Routine markers may flag red breast syndrome risk after ADM reconstruction

In a retrospective cohort study of 70 patients undergoing skin-sparing mastectomy followed by immediate implant-based breast reconstruction after neoadjuvant chemotherapy, 15 of 47 patients whose procedures used an acellular dermal matrix developed red breast syndrome. None of the 23 patients reconstructed without the matrix developed the complication, a difference researchers reported as statistically significant (p = 0.001).

The study was conducted at a single tertiary institution from January 2011 through May 2025. Investigators compared patients who received ADM with those who did not, then used Firth penalized logistic regression with backward elimination to identify preoperative variables independently associated with red breast syndrome within the ADM group. The analysis identified white blood cell count, platelet count and a high Ki-67 category as the three associated factors. For each unit increase in white blood cell count, the reported odds ratio was 1.235 (95% confidence interval 1.066–1.502; p = 0.004). The odds ratio was 1.013 for platelet count (95% CI 1.001–1.028; p = 0.037) and 8.975 for high Ki-67 (95% CI 1.356–155.173; p = 0.020). The wide Ki-67 confidence interval indicates substantial uncertainty in that estimate. These associations do not establish that any of the markers causes the complication.

The researchers developed a composite preoperative score combining white blood cell count, platelet count and high Ki-67, with a cutoff of at least two indicating the score’s positive threshold. Its performance was stronger than that of the individual markers: the score had an area under the receiver operating characteristic curve of 0.816 (p < 0.001), compared with 0.605–0.641 for the individual biomarkers, whose AUC values were not statistically significant. At the selected threshold, the composite score had reported sensitivity of 86.7%, specificity of 71.9% and negative predictive value of 92.0%.

Internal validation used 2,000 bootstrap resamples. The bootstrap-corrected AUC was 0.817, with a 95% confidence interval of 0.636–0.959 and an optimism estimate of −0.001. The investigators also detected no significant temporal trend in incidence across the study period, based on a Cochran–Armitage test with p = 0.527. The source describes the composite score as an exploratory, hypothesis-generating tool for preoperative risk stratification. Its evidence base remains limited by the small retrospective cohort, single-center design and internal rather than external validation; prospective, multi-institutional cohorts are required before clinical application.

Subject of Research: Preoperative risk prediction for red breast syndrome after acellular dermal matrix-assisted breast reconstruction

Article Title: Predicting red breast syndrome after ADM-assisted breast reconstruction: An exploratory scoring model using routine hematologic markers

Article References: Lee, D. H., Byun, K. D., Kim, T. H., Lee, J., Yun, J., & Kim, H. Y. (2026). Predicting red breast syndrome after ADM-assisted breast reconstruction: An exploratory scoring model using routine hematologic markers. PLOS One, 21(10), e0359415. https://doi.org/10.1371/journal.pone.0359415

Image Credits: AI Generated

DOI: 10.1371/journal.pone.0359415

Keywords: red breast syndrome, breast reconstruction, acellular dermal matrix, neoadjuvant chemotherapy, white blood cell count, platelet count, Ki-67, risk prediction, internal validation, Predicting, breast, syndrome