title: Breast cancer local recurrence after mastectomy and TRAM flap reconstruction: incidence and treatment options.
abstract: BACKGROUND
  The transverse rectus abdominis musculocutaneous (TRAM) flap is the standard in autologous breast reconstruction. The management of local recurrence of breast cancer after TRAM flap breast reconstruction has not been well described. The purpose of this study was to examine the incidence of local recurrence of breast cancer after TRAM flap breast reconstruction, evaluate treatment modalities, and determine outcomes in such cases.
  
  
  METHODS
  A retrospective review was conducted of all patients who underwent immediate breast reconstruction with a free or pedicled TRAM flap over a 15-year period. Those patients who experienced local breast cancer recurrence were identified. A subset of complete skin-sparing mastectomy patients was also identified for review.
  
  
  RESULTS
  From 1987 to 2002, 419 TRAM flap breast reconstructions were performed in 395 patients. Thirty-four (9 percent) were complete skin-sparing mastectomy using a periareolar mastectomy incision only. The mean follow-up time in this study was 4.9 years (range, 1 to 14.7 years). Local recurrence occurred in 16 of 419 patients (3.8 percent), with a mean time to local recurrence of 1.6 years (range, 0.2 to 7.0 years). There were no local recurrences seen in patients following complete skin-sparing mastectomy. Treatment of local recurrence included excision, chemotherapy, radiotherapy, and bone marrow transplant. Only three of the 16 patients (19 percent) required removal of the entire TRAM flap to manage local breast cancer recurrence. Nine of 16 patients (56 percent) with local recurrence died of disease at a mean of 1.2 years after the development of recurrence.
  
  
  CONCLUSIONS
  Long-term follow-up demonstrated a local recurrence rate after TRAM flap breast reconstruction similar to that reported in the literature. Local recurrence was effectively managed with surgical excision of the involved tissues, chemotherapy, and/or radiation therapy. Removal of the entire TRAM flap was only necessary in the setting of multifocal recurrence or involvement of the flap pedicle with disease. The risk of local recurrence was not increased following complete skin-sparing mastectomy.
authors.affiliation: Plastic and Reconstructive Surgery Service, Memorial Sloan-Kettering Cancer Center, New York, NY 10021, USA.
authors.forename: Michael A
authors.initials: MA
authors.lastname: Howard
authors.forename: Kristen
authors.initials: K
authors.lastname: Polo
authors.forename: Andrea L
authors.initials: AL
authors.lastname: Pusic
authors.forename: Peter G
authors.initials: PG
authors.lastname: Cordeiro
authors.forename: David A
authors.initials: DA
authors.lastname: Hidalgo
authors.forename: Babak
authors.initials: B
authors.lastname: Mehrara
authors.forename: Joseph J
authors.initials: JJ
authors.lastname: Disa
mesh_terms: D000328:Adult; D001943:Breast Neoplasms / Q000453:epidemiology* / Q000473:pathology / Q000601:surgery; D002285:Carcinoma, Intraductal, Noninfiltrating / Q000601:surgery; D003131:Combined Modality Therapy; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D015994:Incidence; D016462:Mammaplasty; D008408:Mastectomy; D009364:Neoplasm Recurrence, Local / Q000453:epidemiology* / Q000628:therapy; D009367:Neoplasm Staging; D012189:Retrospective Studies; D013524:Surgical Flaps / Q000473:pathology; D035441:Thoracic Wall / Q000473:pathology; D013997:Time Factors