Partial Breast Reconstruction with Lateral Chest Wall Perforator Flap to Facilitate Breast Conservation in Breast Cancer: First 100 Cases with Cancer Outcomes at 8 Years Follow-Up and the Lessons Learned

Abstract

Background: This is a prospective cohort study of partial breast reconstruction (PBR) with a lateral chest wall perforator flap (LCWPF) to facilitate breast conservation surgery (BCS) for women undergoing surgery for breast cancer. The study was undertaken to study the clinical and cancer outcomes.

Methods: Patients diagnosed with ductal carcinoma in situ (DCIS) or breast cancer who consented to undergo BCS with PBR with LCWPF were included in the study. A prospective database has been maintained to collect information on clinico-pathological features, complications, and follow-up. Patients were asked to complete an anonymised PROM questionnaire over the years. The hospital electronic records were interrogated for women who have completed 5 years follow-up to assess for development of recurrence/events.

Results: A total of 105 patients underwent PBR with LCWPFs between 2011 and 2018. Of these, 74% underwent cancer resection and PBR as one operation whilst 26% underwent PBR as a two-stage approach. The median tumor size on pre-op imaging was 30 mm for the one-stage approach and 39.5 mm for the two-stage approach (p-value=0.003). The complication rates were low and the re-operation rate for close margins was 10%, with 4% eventually requiring mastectomy. Good-to-excellent esthetic outcomes were reported in more than 80% of cases by patients and clinicians. The local recurrence rate (LR) was 2%, distant recurrence rate 10.5%, disease free survival (DFS) 86%, distant disease-free survival (DDFS) 89% and overall survival (OS) 94.8% at 4.5 years median follow-up. This procedure provides an effective oncological approach, avoiding mastectomy with a good-to-excellent cosmetic outcome. The follow-up data establishes the safety of this approach.

Discussion: This is the first published series of recurrence and survival data in patients undergoing PBR. We intend to continue with data collection to assess long-term outcomes beyond 10 years. The authors would recommend consideration of this technique to facilitate BCS and avoid mastectomy.

Registration: Not applicable.

Keywords: PBR; PROMs; breast cancer; breast cancer outcomes; breast conservation surgery; lateral chest wall perforator flap; partial breast reconstruction.

Figure 1

Schematic representation of the anatomy of lateral chest wall perforator flaps (CWPF) and the blood supply in relation to breast. T: tumour with outer circle representing the wide local excision; 1) lateral CWPF; 2) latissimus dorsi muscle; 3) lateral thoracic vessels; 4) lateral Intercostal vessels.

Figure 2

One-stage LICAP flap reconstruction (A) 43-year old with 40 mm cancer in the lower outer quadrant of the right breast. Pre-op marking for tumor location and lateral CWPF. The solid vertical line (white arrow) denotes surface marking for lateral thoracic artery (LTA) and stars represent lateral intercostal artery perforators (LICAP). The dotted lines are along the lateral border of pectoralis major and anterior border of latissimus dorsi muscle. (B) Intra-operative picture showing the flap dissected (arrow points towards head with patient in lateral position). (C) 4 weeks post-op with scar on the lateral chest wall. Patient had chemotherapy after surgery. (D) Appearance and symmetry of breasts 4 years after radiotherapy. (E) Appearance of scar 4 years later.

Figure 3

Flowchart depicting axillary lymph node status along with axillary treatment.

Figure 4

Cancer outcomes in the study (Consort format).

Figure 5

Patient before (A) and after (B) contralateral breast augmentation to address asymmetry after PBR with CWPF. The augmentation was performed 2 years after completion of cancer treatment.

Figure 6

Pre-op and post-op photographs of PBR with lateral CWPF in a slim patient with very small breasts. 42-year old with 20 mm cancer in the upper outer quadrant of left breast with an “A” cup. (A) Pre-operative photograph. (B) Pre-op marking for CWPF. (C) 2 weeks after surgery. (D) 1 year after treatment. (E) 3 years after radiotherapy on right side. Patient had chemotherapy after surgery.