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Safety and Quality of Life in Women with Immediate Reconstruction with Polyurethane Implants after Neoadjuvant Chemotherapy: Outcomes from The Preq-20 Trial. Cancers 2023, 15(4):1113. DOI: 10.3390/cancers15041113
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Immediate postmastectomy reconstruction (IPMR) is a valid and safe option for patients who undergo primary surgery after their diagnosis, but there is less evidence on its safety in women treated with neoadjuvant chemotherapy (NAC). Prepectoral breast reconstruction (PBR) has recently been proposed as a safe option in risk-reduction oncologic surgery due to its low morbidity and its safety in terms of postoperative complications and disease-free survival. In this type of IPMR, the preservation of the pectoralis major muscle and the subcutaneous placement of the implant decreases postoperative pain and the incidence of postoperative complications, thereby constituting a good option for women with associated morbidity, as is the case for patients with NAC. However, we currently do not have an algorithm that allows choosing the appropriate method of reconstruction for each patient.
The three meta-analysis that have evaluated the use of NAC prior to oncologic surgery and to IPMR have not identified cytostatics with a risk factor for postoperative complications or for disease-free survival and overall survival. The heterogeneity in the methodology and the retrospective analyses of many of the studies limit the level of evidence of these meta-analyses. The meta-analysis by Son showed a low incidence rate of postoperative complications after NAC in young women, a patient group with a lower incidence of comorbidities. Our prospective study showed two noteworthy results related to postoperative complications. First, IPMR in patients with NAC presented a similar incidence of complications (13.8%) compared with the patients with adjuvant chemotherapy (16.9%) or without chemotherapy (10.9%). Second, the patients with adjuvant chemotherapy presented a significantly greater risk of readmission, reoperation and implant loss compared with the patients with NAC or without chemotherapy. The explanation for this fact is the increased incidence of wound dehiscence and necrosis of NAC in patients with adjuvant chemotherapy, which requires its surgical correction during therapy with cytostatics. Reoperation during the administration of chemotherapy results in implant infection and a lack of healing, a problem that does not occur in patients after NAC because their cytostatic therapy is completed 5–6 weeks earlier. Moreover, the infection rates in our study were low (1.9%) compared with most studies on reconstruction with prepectoral implants. Therefore, in the experiences with implants and biological meshes, infection and implant loss can affect 1.9%–7.3% and 2.4%–10.2% of the patients, respectively, while for synthetic meshes the incidence of infection ranges from 0.8% to 6% and implant loss ranges from 1.2% to 8%. The explanation for this finding could be found in the use of the polyurethane implant in our study. We think that the low incidence of seroma and infection with these implants could be related to the integration of the polyurethane foam into the subcutaneous tissue, which allows implant adherence and tissue growth in its three-dimensional structure. This integration promotes resistance to infection in those cases of dehiscence or skin necrosis with exposure of the implant. This characteristic has enabled maintaining the reconstruction through the use of local flaps.
Our study shows tha IPMR with polyurethane implants in patients with NAC presented a similar incidence of complications compared with the patients with primary surgery. The readmission, reoperation and implant loss rates were lower for the patients with PST (5.2%, 3.4%, 3.4%, respectively) compared with those who underwent adjuvant chemotherapy (20.8%, 18.9%, 13.2%, respectively). There is a high rate of BM among the women with PST (69%), even in the presence of a complete pathologic response (78%) because the majority (88%) have undergone a genetic study during PST and a number of them (36%) presented a mutation. Lastly, the satisfaction and quality of life of the patients with IPMR after PST had not changed at 1 year of follow-up, although there was worsening of the physical wellbeing, as in the other evaluated groups.