

40.  Lee S, Jung Y, Bae Y (2018) Immediate chest wall reconstruction using an external oblique myocutaneous flap for large skin defects after mastectomy in advanced or recurrent breast cancer patients: A single center experience. J Surg Oncol 117: 124-129. [Crossref]

41.  Mir M, Shahdhar M, Ganaie K, Syed Q (2013) Oncological safety of immediate rectus abdominis myocutaneous breast reconstruction in patients with locally advanced disease (stage IIb and III). South Asian J Cancer 2: 239-242. [Crossref]

42.  Le Bouedec G, Kauffmann P, Bournazaux JA, Dauplat J (1994) Latissimus dorsi myocutaneous flaps in oncologic breast surgery. 101 cases. Rev Fr Gynecol Obstet 89: 341-348. [Crossref]

43.  Apffelstaedt J (2002) Indications and complications of latissimus dorsi myocutaneous flaps in oncologic breast surgery. World J Surg 26: 1088-1093. [Crossref]

44.  Lin YN, Ou Yang F, Hsieh MC, Shin Lee S, Huang SH et al. (2020) Use of Extended Pedicled Transverse Rectus Abdominis Myocutaneous Flap for Extensive Chest Wall Defect Reconstruction After Mastectomy for Locally Advanced Breast Cancer. Ann Plast Surg 84: S34-S39. [Crossref]

45.  Charanek AM (2014) A bilobed thoracoabdominal myocutaneous flap for large thoracic defects. Ann Plast Surg 72: 451-456. [Crossref]

46.  Mirza AA, Srinivas KG, Amarendra S, Swamy S, Krishna A et al. (2020) Versatility of Rectus Abdominis Myocutaneous Flap in Primary Reconstruction of Defects in Surgical Oncology. Indian J Surg Oncol 11: 740-745. [Crossref]

47.  Daigeler A, Simidjiiska Belyaeva M, Drucke D et al. (2011) The versatility of the pedicled vertical rectus abdominis myocutaneous flap in oncologic patients. Langenbecks Arch Surg 396: 1271-1279. [Crossref]

48.  Mohamed SA, Sakr MF, El Hammadi HA, Moussa MM, El Sharaky MM (2000) The use of the 'TRAM' flap in some oncological problems. Int Surg 85: 347-352. [Crossref]

49.  Deutsch MF, Smith M, Wang B, Ainsle N, Schusterman MA (1999) Immediate breast reconstruction with the TRAM flap after neoadjuvant therapy. Ann Plast Surg 42: 240-244. [Crossref]

50.  Shoham Y, Koretz M, Kachko L, Silberstien E, Krieger Y et al. (2013) Immediate reconstruction of the chest wall by latissimus dorsi and vertical rectus abdominis musculocutaneous flaps after radical mastectomy for a huge pleomorphic liposarcoma. J Plast Surg Hand Surg 47: 152-154. [Crossref]

51.  Song D, Liu D, Pafitanis G, Liu Z, Wang X et al. (2020) Extensive Microsurgical Reconstruction of Chest Wall Defects for Locally Advanced Breast Cancer: A 10-Year Single-Unit Experience. Ann Plast Surg 84: 293-299. [Crossref]

52.  Ribuffo D, Marcellino M, Barnett GR, Houseman ND, Scuderi N (2001) Breast reconstruction with abdominal flaps after abdominoplasties. Plast Reconstr Surg 108: 1604-1608. [Crossref]

53.  Vieira RAC, Haikel RL, Branquinho LI, Olivieira Junior I (2021) VRAM flap for locally advanced breast cancer. Mastology 31: e20200086.

54.  Silva KMT, Torres Junior AC, Pinto MC, Silva CM, Haikel RL et al. (2015) Full-thickness chest wall resection with internal mammary lymph node lymphadenectomy for isolated breast cancer recurrence. Rev Bras Mastol 25: 160-165.

55.  Daigeler A, Harati K, Goertz O, et al. (2014) Thoracic Wall Reconstruction in Advanced Breast Tumours. Geburtshilfe Frauenheilkd 74: 548-556. [Crossref]

56.  Chagpar A, Meric Bernstam F, Hunt KK, Ross MI, Cristofanilli M et al. (2003) Chest wall recurrence after mastectomy does not always portend a dismal outcome. Ann Surg Oncol 10: 628-634. [Crossref]

57.  Thomas PA, Brouchet L (2010) Prosthetic reconstruction of the chest wall. Thorac Surg Clin 20: 551-558. [Crossref]

58.  Petrella F, Spaggiari L (2020) Surgery of the chest wall: indications, timing and technical aspects. J Thorac Dis 12: 1-2. [Crossref]

59.  Corkum JP, Garvey PB, Baumann DP, Abraham J, Liu J et al. (2020) Reconstruction of massive chest wall defects: A 20-year experience. J Plast Reconstr Aesthet Surg 73: 1091-1098. [Crossref]

60.  Goodman MD, McIntyre B, Shaughnessy EA, Lowy AM, Ahmad SA (2005) Forequarter amputation for recurrent breast cancer: a case report and review of the literature. J Surg Oncol 92: 134-141. [Crossref]

61.  Pundi KN, AlJamal YN, Ruparel RK, Farley DR (2015) Forequarter amputation for recurrent breast cancer. Int J Surg Case Rep 11: 24-27. [Crossref]

62.  Vieira RAC, Toller EA, Morgan AM, Oliveira Junior I (2020) Forequarter amputation in a patient with locally advanced recurrent breast carcinoma. Mastology 30: e20190021.

63. Kubo K, Takei H, Hamahata A (2021) Rhomboid Flap Reconstruction after Mastectomy for Locally Advanced Breast Cancer. J Nippon Med Sch 88: 63-70. [Crossref]