Tamoxifen Increases the Risk of Microvascular Flap Complications in Patients Undergoing Microvascular Breast Reconstruction

Abstract

Background Tamoxifen citrate (tamoxifen) has been associated with increased rates of thromboembolic events, which have prompted concerns that tamoxifen may increase the risk of complications after microvascular breast reconstruction. Some centers have implemented protocols to temporarily stop tamoxifen before microvascular breast reconstruction. We sought to determine whether this practice is warranted. Methods We retrospectively compared rates of microvascular flap complications and pulmonary emboli between patients who were and were not receiving tamoxifen at the time of reconstruction in 670 patients who underwent delayed microsurgical breast reconstruction at our institution between January 2000 and April 2010. Results Two hundred five patients received tamoxifen within 28 days before reconstruction (these were considered to be receiving tamoxifen at reconstruction); 465 patients did not. Patients who received tamoxifen were significantly younger (p < 0.0001) and thinner (p = 0.0025) with less cardiovascular morbidity (p = 0.04) and shorter durations of surgery (p = 0.05). Despite fewer comorbidities, microvascular flap complications were significantly more common in patients who received tamoxifen (21.5% versus 15%; p = 0.04). Patients who received tamoxifen had 1.7 times the risk of complications (p = 0.015) and 1.8 times the risk of follow-up complications (p = 0.03) than patients in the no-tamoxifen group. In tamoxifen-group patients, cardiovascular co-morbidities significantly increased the risk of flap complications (p = 0.002). Tamoxifen-group patients had a significantly increased rate of immediate total flap loss (p = 0.041) and a lower rate of flap salvage (p = 0.023). Tamoxifen did not appear to increase the risk of pulmonary embolus during or after delayed microvascular breast reconstruction. Conclusions Tamoxifen may increase the risk of microvascular flap complications. Surgeons should consider temporarily stopping the drug 14-days before microsurgical breast reconstruction.

The Impact of Radiation Therapy, Lymph Node Dissection, and Hormonal Therapy on Outcomes of Tissue Expander–Implant Exchange in Prosthetic Breast Reconstruction

“…7,8 The available options include tamoxifen, aromatase inhibitors, and fulvestrant. [9][10][11][12][13][14][15] Furthermore, approximately 15 to 20 percent of breast cancers have amplification of the human epidermal growth factor receptor-2 (HER-2) gene, which plays a role in epithelial cell mitosis, invasion, and antiapoptosis. 16,17 Trastuzumab (Herceptin; Genentech, South San Francisco, Calif.) is a fully humanized monoclonal antibody developed to target the extracellular domain of HER-2 and is widely used in patients with HER-2-positive breast cancer.…”

The Effects of Perioperative Tamoxifen Therapy on Microvascular Flap Complications in Transverse Rectus Abdominis Myocutaneous/Deep Inferior Epigastric Perforator Flap Breast Reconstruction

“…The study by Mirzabeigi et al 8 suggests that, at a minimum, tamoxifen therapy can continue up to at least 2 weeks prior to reconstruction without affecting microvascular flap complications. Kelley et al, 7 however, stated that tamoxifen may need to be held up to 1 month prior to surgery. As previously described, the inclusion of non-abdominally based flaps and higher irradiation rates in the tamoxifen group may have contributed to the increased complication rates that were observed by the authors.…”

“…Recent retrospective studies comparing stopping tamoxifen at different timepoints prior to reconstruction have provided conflicting conclusions. Kelley et al 7 reported an increased in flap complications by 1.7 times in patients receiving tamoxifen up to 1 month prior to reconstruction. On the other hand, a recent study by Mirzabeigi et al 8 showed no increase in complications in patients who stopped tamoxifen 2 weeks prior to abdominally based microvascular breast reconstruction.…”

“…7,8 Withholding tamoxifen even longer, for up to 1 month prior to surgery, has also been advocated. 7 There is no definitive evidence, however, that these practices decrease thrombotic complications and improve reconstructive outcomes in these procedures. Recent retrospective studies comparing stopping tamoxifen at different timepoints prior to reconstruction have provided conflicting conclusions.…”

Impact of different type of cancer treatment on the effectiveness of breast reconstruction

“…The available options include tamoxifen, aromatase inhibitors, and fulvestrant (11)(12)(13)(14)(15)(16). A prospective randomized trial performed in 1995, comparing modified radical mastectomy to hormone therapy followed by modified radical mastectomy found that there was no significant difference in the risk of complications and that immediate breast reconstruction was not an independent predictor of complications (17).…”