Reconstruction Options and Outcomes for Breast Sarcoma Patients
Hannah M. Carl, BS, Charalampos Siotos, MD, Dennis G. Foster, III, MS, Tobias J. Bos, BSc, Nicholas A. Calotta, MD, Michele A. Manahan, MD, Carisa M. Cooney, MPH, Justin M. Sacks, MD, MBA, Gedge D. Rosson, MD.
Johns Hopkins University School of Medicine, Baltimore, MD, USA.
PURPOSE: Sarcomas of the breast constitute a rare and heterogeneous group of mesenchymal cancers. The standard treatment for sarcomas is surgery. However, given their aggressive nature, the high rates of adjuvant radiotherapy, and the heightened concern for recurrence, these tumors require unique considerations when planning resection and breast reconstruction. As a result of these factors as well as the potential for more complicated resections or modified radical mastectomy, the rates of reconstruction in this population have been low. The purpose of the study is to examine whether there are demographic, clinical, or histological differences between patients who receive reconstruction and those who do not. Secondary outcomes include examining complications and long-term cancer recurrence after reconstruction.
METHODS: This study was a retrospective review of subjects derived from a prospectively collected single-institution breast cancer registry. Included patients presented with primary breast sarcoma at our institution and were treated within the Division of Surgical Oncology between 2003-2015. Demographic data, medical comorbidities, tumor characteristics, oncologic treatment, and cancer recurrences were evaluated. Furthermore, for those patients who received breast reconstruction, we examined the timing of reconstruction, the type of reconstruction, and post-operative complications.
RESULTS: Thirty-four patients with primary breast sarcoma confirmed by final pathology report were identified. The average age of the cohort was 51.9 and the average follow-up was 4.7 years. The most common histological type was malignant phyllodes (61.8%) followed by hemangiosarcoma (17.6%). There were no significant differences in age, race, average income, insurance type, tumor stage, or histologic subtype between the reconstruction and no reconstruction groups. Patients who did not have reconstruction had higher rates of adjuvant radiation (p=0.03) and trended towards living farther from our hospital (p=0.09). Two out of 12 (16.7%) patients in the reconstruction group experienced cancer recurrence and 0 out of 22 patients in the no reconstruction group had recurrence. Ninety-seven percent of patients were alive at the latest follow-up.
Twelve out of 17 (70.6%) patients who underwent total simple or modified radical mastectomy had breast reconstruction. Of these 12 patients, 4 underwent implant based reconstruction, 7 had autologous tissue based reconstruction, and 1 had both implant based and autologous reconstruction. The deep inferior epigastric perforator (DIEP) flap was the most common flap type (75.0%). Three patients in our cohort highlight the special reconstruction considerations for breast sarcoma patients. Two patients required rib resection that necessitated muscle to fill the dead space and one patient required both a free and pedicle transverse rectus abdominis myocutaneous (TRAM) flap for chest wall reconstruction. Major complications after reconstruction were one flap loss and one implant removal secondary to cancer recurrence.
CONCLUSIONS: Given the low recurrence rate in our cohort and the advanced oncological treatments available, breast reconstruction should be considered safe. However, breast sarcoma patients should be counseled that they may require extensive resection, chest wall reconstruction, and implant or flap removal if cancer recurs. Our higher rates of breast reconstruction compared to previous studies suggest a newly increased willingness to offer reconstruction to this rarer group of breast cancer patients.
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