Surgical Resection With Pedicled Rotation Flap for Post-mastectomy Locoregional Breast Cancer Recurrence

Discussion

A locoregional chest wall recurrence after mastectomy is a frequent form of breast cancer recurrence (2, 3). For patients with an isolated chest wall recurrence, surgical resection is considered to be the mainstay of therapy (4). It has been shown that complete tumor resection with a safe margin is associated with better outcomes (5), but to achieve a safe tumor margin, the skin defect is large and skin grafting is often needed for skin closure. Because skin grafting is a troublesome procedure and there is a risk of graft necrosis, easier and safer methods of resection are needed for breast cancer patients.

Flaps are an indispensable tool in wound closure by reducing and redirecting tension. A rotation flap is a procedure in which the flap is pivoted around an axis to close a primary defect, essentially rotating the skin into the defect (6). A rotation flap is used when simpler types of closure, such as healing by secondary intention, a primary closure, or a skin graft, do not yield adequate functional and cosmetic results (6). Herein, we have described a surgical technique with a pedicled rotation flap to provide an adequate resection margin and close the resulting skin defect in breast cancer patients with a post-mastectomy LRR. With this procedure we achieved an acceptable margin from the tumor and removed the recurrent lesion completely. Although the limit of resection size is unknown, the maximum size of resection was 10×8 cm based on our experience. It might be undesirable to make a skin flap that is too large because ischemic graft necrosis may develop. In our procedure, skin extension was needed; however, it might be difficult to use our technique if patients had received PMRT after the first surgery and had a skin reaction. None of our patients received radiation therapy before the second operation, and therefore the effects of radiation therapy on our technique, if any, are unknown. Additionally, our technique might be difficult for patients with a slender body habitus because flap extension may not have enough stretch.

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Figure 1.

The surgical procedure is shown. The surgical margin is set 2 cm apart from the tumor margin. The pedicled skin and fat flap were set along the resected margin and the size was set at the same size of the resected skin (a). After the tumor was resected (b), the pedicled flap was formed (c). The wound had some tension (d), but enabled us to perform a simple closure without a skin graft (e).

With systemic therapy after resection of an isolated LRR, the CALOR trial showed that chemotherapy improves the prognosis and adjuvant chemotherapy is recommended, especially if the recurrence is ER-negative (5). We selected endocrine therapy for ER-positive patients, and chemotherapy with trastuzumab for HER2-positive patients. We chose the above systemic therapy regimen based on the recurrent tumor status. It was interesting that ER- or HER2-positivity changed in two of three patients, and new information was added in one patient with an unknown primary tumor sub-type because her breast cancer was resected 20 years earlier.

Irradiation after resection for a locoregional chest wall recurrence is recommended if the patient did not receive PMRT (7). None of our patients received PMRT, but 3 of 4 patients received 50 Gy of irradiation after resection of the locoregional chest wall recurrence. One patient did not undergo irradiation at her request. Distant metastases occurred 3 months after LRR resection in one patient, but all patients were alive and well during our mean observation period of 41 months (range=8-55 months). None of the patients had locoregional re-recurrences.

Surgical resection with a pedicled rotation flap for post-mastectomy locoregional breast cancer recurrence is a feasible way to achieve complete resection.