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

Figures & data

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.

Table 1 Distribution of the Clinic-Pathological and Treatment Parameters

Tumor Characteristics and Treatment	Number of Patients (%) (Total = 105)
Symptomatic presentation	76 (72.4%)
Screen detected cancers	29 (27.6%)
Invasive cancers	97 (1 metastatic at presentation) (92.4%)
IDC	78 (80%)
ILC	14 (14.5%)
Mixed	3
Others (medullary, squamous)	2
DCIS only	8 (1 had microinvasion) (7.6%)
High grade	5
Intermediate grade	3
Invasive tumor size on histology** (excluding NAC)	80
T1	27
T2	50
T3	3
Invasive tumor size on histology post-NAC	16
pCR	4
T1	5
T2	6 (2 were bifocal)
T3	1
*Tumor grade (invasive cancer only)
Gr 1	14 (15%)
Gr 2	42 (43%)
Gr 3	41 (42%)
*Node positive at diagnosis	15 (15.6%)
*Axillary nodes positive (total)	47 (49%)
*Triple negative cancers	18 (18.5%) (6 had NAC, 2 declined adjuvant chemo, 10 had adjuvant)
*ER positive (invasive cancers)	73 (75%)
*ER positive and Her-2 negative	63 (65%)
*Her-2 positive cancers	16 (16.4%) (ER+: 10, ER-: 6)
*Neo-adjuvant chemotherapy (NAC)	16 (16.6%)
*Patients received chemotherapy (adjuvant and NAC)	57 (+3 declined)
Patients received adjuvant radiotherapy	100 (1 declined, 4 were not recommended)
*Patients received adjuvant endocrine therapy	74

Notes: * This information applies to invasive cancers only. ** Fourteen had multifocality and 10 had extensive DCIS to increase the whole tumor size by more than 50% (influencing the need for wider resection than indicated by T status).

Abbreviations: NAC, neoadjuvant chemotherapy; pCR, pathological complete response.

Table 2 Details of the Median Tumor Size in Relation to the Bra Cup

Breast Size	Number of Patients	Median Tumor Size on Imaging (Pre-Op)*
AA	3	18
A	7	24
B	33	26
C	39	33
D	23	35

Note: *Including patients who had NAC.

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.

Table 3 Tumor Characteristic of Patients Undergoing One-Stage and Two-Stage Approaches

	One-Stage (78)	Two-Stage (27)	p-value
Mean tumor size (mm) (on pre-op imaging)	30.7	39.9	0.003
Total number of patients	78	27
DCIS only	4	4 (1 with microinvasion)
Invasive cancers	74^$	23
Neo-adjuvant chemotherapy	11	5
Chemotherapy (adjuvant and NAC)	46* (61%)	14 (64%)
Her-2 positive cancers	12 (16%)	4 (18%)
Node positive cancers	35 (47%)	12 (54%)
TNBC	15 (18%)	3 (14%)

Notes: * Three declined. ^$ One patient had metastatic cancer.

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.