This study included 249 consecutive patients with invasive breast cancer who underwent SSM and IBR using pedicled TRAM flap. The avoidance of patient selection and the use of only one type of reconstruction method and a standardized management protocol may provide a more thorough perspective on this treatment approach.
One concern regarding immediate reconstruction is whether it hinders or delays the detection of local recurrence . All five local recurrences (three local alone and two concurrent local and systemic) that developed in our series were detectable by physical examination even in cases of recurrent tumor size <1 cm in diameter. This result is consistent with two other series in which all three and five of six local recurrences, respectively, were detectable by physical examination [9, 15]. Of 16 local recurrences after immediate TRAM flap reconstruction reported by Howard and colleagues , all were identified by physical examination or subjective symptoms that were subsequently confirmed by physical examination or imaging studies. Our experience also highlights the importance of physical examination, because the presence of local recurrence may herald systemic metastasis either synchronously or metachronously. Three patients with local recurrences (3/5, 60.0%) developed distant metastasis in our series.
In addition to physical examination, we routinely use sonography for screening the reconstructed breast. The ideal modalities for recurrence surveillance in this population have not yet been determined. Some authors recommended routine mammography and have used it as an aid in the differentiation between fat necrosis and cancer. However, these two different lesions cannot always be distinguished solely on the basis of mammographic findings [9, 16]. Pathological diagnosis remains the gold standard, and biopsy is warranted for any new or persistent lesion in the reconstructed breast.
The reported local recurrence rates after SSM and IBR in studies with more than 100 patients range from 0.2 to 7.0% [17, 18]. When limiting the study population to patients with locally advanced breast cancer undergoing the same procedure, the reported rates of local recurrence are between 1 and 10% [6, 11, 19]. The local recurrence rate for stage III patients (2/37, 5.5%) in our study is comparable with that reported previously [6, 11, 19]. Despite the relatively small number of patients with stage III disease in this series, our findings might strengthen the rational use of SSM and immediate TRAM flap reconstruction in patients with advanced-stage disease. A larger study with more patients is warranted to further address this issue. Several studies have reported no significant difference in recurrence pattern or incidence between patients undergoing SSM and conventional mastectomy [17, 20]. Comparable results have also been observed for patients with stage III disease .
The median time to locoregional recurrence was 23 months, 3 months shorter than that to distant relapse, in our study. This finding is comparable with previously reported results [10, 21]. In a series of 1,392 breast cancer patients who underwent mastectomy, Crowe and colleagues found that locoregional recurrence occurred within the first 3 years in most cases, with a peak in the second year . The recurrence rate then dropped sharply and remained relatively constant over a long period of time. However, recurrence occurring 10 years after mastectomy has been reported, and a longer follow-up time is warranted .
The rate of distant recurrence was significantly higher in patients with advanced-stage disease, and distant metastasis was the cause of all deaths that occurred in our series. Despite multimodal treatment, > 60% of patients died within 2 years after first distant relapse. In contrast to the distant metastasis rate, the locoregional recurrence rate did not increase significantly from stage I disease to stage III disease. This difference may be ascribed to the aggressive use of systemic therapy in this study.
In recent years, a trend of decreased local recurrence rate has been observed . Some authors considered this decline attributable, at least in part, to the increasing use of adjuvant therapy . Our result may further support the effectiveness of systemic treatment in reducing the risk of locoregional recurrence and narrowing the gap in outcome between different stages. Nevertheless, such intensive adjuvant therapy can pose a heavy financial burden to patients. In Taiwan, most of the cancer treatment cost is covered by national health insurance. Thus, this type of treatment was affordable for the majority of patients in this series.
Based on our results, solitary local or regional recurrence as the first recurrence event was associated with a better prognosis than the development of locoregional recurrence as part of systemic metastasis. Differentiation between different recurrence patterns may thus be of great help in predicting prognosis, and a thorough metastatic survey at the time of the first recurrence is warranted. Recently, the use of nipple-sparing mastectomy has been on the rise, although its clinical application is usually limited to prophylactic risk reduction and ductal carcinoma in situ. The oncologic safety of this procedure remains the major concern that hampers its application. Our results may further support the possible implementation of nipple-sparing mastectomy for cases of advanced disease.