Since pedicled transverse rectus abdominis (TRAM) flap was first introduced by Hartrampf in 1982, options for breast reconstruction based on autologous tissue insertion have expanded into free TRAM flap, free deep inferior epigastric perforator flap, and procedures involving gluteal or thigh tissues [9-11]. Separately, implant-based reconstruction has evolved since it was first introduced by Snyderman in 1971 and, today, more implant-based breast reconstruction surgery is being performed . In addition, the invention of an instrument such as an indocyanine green camera, which is capable of directly identifying the tissue circulation, had played a major role in reducing the number of surgical complications [13, 14], while the development of acellular dermal matrix and a new generation of implants has minimized the incidence of capsular contracture and seroma . In this regard, rates of breast reconstruction are expanding alongside continued advances in equipment, technology, and materials.
Because both advantages and disadvantages, though different depending upon the choice of breast reconstruction method, remain in existence overall, doctors must discuss with individual patients the reconstruction method to be used in each case. Results of previous studies on breast cancer recurrence and survival rates have supported that reconstruction does not increase the recurrence of breast cancer and cannot affect the survival rate of these patients [16-27]. However, some surgeons still have concerns that autologous tissues or implants may act as obstacles in the diagnosis of the local recurrence of breast cancer .
Siotos et al. studied differences in survival rates between reconstructed and non-reconstructed cases among 1,517 patients with breast cancer. According to their study, there was a 20% higher overall survival benefit in the reconstruction group . Factors contributing to survival, such as differences in race, income, and socioeconomic status, and the varying effects of instruction and counseling on reconstruction outcomes among those who might appreciate such (i.e., those with a higher education level) versus those who may not are not yet fully understood.
Kanchwala et al. studied 41 patients with locoregional recurrence. The time required to pinpoint recurrence did not differ between the immediate implant and autologous tissue groups. The average tumor size in patients with recurrent cancer was 1.5 cm in the immediate implant group and 2.9 cm in the autologous tissue group, with the immediate implant group showing nearly double the rate of index reconstruction loss . However, it was hard to elucidate the incidence of locoregional recurrence because the authors did not report the total numbers of mastectomy and reconstruction procedures. Furthermore, when assessing reconstruction salvage, the implant can be clearly distinguished because device explantation is considered as a failure, while in cases of autologous reconstruction, the salvage definition might be more vague, which potentially affected the credibility of their data.
In this study, attempting to assess the local recurrence is consistent with our research, we clarified the definition of salvage in the autologous group. Furthermore, medical treatment was conducted through a single and equivalent public insurance system. These can bring us the benefit of data accuracy because these kinds of social systems automatically control variables and factors that may bias statistics.
According to our data analysis, the period from cancer surgery to recurrence detection was shorter in the immediate implant group. Two interpretations are possible in the result: First thing is the local recurrence may be found late or the tumor may relapse late. Given that the tendency of unplanned visits was low among patients with autologous tissues, it may be more difficult to palpate an existing lesion among patients in the autologous tissue group. Second thing is that the autologous tissue group had earlier cancer stages and a small number of patients in this group received neoadjuvant chemotherapy, which can lead to late tumor growth. The finding that there was no difference in the tumor size at the time of detection supports those hypotheses. If relapse had occurred earlier and the tumor had been allowed to grow for a longer period, the tumor would have been larger-sized.
The finding that there was no difference in the tumor size at the time of detection supports those hypotheses. If relapse had occurred earlier and the tumor had been allowed to grow for a longer period, the tumor would have been larger-sized.
Based on the linear regression test that was completed to determine the factors affecting the time from initial breast cancer resection to the diagnosis of local recurrence, only neoadjuvant chemotherapy was found to have an effect. As mentioned earlier, the autologous tissue group, which included fewer patients who received neoadjuvant chemotherapy, had more cases of early-stage cancer, and it is likely that tumor growth began later.
Another factor that can have a significant effect on the cancer surgery to local recurrence detection period is the hormone receptor and Her2 expression. According to previous studies, the prognosis is the best for ER-positive, any PR, and Her2-negative breast cancer and poor for triple-negative breast cancer [31, 32]. As a result of the classification by hormone receptor and Her2 expression, results similar to those of previous studies were obtained in absolute values, although statistical significance could not be observed. When the hormone receptor and Her2 distributions in the autologous and implant group patients were summarized, 39.78 percent of patients were ER positive and Her2 negative patients in the autologous group; however, only 24 percent of patients were diagnosed ER positive and Her2 negative in the implant group; whereas 11 (44%) patients were ER and Her2 positive patients. A total of 3 (3.23%) patients were triple-negative breast cancer patients in the autologous group; however, the percentage of triple-negative breast cancer was more than twice as much in the case of the implant group.(2 (8%) patients, p = 0.636) These data also indicate that local recurrence occurred later in the autologous group than in the implant group.
Survival rate is the most important factor to distinguish the difference of local recurrence prognosis. Ultimately, in this study, the postoperative survival period and survival period after recurrence detection were not statistically significantly different between the two groups. Contrary to the concerns of some surgeons, there was no difference in local recurrence findings between autologous tissue reconstruction and implants nor any statistical difference in terms of survival.
Separately, the incidence of the local recurrence of breast cancer in this study was less than 5%; therefore, the study population may be too small in this regard to draw certain conclusions from in this study. However, the present study drew conclusions based on the accumulation of 15 years of data. Furthermore, unlike in previous papers of locoregional recurrence which include the recurrence of lymph nodes or distant metastasis, our study clarified the definition of local recurrence while excluding lymph node recurrence or metastasis. And distant metastasis cases were also excluded for this same reason. Therefore, the present study offers good practical evidence regarding the direct effect of the two reconstruction methods on the diagnosis of local recurrence.
Because the study was conducted with patients belonging to a single race who benefited from the national health care service, the environmental factor was automatically controlled to increase the reliability of the study. Altogether, this study followed a systematic approach to determine whether there exist variations in the recurrence detection and survival period of patients when treated with different breast reconstruction methods. It is expected that this will be a reasonable basis for the assumption that breast implant or autologous tissue reconstruction does not cause harmful effects in the diagnosis and the treatment of local recurrence.
There are some limitations to this study. First, the immediate reconstruction method involving the use of implants was initiated in 2008, resulting in a relatively small number of reconstructions and a short follow-up period. Second, although no significance was observed in both the univariate and multivariate analyses, patient age and BMI values were different between the two groups. This may be a limitation because of the small number of patients who only developed local recurrence after breast cancer surgery. We expect that more accurate results will be obtained if we examined the matched patients throughout a longer follow-up period.