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Chemotherapy and Postoperative Complications in Women Undergoing Mastectomy and Immediate Breast Reconstruction

Authors

Mary Beth Nierengarten

Results of a retrospective review [Arch Surg. 2010;145(9):880-885] indicate that complication rates after mastectomy and immediate breast reconstruction surgery are not significantly affected by inclusion of chemotherapy nor by timing of chemotherapy administration. Although historically women who undergo mastectomy wait until they complete adjuvant chemotherapy and/or radiation therapy before they undergo breast reconstruction, increasingly more centers are offering women the option of immediate breast reconstruction at the time of initial mastectomy. Studies have shown an association between radiation therapy and postoperative complications in this setting, but few studies have examined the role of chemotherapy on outcomes following immediate breast reconstruction. Among the possible concerns with the use of chemotherapy in patients who undergo immediate breast reconstruction is the potential for increased risk of developing infections given the increased risk of neutropenia associated with chemotherapy, particularly dose-dense regimens. To determine whether the inclusion of chemotherapy or the timing of its administration affects postoperative complication rates in patients who undergo mastectomy and immediate breast reconstruction, investigators retrospectively reviewed data from medical treatment records of 163 patients who underwent mastectomy and immediate breast reconstruction between January 1, 2005, and December 31, 2007, at a single institution in California. Of these patients, 66% had immediate reconstruction with tissue expander placement and subsequent implant exchange or initial implant placement, and the rest of the patients had autologous reconstruction, the researchers said. Patients were categorized based on whether they received chemotherapy and, in those who did, when. Of the 163 patients, 57 received neoadjuvant chemotherapy, 41 received adjuvant chemotherapy, and 65 received no chemotherapy. Most patients who received either neoadjuvant or adjuvant chemotherapy received a standard chemotherapeutic regimen of doxorubicin hydrochloride/cyclophosphamide followed by paclitaxel. Trastuzumab therapy was also given to 21% of patients who received neoadjuvant chemotherapy and 17% who received adjuvant chemotherapy. None of the patients were treated with bevacizumab. Patient characteristics were similar among the 3 groups in terms of age (mean, 48.2 years; range, 25-72 years), body mass index (mean, 25.1), and history of smoking. Significantly more patients in the adjuvant chemotherapy group received radiation therapy compared with the neoadjuvant chemotherapy group and the group not receiving chemotherapy (24% vs 7% vs 12%, respectively; P=.05). All patients received routine prophylactic intravenous antibiotics prior to skin incision, either cefazolin (1 g) or, in patients allergic to penicillin, clindamycin hydrochloride (600 mg). Using the data, the investigators prospectively collected surgical outcomes that included wound complications (skin flap necrosis, flap loss, or nippleareolar complex loss), unplanned return to the operating room (for hematoma evacuation, irrigation and debridement for wound infections or necrosis, tissue expander or implant removal in cases of severe infection, and repair of incisional hernias or rectus diastasis), donor-site complications in patients undergoing autologous reconstruction, and cancer outcomes. At a mean postoperative follow-up of 19.2 months, the study found that the most common postoperative complications were postoperative infections, unplanned return to the operating room, and tissue expander or implant loss. Based on an intent-to-treat analysis, no differences were found among patients who received no chemotherapy, neoadjuvant chemotherapy, or adjuvant chemotherapy in terms of complications that required return to the operating room (28% vs 33% vs 32%, respectively; P=.79) or implant/expander loss (18% vs 26% vs 22%, respectively; P=.70). Patients who received adjuvant chemotherapy had the highest rate of infectious complications (44%) compared with those who received neoadjuvant chemotherapy (23%) and those not treated by chemotherapy (25%) (P=.05), indicating that the postoperative infection was not attributable to chemotherapy. However, the authors emphasize the clinical importance of this finding, as it likely indicates that systemic chemotherapy was delayed by surgical complications in the patients who received adjuvant chemotherapy. Based on these results, the authors conclude that neoadjuvant chemotherapy is a safe option for women who are planning to undergo mastectomy and immediate reconstruction. In addition, they emphasize that “the use of neoadjuvant chemotherapy in this setting may prevent delay to systemic chemotherapy in a notable proportion of patients who develop postoperative complications.”

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