Introduction: Historically, locoregional recurrence and chest wall involvement in breast cancer have been considered harbingers of distant metastasis and poor prognosis. The use of neoadjuvant chemotherapy has resulted in selected patients with advanced disease, previously deemed “inoperable”, to be referred for radical resection requiring reconstruction. Purpose: To define the safety, efficacy, and reconstructive arena of radical ablation in patients with locally advanced breast neoplasms. Methods: Data for 92 patients with advanced breast cancer treated by surgical resection and reconstruction from1988-2000 were compiled retrospectively. Inclusion criteria included clinical tumor size of 5 cm or greater, primary or recurrent with chest wall invasion requiring flap reconstruction with a minimum 6-month postoperative follow-up. Patient demographics and outcomes including survival, local and/or distant metastases, reconstructive strategies, and complications were evaluated. Results: All patients were female with T4 tumors, either Stage IIIb (N=80) or Stage IV (N=13). Mean age was 53 years (Range(R)=28-86) with an average of 28 months follow-up (R=6-144). All patients received adjuvant/neoadjuvant chemotherapy. Two-thirds of the patients had primary locally advanced breast cancer (LABC N=55), and one-third had recurrent disease (RC N=37). Median survival was 40.48 months, with a median disease free survival of 17.75 months. Survival of LABC was not statistically different from RC (28.5 versus 22.1 months, p=0.318). Mean tumor size was 6.8 cm (R=5.0-8.5) with a resultant defect size of 264 cm2 (R=70-900) necessitating 116 flaps in 92 patients to achieve wound closure. Twenty patients required more than one flap. The latissimus dorsi and rectus abdominus myocutaneous flaps were the most commonly utilized. Pedicled flaps were more common than free flaps. Prosthetic materials were utilized in 33 patients (mesh N=25; methylmethacrylate N=8). There were no perioperative deaths. Hospital stay averaged 7.0 days (R=2-34). Complications included: Flap loss (total N=4; partial N=6) cellulitis (N=10) seroma (N=13) respiratory compromise and/or systemic infection (N=29). Conclusions: In the largest series to date, we have demonstrated that radical ablation and reconstruction in large locally advanced or recurrent breast cancers can be safely carried out with an acceptable risk even if multiple flaps are required for closure. Overall survival with this regime is favorable to historic controls. Some patients may experience a long disease free interval and a few, long-term survival. While rarely curative, this surgery appears to decrease morbidity by palliation in the final stages of terminal disease and therefore appears warranted in selected cases.
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