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Clark RC, Segal R, Kordahi A, Sendek G, Alving-Trinh A, Abramson W, Sztain J, Swisher M, Gabriel RA, Gosman A, Said ET, Reid CM. An Interdisciplinary, Comprehensive Recovery Pathway Improves Microsurgical Breast Reconstruction Delivery. Ann Plast Surg 2024; 92:549-556. [PMID: 38563567 DOI: 10.1097/sap.0000000000003833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
INTRODUCTION Free-flap (autologous) breast reconstruction demonstrates superiority over alloplastic approaches but is offered infrequently. Enhanced recovery protocols can address postoperative challenges, but most literature is limited to inpatient interventions and outcomes. This study describes an adoptable, longitudinally comprehensive and multidisciplinary recovery pathway for autologous reconstruction which adds to the current guidelines. The authors aimed to allow perioperative outcomes comparable to alloplastic reconstructions. METHODS All autologous Comprehensive Recovery Pathway (CRP) subjects from a single surgeon were retrospectively included. A comparator group of equal size was randomly selected from institutional subpectoral and dual-plane tissue expander patients having Enhanced Recovery After Surgery guideline-directed care. All subjects in both cohorts received preoperative paravertebral regional blocks. Operative detail, inpatient recovery, longitudinal morphine equivalents (MEs) required, and complications were compared. RESULTS Each cohort included 71 cases (99 breasts). Despite longer operations, intraoperative MEs were fewer in autologous cases ( P = 0.02). Morphine equivalents during inpatient stay were similar between cohorts, with both being discharged on median day 2. Multivariate regression demonstrated a 0.8-day increased stay for autologous subjects with additional contribution from bilateral cases, body mass index, and age ( P < 0.05). Autologous subjects were regularly discharged postoperative day 1 (17%) and postoperative day 2 (39%), with trend toward earlier discharge ( P < 0.01). Outpatient MEs were significantly fewer in autologous subjects, corresponding to a 30- to 150-mg oxycodone difference ( P < 0.01). Major complication occurred in 12.7% of autologous and 22.5% of alloplastic subjects ( P = 0.11). Flap loss occurred in 1 autologous subject versus 11 alloplastic failures ( P < 0.01). CONCLUSIONS This study details partnership between the plastic surgery service, regional and acute pain anesthesia services, and dedicated nursing with longitudinal optimizations allowing perioperative outcomes improved over current literature. Patients in the CRP used fewer opioids from operation through follow-up with comparable length of stay and significantly fewer reconstructive failures than alloplastic subjects. The pathway may be quickly adopted into academic practice patterns and mitigates traditional barriers, allowing extension of autologous reconstruction offerings.
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Affiliation(s)
| | | | | | | | | | - Wendy Abramson
- Department of Anesthesiology, University of California San Diego, San Diego, CA
| | - Jacklynn Sztain
- Department of Anesthesiology, University of California San Diego, San Diego, CA
| | - Matthew Swisher
- Department of Anesthesiology, University of California San Diego, San Diego, CA
| | - Rodney A Gabriel
- Department of Anesthesiology, University of California San Diego, San Diego, CA
| | | | - Engy T Said
- Department of Anesthesiology, University of California San Diego, San Diego, CA
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Ren Y, Yu Y, Xu K, Li Z, Wang X. Meta-Analysis of Immediate Implant-Based Breast Reconstruction Versus Autologous Breast Reconstruction in the Setting of PMRT. Aesthetic Plast Surg 2024; 48:1940-1948. [PMID: 37380747 DOI: 10.1007/s00266-023-03430-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 05/08/2023] [Indexed: 06/30/2023]
Abstract
BACKGROUND It is still a controversial debate that which type of immediate breast reconstruction should be operated on breast cancer patients in the setting of postmastectomy radiotherapy. This meta-analysis compared incidence of complications requiring reoperation (CRR), reconstruction failure (RF) and patient-reported outcome between immediate autologous breast reconstruction (ABR) and immediate implant-based breast reconstruction (IBBR), tissue expander/implant reconstruction mostly, in the setting of postmastectomy radiotherapy. METHODS Systematic and thorough research was conducted to search for studies published before August 1, 2022, by using three online databases. Studies that covered complications or reconstruction failure between two cohorts were included. To evaluate the possible bias in the included studies, the Newcastle-Ottawa Scale was applied. RESULTS Eight studies presenting 1261 patients were enrolled. The relative risk associated with reconstructive failure favored IBBR (RR = 8.61; 95% CI, 2.84-26.08; P = 0.0001). While the risk for complications requiring reoperation was not significantly different between two groups, either include reconstruction failure (RR = 1.45 95% CI, 0.82-2.55; P = 0.20) or not (RR = 0.63 95% CI, 0.28-1.43; P = 0.27). However, because statistical definitions and methodologies vary, the synthesized result should be taken critically. CONCLUSION Patients with IBBR have more possibility experiencing RF compared that with ABR, while the chance for CRR is not that different between two groups. For the purpose of clinical practice refinement, more high-quality studies are needed. LEVEL OF EVIDENCE III This journal requires that authors assign a level of evidence to each article. For a full description of these evidence-based medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
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Affiliation(s)
- Yanxin Ren
- Hebei Medical University, Shijiazhuang, 050018, Hebei Province, People's Republic of China
- Department of Medical Cosmetology, Surgery, Hebei Province General Hospital, 348, West He-Ping Road, Shijiazhuang, 050051, Hebei Province, People's Republic of China
| | - Yan Yu
- Department of Medical Cosmetology, Surgery, Hebei Province General Hospital, 348, West He-Ping Road, Shijiazhuang, 050051, Hebei Province, People's Republic of China
| | - Kexin Xu
- Hebei Medical University, Shijiazhuang, 050018, Hebei Province, People's Republic of China
- Department of Medical Cosmetology, Surgery, Hebei Province General Hospital, 348, West He-Ping Road, Shijiazhuang, 050051, Hebei Province, People's Republic of China
| | - Zhoujian Li
- Department of Medical Cosmetology, Surgery, Hebei Province General Hospital, 348, West He-Ping Road, Shijiazhuang, 050051, Hebei Province, People's Republic of China
- Hebei North University, Shijiazhuang, 075000, Hebei Province, People's Republic of China
| | - Xiao Wang
- Department of Medical Cosmetology, Surgery, Hebei Province General Hospital, 348, West He-Ping Road, Shijiazhuang, 050051, Hebei Province, People's Republic of China.
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Musmann RJ, Andree C, Munder B, Hagouan M, Janku D, Daniels M, Aufmesser-Freyhardt B, Becker K, Oramary A, Bromba A, Stockhausen N, Wolter A, Fertsch S. Secondary solution for breast reconstruction following total DIEP flap loss: A single-center experience after 3270 DIEP flaps. J Plast Reconstr Aesthet Surg 2024; 92:11-25. [PMID: 38489983 DOI: 10.1016/j.bjps.2024.02.059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 02/02/2024] [Accepted: 02/22/2024] [Indexed: 03/17/2024]
Abstract
BACKGROUND Total deep inferior epigastric perforator (DIEP) flap failure is a significant concern in autologous breast reconstruction. Literature on secondary reconstruction options following total flap failure is limited. This study outlines the outcomes of patients who underwent reconstruction post-DIEP flap failure at our institution. METHODS We conducted a retrospective analysis of patients receiving autologous breast reconstruction between 2004 and 2021. We aimed to identify causes of total DIEP flap failure, outcomes of revision surgery, and outcomes of secondary breast reconstruction procedures. RESULTS From 2004 to 2021, 3456 free flaps for breast reconstruction were performed, with 3270 being DIEP flaps for 2756 patients. DIEP flap failure was observed in 40 cases (1.22%). Bilateral reconstructions had a higher failure rate (2.31%) than unilateral (0.72%). The primary cause was intraoperative complications during flap harvest (18 cases), followed by insufficient arterial perfusion (seven cases). Other causes included postoperative hematoma (seven cases), venous congestion (six cases), and late-onset fat necrosis (two cases). Post-failure, five patients received a second free flap with three cases of repeated flap failure. Twenty patients received implant-based reconstruction with two cases of reconstruction failure, while seven patients received a pedicled latissimus dorsi (LD) flap reconstructions with no cases of reconstruction failure. Eight patients declined further reconstruction. CONCLUSION A second free flap post-DIEP failure was associated with a high risk of reconstruction failure, suggesting the need for careful patient selection. Implant-based and pedicled LD flap seem to be reliable secondary reconstruction options.
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Affiliation(s)
- R J Musmann
- Dept. of Plastic and Aesthetic Surgery, Sana Krankenhaus Gerresheim, Gräulinger Straße 120, D-40625 Düsseldorf, Germany.
| | - C Andree
- Dept. of Plastic and Aesthetic Surgery, Sana Krankenhaus Gerresheim, Gräulinger Straße 120, D-40625 Düsseldorf, Germany; Heinrich-Heine-Universität Düsseldorf, Universitätsstraße 1, 40225 Düsseldorf
| | - B Munder
- Dept. of Plastic and Aesthetic Surgery, Sana Krankenhaus Gerresheim, Gräulinger Straße 120, D-40625 Düsseldorf, Germany
| | - M Hagouan
- Dept. of Plastic and Aesthetic Surgery, Sana Krankenhaus Gerresheim, Gräulinger Straße 120, D-40625 Düsseldorf, Germany
| | - D Janku
- Dept. of Plastic and Aesthetic Surgery, Sana Krankenhaus Gerresheim, Gräulinger Straße 120, D-40625 Düsseldorf, Germany
| | - M Daniels
- Dept. of Plastic and Aesthetic Surgery, Sana Krankenhaus Gerresheim, Gräulinger Straße 120, D-40625 Düsseldorf, Germany; Universität Witten-Herdecke, Fakultät für Gesundheit, Alfred-Herrhausen-Straße 45, 58455 Witten, Germany
| | - B Aufmesser-Freyhardt
- Dept. of Plastic and Aesthetic Surgery, Sana Krankenhaus Gerresheim, Gräulinger Straße 120, D-40625 Düsseldorf, Germany
| | - K Becker
- Dept. of Plastic and Aesthetic Surgery, Sana Krankenhaus Gerresheim, Gräulinger Straße 120, D-40625 Düsseldorf, Germany
| | - A Oramary
- Dept. of Plastic and Aesthetic Surgery, Sana Krankenhaus Gerresheim, Gräulinger Straße 120, D-40625 Düsseldorf, Germany
| | - A Bromba
- Dept. of Plastic and Aesthetic Surgery, Sana Krankenhaus Gerresheim, Gräulinger Straße 120, D-40625 Düsseldorf, Germany
| | - N Stockhausen
- Dept. of Plastic and Aesthetic Surgery, Sana Krankenhaus Gerresheim, Gräulinger Straße 120, D-40625 Düsseldorf, Germany
| | - A Wolter
- Dept. of Plastic and Aesthetic Surgery, Sana Krankenhaus Gerresheim, Gräulinger Straße 120, D-40625 Düsseldorf, Germany; Universität Witten-Herdecke, Fakultät für Gesundheit, Alfred-Herrhausen-Straße 45, 58455 Witten, Germany
| | - S Fertsch
- Dept. of Plastic and Aesthetic Surgery, Sana Krankenhaus Gerresheim, Gräulinger Straße 120, D-40625 Düsseldorf, Germany; Universität Witten-Herdecke, Fakultät für Gesundheit, Alfred-Herrhausen-Straße 45, 58455 Witten, Germany
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Chun SJ, Jang BS, Choi HS, Chang JH, Shin KH. Prediction of Overall Disease Burden in (y)pN1 Breast Cancer Using Knowledge-Based Machine Learning Model. Cancers (Basel) 2024; 16:1494. [PMID: 38672575 PMCID: PMC11048634 DOI: 10.3390/cancers16081494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Revised: 04/01/2024] [Accepted: 04/10/2024] [Indexed: 04/28/2024] Open
Abstract
BACKGROUND We aimed to construct an expert knowledge-based Bayesian network (BN) model for assessing the overall disease burden (ODB) in (y)pN1 breast cancer patients and compare ODB across arms of ongoing trials. METHODS Utilizing institutional data and expert surveys, we developed a BN model for (y)pN1 breast cancer. Expert-derived probabilities and disability weights for radiotherapy-related benefit (e.g., 7-year disease-free survival [DFS]) and toxicities were integrated into the model. ODB was defined as the sum of disability weights multiplied by probabilities. In silico predictions were conducted for Alliance A011202, PORT-N1, RAPCHEM, and RT-CHARM trials, comparing ODB, 7-year DFS, and side effects. RESULTS In the Alliance A011202 trial, 7-year DFS was 80.1% in both arms. Axillary lymph node dissection led to higher clinical lymphedema and ODB compared to sentinel lymph node biopsy with full regional nodal irradiation (RNI). In the PORT-N1 trial, the control arm (whole-breast irradiation [WBI] with RNI or post-mastectomy radiotherapy [PMRT]) had an ODB of 0.254, while the experimental arm (WBI alone or no PMRT) had an ODB of 0.255. In the RAPCHEM trial, the radiotherapy field did not impact the 7-year DFS in ypN1 patients. However, there was a mild ODB increase with a larger irradiation field. In the RT-CHARM trial, we identified factors associated with the major complication rate, which ranged from 18.3% to 22.1%. CONCLUSIONS The expert knowledge-based BN model predicted ongoing trial outcomes, validating reported results and assumptions. In addition, the model demonstrated the ODB in different arms, with an emphasis on quality of life.
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Affiliation(s)
- Seok-Joo Chun
- Department of Radiation Oncology, Seoul National University Hospital, Seoul 03080, Republic of Korea
- Department of Radiation Oncology, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang 10326, Republic of Korea
| | - Bum-Sup Jang
- Department of Radiation Oncology, Seoul National University Hospital, Seoul 03080, Republic of Korea
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul 03080, Republic of Korea
| | - Hyeon Seok Choi
- Department of Radiation Oncology, Seoul National University Hospital, Seoul 03080, Republic of Korea
| | - Ji Hyun Chang
- Department of Radiation Oncology, Seoul National University Hospital, Seoul 03080, Republic of Korea
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul 03080, Republic of Korea
| | - Kyung Hwan Shin
- Department of Radiation Oncology, Seoul National University Hospital, Seoul 03080, Republic of Korea
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul 03080, Republic of Korea
- Institute of Radiation Medicine, Seoul National University Medical Research Center, Seoul 03080, Republic of Korea
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Zhu M, Mao J, Fang J, Chen D. Risk factors for severe complications and salvage management in direct-to-implant immediate breast reconstruction: A retrospective study. Medicine (Baltimore) 2024; 103:e37365. [PMID: 38457600 PMCID: PMC10919468 DOI: 10.1097/md.0000000000037365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 02/01/2024] [Accepted: 02/02/2024] [Indexed: 03/10/2024] Open
Abstract
Controversies regarding the risk factors affecting direct-to-implant (DTI) immediate breast reconstruction still exist. This study aimed to evaluate the risk factors for severe complications in DTI breast reconstruction and explore potential salvage management strategies. We conducted a retrospective review of 238 patients (240 breasts) who underwent DTI immediate breast reconstruction between 2011 and 2020. Multivariate logistic regression analyses were used to identify the risk factors predicting severe complications. Seventeen (7.08%) reconstructed breasts experienced severe complications, of which only 5 were successfully salvaged through surgical revision, while the others failed and resulted in implant removal. Multivariate analyses demonstrated that mesh use [odds ratio (OR) = 4.054, 95% confidence interval: 1.376-11.945, P = .011] and post-mastectomy radiotherapy (odds ratio = 4.383, 95% confidence interval 1.142-16.819, P = .031) were independent predictors of severe complications. Mesh use and post-mastectomy radiotherapy for breast reconstruction increase the risk of severe complications. Despite positive surgical treatment, the successful salvage rate was poor.
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Affiliation(s)
- Meizhen Zhu
- Department of Breast Surgery, The Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Institute of Basic Medicine and Cancer (IBMC), Chinese Academy of Sciences, Hangzhou, China
| | - Jiefei Mao
- Department of Breast Surgery, The Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Institute of Basic Medicine and Cancer (IBMC), Chinese Academy of Sciences, Hangzhou, China
| | - Jun Fang
- Department of Radiation Therapy, The Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Institute of Basic Medicine and Cancer (IBMC), Chinese Academy of Sciences, Hangzhou, China
| | - Daobao Chen
- Department of Breast Surgery, The Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Institute of Basic Medicine and Cancer (IBMC), Chinese Academy of Sciences, Hangzhou, China
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Berlin E, Yegya-Raman N, Hollawell C, Haertter A, Fosnot J, Rhodes S, Seol SW, Gentile M, Li T, Freedman GM, Taunk NK. Breast Reconstruction Complications After Postmastectomy Proton Radiation Therapy for Breast Cancer. Adv Radiat Oncol 2024; 9:101385. [PMID: 38495035 PMCID: PMC10943514 DOI: 10.1016/j.adro.2023.101385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 10/03/2023] [Indexed: 03/19/2024] Open
Abstract
Purpose Our purpose was to report complications requiring surgical intervention among patients treated with postmastectomy proton radiation therapy (PMPRT) for breast cancer in the setting of breast reconstruction (BR). Methods and Materials Patients enrolled on a prospective proton registry who underwent BR with immediate autologous flap, tissue expander (TE), or implant in place during PMPRT (50/50.4 Gy +/- chest wall boost) were eligible. Major reconstruction complication (MRC) was defined as a complication requiring surgical intervention. Absolute reconstruction failure was an MRC requiring surgical removal of BR. A routine revision (RR) was a plastic surgery refining cosmesis of the BR. Kaplan-Meier method was used to assess disease outcomes and MRC. Cox regression was used to assess predictors of MRC. Results Seventy-three courses of PMPRT were delivered to 68 women with BR between 2013 and 2021. Median follow-up was 42.1 months. Median age was 47 years. Fifty-six (76.7%) courses used pencil beam scanning PMPRT. Of 73 BR, 29 were flaps (39.7%), 30 implants (41.1%), and 14 TE (19.2%) at time of irradiation. There were 20 (27.4%) RR. There were 9 (12.3%) MRC among 5 implants, 2 flaps, and 2 TE, occurring a median of 29 months from PMPRT start. Three-year freedom from MRC was 86.9%. Three (4.1%) of the MRC were absolute reconstruction failure. Complications leading to MRC included capsular contracture in 5, fat necrosis in 2, and infection in 2. On univariable analysis, BR type, boost, proton technique, age, and smoking status were not associated with MRC, whereas higher body mass index trended toward significance (hazard ratio, 1.07; 95% CI, 0.99-1.16; P = .10). Conclusions Patients undergoing PMPRT to BR had a 12.3% incidence of major complications leading to surgical intervention, and total loss of BR was rare. MRC rates were similar among reconstruction types. Minor surgery for RR is common in our practice.
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Affiliation(s)
| | | | | | | | - Joshua Fosnot
- Division of Plastic Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Jang BS, Chun SJ, Choi HS, Chang JH, Shin KH. Estimating the risk and benefit of radiation therapy in (y)pN1 stage breast cancer patients: A Bayesian network model incorporating expert knowledge (KROG 22-13). COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2024; 245:108049. [PMID: 38295597 DOI: 10.1016/j.cmpb.2024.108049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 01/07/2024] [Accepted: 01/23/2024] [Indexed: 02/02/2024]
Abstract
BACKGROUND We aimed to evaluate the risk and benefit of (y)pN1 breast cancer patients in a Bayesian network model. METHOD We developed a Bayesian network (BN) model comprising three parts: pretreatment, intervention, and risk/benefit. The pretreatment part consisted of clinical information from a tertiary medical center. The intervention part regarded the field of radiotherapy. The risk/benefit component encompasses radiotherapy (RT)-related side effects and effectiveness, including factors such as recurrence, cardiac toxicity, lymphedema, and radiation pneumonitis. These factors were evaluated in terms of disability weights and probabilities from a nationwide expert survey. The overall disease burden (ODB) was calculated as the sum of the probability multiplied by the disability weight. A higher value of ODB indicates a greater disease burden for the patient. RESULTS Among the 58 participants, a BN model utilizing discretization and clustering techniques revealed five distinct clusters. Overall, factors associated with breast reconstruction and RT exhibited high discrepancies (24-34 %), while RT-related side effects demonstrated low discrepancies (3-11 %) among the experts. When incorporating recurrence and RT-related side effects, the mean ODB of (y)pN1 patients was 0.258 (range, 0.244-0.337), with a higher tendency observed in triple-negative breast cancer (TNBC) or mastectomy cases. The ODB for TNBC patients undergoing mastectomy without postmastectomy radiotherapy was 0.327, whereas for non-TNBC patients undergoing breast conserving surgery with RT, the disease burden was 0.251. There was an increasing trend in ODB as the field of RT increased. CONCLUSION We developed a Bayesian network model based on an expert survey, which helps to understand treatment patterns and enables precise estimations of RT-related risk and benefit in (y)pN1 patients.
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Affiliation(s)
- Bum-Sup Jang
- Department of Radiation Oncology, Seoul National University Hospital, Seoul, South Korea; Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, South Korea
| | - Seok-Joo Chun
- Department of Radiation Oncology, Seoul National University Hospital, Seoul, South Korea
| | - Hyeon Seok Choi
- Department of Radiation Oncology, Seoul National University Hospital, Seoul, South Korea
| | - Ji Hyun Chang
- Department of Radiation Oncology, Seoul National University Hospital, Seoul, South Korea; Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, South Korea
| | - Kyung Hwan Shin
- Department of Radiation Oncology, Seoul National University Hospital, Seoul, South Korea; Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, South Korea; Institute of Radiation Medicine, Seoul National University Medical Research Center, Seoul, South Korea.
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Vincent L, Laville C, Jacinto S, Coutant C, Burnier P. [Updated indications and techniques for immediate breast reconstruction, particularly in the case of adjuvant radiotherapy]. GYNECOLOGIE, OBSTETRIQUE, FERTILITE & SENOLOGIE 2024; 52:165-169. [PMID: 38307494 DOI: 10.1016/j.gofs.2024.01.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Accepted: 01/29/2024] [Indexed: 02/04/2024]
Abstract
In 2023, 62,000 patients were diagnosed with breast cancer in France. Every year, 22,000 mastectomies are performed. Breast reconstruction (BR) should be an integral part of breast cancer management. Yet the MR rate in France is only 28% within 3 years of mastectomy, of which 14% are immediate breast reconstruction (IBR). The number of contraindications to RMI has steadily declined over the last few decades, although some of them remain definitive, such as inflammatory cancer (T4d). Today, many specialists involved in the management of breast cancer consider that IBR can be proposed in cases where adjuvant chemotherapy and/or radiotherapy is indicated, if it is not expected to delay carcinological management. The surgical team must then inform the patient of all available BR techniques. If a team does not offer a particular technique, the patient should be referred to a center that does. In all cases, the proposal for curative and reparative treatment should be the subject of a multidisciplinary discussion involving, in particular, a surgeon, a radiotherapist and a medical oncologist. When adjuvant radiotherapy is indicated, the patient must be informed of the increased risk of complications and deterioration of the aesthetic result. In this indication, RMI by prosthesis is a validated technique. However, if the patient has a history of radiotherapy, autologous techniques should be preferred. In a context of shared decision-making, the choice of whether or not to undergo MR and the type of technique must ultimately be made by the patient, in agreement with the multidisciplinary team.
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Affiliation(s)
- Laura Vincent
- Département de chirurgie oncologique, centre Georges-François-Leclerc, 1, rue du Professeur-Marion, 21000 Dijon, France
| | - Clémentine Laville
- Département de chirurgie oncologique, centre Georges-François-Leclerc, 1, rue du Professeur-Marion, 21000 Dijon, France
| | - Sarah Jacinto
- Département de chirurgie oncologique, centre Georges-François-Leclerc, 1, rue du Professeur-Marion, 21000 Dijon, France; Université de Bourgogne, 7, boulevard Jeanne-d'Arc, 21000 Dijon, France
| | - Charles Coutant
- Département de chirurgie oncologique, centre Georges-François-Leclerc, 1, rue du Professeur-Marion, 21000 Dijon, France; Université de Bourgogne, 7, boulevard Jeanne-d'Arc, 21000 Dijon, France
| | - Pierre Burnier
- Département de chirurgie oncologique, centre Georges-François-Leclerc, 1, rue du Professeur-Marion, 21000 Dijon, France.
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Couto-González I, Brea-García B, Fernández-Marcos AÁ, Taboada-Suárez A. Conversion to Autologous Breast Reconstruction with Latissimus Dorsi and Immediate Fat Grafting in Patients with Previous Implant Failure: An Efficient, Reproducible, and Safe Technique. Indian J Plast Surg 2024; 57:16-23. [PMID: 38450013 PMCID: PMC10914543 DOI: 10.1055/s-0044-1779479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2024] Open
Abstract
Introduction Implant-based breast reconstructions (IBBRs) increased last years despite the growing indications for radiotherapy in the treatment of breast cancer. As a result, complications and reconstructive failures associated to IBBR have increased. Autologous breast reconstruction (ABR) using fat-augmented latissimus dorsi (FALD) has become popular in recent years. Methods We aimed to evaluate conversion to ABR using latissimus dorsi and immediate fat grafting in 61 cases with IBBR failure. Results Immediate reconstruction was found significatively related with an increased number of surgeries resulting from IBBR complications ( p < 0.001). Note that 41% of the cases presented a grade III/IV Baker and Palmer capsular contracture, 29% implant extrusion, and 21% implant infection. Mean survival of the first implant was 16.95 months. ABR process was completed in 47% of cases with a single surgery. Statistically significant differences were observed between this fact and previous IBBR failure due to infection ( p = 0.03) or extrusion ( p = 0.01). Mean volume of fat graft was 429.61 mL, mean length of the surgical procedure was 3.17 hours, and the average length of hospital stay after surgery was 2.67 days. Only 3.3% of the cases developed some major complication. None of the cases presented reconstructive failure. Conclusion FALD is a very safe total ABR technique, an important fact in patients with previous reconstructive failures. The large volume of fat that can be grafted in a single surgery allows the reconstruction of breast in a reasonable size. The reduced length of surgery and hospital stay make the FALD technique an option to consider when an autologous but efficient and safe reconstruction is desired.
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Affiliation(s)
- Ivan Couto-González
- Department of Plastic and Reconstructive Surgery, Complexo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | - Beatriz Brea-García
- Department of Plastic and Reconstructive Surgery, Complexo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | | | - Antonio Taboada-Suárez
- Department of Plastic and Reconstructive Surgery, Complexo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, Spain
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Vinsensia M, Schaub R, Meixner E, Hoegen P, Arians N, Forster T, Hoeltgen L, Köhler C, Uzun-Lang K, Batista V, König L, Zivanovic O, Hennigs A, Golatta M, Heil J, Debus J, Hörner-Rieber J. Incidence and Risk Assessment of Capsular Contracture in Breast Cancer Patients following Post-Mastectomy Radiotherapy and Implant-Based Reconstruction. Cancers (Basel) 2024; 16:265. [PMID: 38254756 PMCID: PMC10813520 DOI: 10.3390/cancers16020265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 12/29/2023] [Accepted: 01/04/2024] [Indexed: 01/24/2024] Open
Abstract
Our study aims to identify the risk factors and dosimetry characteristics associated with capsular contracture. METHODS We retrospectively analyzed 118 women with breast cancer who underwent PMRT following an IBR between 2010 and 2022. Patients were treated with PMRT of 50.0-50.4 Gy in 25-28 fractions. Capsular contracture was categorized according to the Baker Classification for Reconstructed Breasts. RESULTS After a median follow-up of 22 months, the incidence of clinically relevant capsular contracture (Baker III-IV) was 22.9%. Overall, capsular contracture (Baker I-IV) occurred in 56 patients (47.5%) after a median of 9 months after PMRT. The rate of reconstruction failure/implant loss was 25.4%. In the univariate analysis, postoperative complications (prolonged pain, prolonged wound healing, seroma and swelling) and regional nodal involvement were associated with higher rates of capsular contracture (p = 0.017, OR: 2.5, 95% CI: 1.2-5.3 and p = 0.031, respectively). None of the analyzed dosimetric factors or the implant position were associated with a higher risk for capsular contracture. CONCLUSION Postoperative complications and regional nodal involvement were associated with an increased risk of capsular contracture following breast reconstruction and PMRT, while none of the analyzed dosimetric factors were linked to a higher incidence. Additional studies are needed to identify further potential risk factors.
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Affiliation(s)
- Maria Vinsensia
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), 69120 Heidelberg, Germany
- National Center for Tumor Diseases (NCT), 69120 Heidelberg, Germany
| | - Riccarda Schaub
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Eva Meixner
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), 69120 Heidelberg, Germany
- National Center for Tumor Diseases (NCT), 69120 Heidelberg, Germany
| | - Philipp Hoegen
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), 69120 Heidelberg, Germany
- National Center for Tumor Diseases (NCT), 69120 Heidelberg, Germany
- Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
| | - Nathalie Arians
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), 69120 Heidelberg, Germany
- National Center for Tumor Diseases (NCT), 69120 Heidelberg, Germany
| | - Tobias Forster
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), 69120 Heidelberg, Germany
- National Center for Tumor Diseases (NCT), 69120 Heidelberg, Germany
| | - Line Hoeltgen
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), 69120 Heidelberg, Germany
- National Center for Tumor Diseases (NCT), 69120 Heidelberg, Germany
| | - Clara Köhler
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), 69120 Heidelberg, Germany
- National Center for Tumor Diseases (NCT), 69120 Heidelberg, Germany
| | - Kristin Uzun-Lang
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), 69120 Heidelberg, Germany
- National Center for Tumor Diseases (NCT), 69120 Heidelberg, Germany
| | - Vania Batista
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), 69120 Heidelberg, Germany
| | - Laila König
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), 69120 Heidelberg, Germany
- National Center for Tumor Diseases (NCT), 69120 Heidelberg, Germany
| | - Oliver Zivanovic
- Department of Gynecology and Obstetrics, Heidelberg University Hospital, 69120 Heidelberg, Germany
- Brustzentrum Heidelberg Klinik St. Elisabeth, 69121 Heidelberg, Germany
| | - Andre Hennigs
- Department of Gynecology and Obstetrics, Heidelberg University Hospital, 69120 Heidelberg, Germany
- Brustzentrum Heidelberg Klinik St. Elisabeth, 69121 Heidelberg, Germany
| | - Michael Golatta
- Department of Gynecology and Obstetrics, Heidelberg University Hospital, 69120 Heidelberg, Germany
- Brustzentrum Heidelberg Klinik St. Elisabeth, 69121 Heidelberg, Germany
| | - Jörg Heil
- Department of Gynecology and Obstetrics, Heidelberg University Hospital, 69120 Heidelberg, Germany
- Brustzentrum Heidelberg Klinik St. Elisabeth, 69121 Heidelberg, Germany
| | - Jürgen Debus
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), 69120 Heidelberg, Germany
- National Center for Tumor Diseases (NCT), 69120 Heidelberg, Germany
- Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
- Department of Radiation Oncology, Heidelberg Ion Beam Therapy Center (HIT), Heidelberg University Hospital, 69120 Heidelberg, Germany
- German Cancer Consortium (DKTK), Partner Site Heidelberg, 69120 Heidelberg, Germany
| | - Juliane Hörner-Rieber
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), 69120 Heidelberg, Germany
- National Center for Tumor Diseases (NCT), 69120 Heidelberg, Germany
- Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
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Couto-González I, Fernández-Marcos AÁ, Brea-García B, González-Giménez N, Canseco-Díaz F, García-Arjona B, Mato-Codesido C, Taboada-Suárez A. Silicone Shell Breast Implants in Patients Undergoing Risk-Reducing Mastectomy With a History of Breast-Conserving Surgery and Adjuvant Radiotherapy: A Long-term Study. Aesthet Surg J 2023; 44:NP60-NP68. [PMID: 37706356 DOI: 10.1093/asj/sjad300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 08/31/2023] [Accepted: 09/06/2023] [Indexed: 09/15/2023] Open
Abstract
BACKGROUND Indications for breast-conserving surgery and adjuvant radiotherapy (BCSAR) in patients with breast carcinoma are increasing, as are indications for risk-reducing mastectomy (RRM) in healthy subjects. Most of these cases are reconstructed with silicone shell breast implants (SSBIs). OBJECTIVES The aim of this work was to study complications of SSBIs in breast reconstruction in patients undergoing RRM with previous BCSAR. METHODS A prospective cohort study was designed. The study group included cases of RRM reconstructed with SSBI in patients who had previously undergone BCSAR in the same breast. The control group consisted of patients with high-risk breast cancer who had undergone RRM and immediate SSBI reconstruction without previous BCSAR. RESULTS There was a history of BCSAR in 15.8% of cases. The first SSBI used in immediate reconstruction after RRM was replaced in 51.5% of cases with a mean [standard deviation] survival of 24.04 [28.48] months. BCSAR was significantly associated with pathological capsular contracture (P = .00) with this first SSBI (37.5% vs 5.9%). Of the cases requiring the replacement of the first SSBI, 44.23% suffered failure of the second SSBI, with a mean survival of 27.95 [26.53] months. No significant association was found between the consecutive development of capsular contracture in the second SSBI and a previous history of BCSAR (P = .10). CONCLUSIONS BCSAR prior to RRM reconstructed with an SSBI is associated with a significant increase in pathological capsular contracture. Patients should be warned of the high rate of SSBI complications and reconstruction failure. Polyurethane-coated implants may provide an alternative in cases in which alloplastic reconstruction is considered in patients with previous BCSAR. LEVEL OF EVIDENCE: 3
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12
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Lisa A, Carbonaro R, Bottoni M, Ostapenko E, Rietjens M. Bovine Acellular Dermal Matrix-Based Breast Reconstruction in Previously Irradiated Breasts: Complications and Outcomes From a Single-Center Experience. Ann Plast Surg 2023; 91:686-692. [PMID: 37624913 DOI: 10.1097/sap.0000000000003667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/27/2023]
Abstract
ABSTRACT Radiation therapy is considered today an integral part of the management of breast cancer. However, radiotherapy significantly increases the incidence of total complications in breast reconstruction. Several procedures have been adopted to reduce complication rates in irradiated fields, including the use of acellular dermal matrices (ADMs). We conducted a retrospective analysis of our single-center experience with ADM-assisted implant-based reconstruction or revision surgeries for capsular contracture treatment in irradiated breasts. We divided our population into 4 groups based on prior surgical history: group A (previous quadrantectomy), group B (previous mastectomy and expander reconstruction), group C (previous mastectomy and implant reconstruction), and group D (prior quadrantectomy followed by mastectomy and implant reconstruction). At the European Oncology Institute in Milan, Italy, between June 2017 and April 2019, we identified 84 patients for a total of 86 irradiated breasts reconstructed with implant and ADM. We observed a total of 12 reconstructive failure, with the highest rate of failure in group B (16.6%) and in group D (15.38%). Overall, we recorded 22 total complications (24.4%): 12 major complications and 10 minor complications. The most common complication was infection, with 9 cases (10.4%), 6 of which were classified as severe and required implant removal. In group B, we observed the highest complication rate, both major and minor, with 7 of 42 patients (16.6%) experiencing each. Before reconstruction with ADM, the Baker grade ranged from 3 to 4, with a mean of 3.25. At the 2-year follow-up, the Baker grade ranged from 1 to 4, with a mean of 1.9. Surgeons were highly satisfied with the aesthetic result in 72.1% of cases, moderately in 8.1% and unsatisfied in 5.81%, and in 13.9%, the outcome was not assessable because of reconstructive failure. The worst aesthetic result was in group B. We observed significant reduction in capsular contracture in revision surgeries despite a moderately high rate of complications in previous quadrantectomy and radiotherapy. In our experience, breast reconstruction with implant and ADM is not the primary surgical indication in case of prior irradiation, but it can be considered as a valid alternative with reasonable safety profile, to be used in selected cases.
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Affiliation(s)
| | | | - Manuela Bottoni
- From the Department of Plastic and Reconstructive Surgery, European Institute of Oncology, IRCCS (Istituto di Ricovero e Cura a Carattere Scientifico)
| | | | - Mario Rietjens
- From the Department of Plastic and Reconstructive Surgery, European Institute of Oncology, IRCCS (Istituto di Ricovero e Cura a Carattere Scientifico)
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Shauly O, Olson B, Marxen T, Menon A, Losken A, Patel KM. Direct-to-implant versus autologous tissue transfer: A meta-analysis of patient-reported outcomes after immediate breast reconstruction. J Plast Reconstr Aesthet Surg 2023; 84:93-106. [PMID: 37329749 DOI: 10.1016/j.bjps.2023.05.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 05/12/2023] [Accepted: 05/15/2023] [Indexed: 06/19/2023]
Abstract
BACKGROUND The effect of immediate implant and autologous breast reconstruction on complication rates has been studied extensively; however, the patient-reported outcomes for these procedures during immediate, one-stage reconstruction has yet to be comprehensively investigated. OBJECTIVE This study compared the patient-reported outcomes for immediate implant reconstruction with those associated with immediate autologous reconstruction to determine the advantages and disadvantages for each modality from the patient's perspective. METHODS A literature search of PubMed between 2010 and 2021 was performed, and 21 studies containing patient-reported outcomes were selected for the analysis. A meta-analysis of patient-reported outcome scores was performed separately for immediate breast reconstruction using autologous tissue transfer and synthetic implants. RESULTS Nineteen manuscripts were included, representing data on a total of 1342 patients across all studies. The pooled mean of patients' satisfaction with their breasts was 70.7 (95% CI, 69.4-72.0) after immediate autologous reconstruction and 68.5 (95% CI, 67.1-69.9) after immediate implant reconstruction, showing a statistically significant difference in outcomes (p < 0.05). The pooled mean of patients' sexual well-being was 59.3 (95% CI, 57.8-60.8) after immediate autologous reconstruction and 62.8 (95% CI, 60.7-64.8) after immediate implant reconstruction (p < 0.01). The pooled mean of patients' satisfaction with their outcome was 78.8 (95% CI, 76.2-81.3) after immediate autologous reconstruction and 82.3 (95% CI, 80.4-84.1) after immediate implant reconstruction (p < 0.05). The results of each meta-analysis were summarized on forest plots depicting the distribution of patient-reported outcome scores from each study. CONCLUSIONS Immediate reconstruction with implants may have a similar or greater capacity to achieve patient satisfaction and improve patients' QoL compared to those associated with immediate reconstruction with autologous tissue transfer when both procedures are available.
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Affiliation(s)
- Orr Shauly
- Emory University School of Medicine, Division of Plastic and Reconstructive Surgery, GA, United States
| | - Blade Olson
- University of Southern California, Keck School of Medicine, Division of Plastic and Reconstructive Surgery, CA, United States
| | - Troy Marxen
- Emory University School of Medicine, Division of Plastic and Reconstructive Surgery, GA, United States.
| | - Ambika Menon
- Emory University School of Medicine, Division of Plastic and Reconstructive Surgery, GA, United States
| | - Albert Losken
- Emory University School of Medicine, Division of Plastic and Reconstructive Surgery, GA, United States
| | - Ketan M Patel
- University of Southern California, Keck School of Medicine, Division of Plastic and Reconstructive Surgery, CA, United States
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Atiyeh B, Emsieh S. Letter-to-the-Editor: Two-Stage Expander-Based (EB) or Single-Stage Direct-to-Implant (DTI) Breast Reconstruction-An Ongoing Debate. Aesthetic Plast Surg 2023; 47:154-158. [PMID: 36171405 DOI: 10.1007/s00266-022-03113-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 09/08/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Bishara Atiyeh
- American University of Beirut Medical Center, Beirut, Lebanon.
| | - Saif Emsieh
- American University of Beirut Medical Center, Beirut, Lebanon
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15
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Saiga M, Nakagiri R, Mukai Y, Matsumoto H, Kimata Y. Trends and issues in clinical research on satisfaction and quality of life after mastectomy and breast reconstruction: a 5-year scoping review. Int J Clin Oncol 2023:10.1007/s10147-023-02347-5. [PMID: 37160493 DOI: 10.1007/s10147-023-02347-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 04/20/2023] [Indexed: 05/11/2023]
Abstract
Breast reconstruction (BR) aims to improve the satisfaction and quality of life (QOL) of breast cancer survivors. Clinical studies using patient-reported outcomes (PROs) can therefore provide relevant information to the patients and support decision-making. This scoping review was conducted to analyze recent trends in world regions, methods used, and factors investigated. The literature search was conducted in August 2022. Databases of PubMed, MEDLINE, and CINAHL were searched for relevant English-language studies published from 2017 to 2022. Studies involving women with breast cancer who underwent BR after mastectomy and investigated PROs after BR using BR-specific scales were included. Data on the country, publication year, study design, PRO measures (PROMs) used, time points of surveys, and research themes were collected. In total, 147 articles met the inclusion criteria. BREAST-Q was the most widely used, contributing to the increase in the number and diversification of studies in this area. Such research has been conducted mainly in North America and Europe and is still developing in Asia and other regions. The research themes involved a wide range of clinical and patient factors in addition to surgery, which could be influenced by research methods, time since surgery, and even cultural differences. Recent BR-specific PROMs have led to a worldwide development of research on factors that affect satisfaction and QOL after BR. PRO after BR may be influenced by local cultural and social features, and it would be necessary to accumulate data in each region to draw clinically useful conclusion.
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Affiliation(s)
- Miho Saiga
- Department of Plastic Surgery, Okayama University Hospital, 2-5-1, Shikata-cho, Kita-ku, Okayama City, Okayama, 700-8558, Japan.
| | - Ryoko Nakagiri
- Department of Plastic Surgery, Okayama University Hospital, 2-5-1, Shikata-cho, Kita-ku, Okayama City, Okayama, 700-8558, Japan
| | - Yuko Mukai
- Department of Plastic Surgery, Okayama Rosai Hospital, Okayama, Japan
| | - Hiroshi Matsumoto
- Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Yoshihiro Kimata
- Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
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Makarewicz N, Perrault D, Sharma A, Shaheen M, Kim J, Calderon C, Sweeney B, Nazerali R. Comparing the Outcomes and Complication Rates of Biologic vs Synthetic Meshes in Implant-Based Breast Reconstruction: A Systematic Review. Ann Plast Surg 2023; 90:516-527. [PMID: 37146317 DOI: 10.1097/sap.0000000000003512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
Abstract
OBJECTIVE This systematic review evaluates all published studies comparing biologic and synthetic meshes in implant-based breast reconstruction (IBBR), to determine which category of mesh produces the most favorable outcomes. SUMMARY BACKGROUND DATA Breast cancer is the most common cancer in women globally. Implant-based breast reconstruction is currently the most popular method of postmastectomy reconstruction, and recently, the use of surgical mesh in IBBR has become commonplace. Although there is a long-standing belief among surgeons that biologic mesh is superior to synthetic mesh in terms of surgical complications and patient outcomes, few studies exist to support this claim. METHODS A systematic search of the EMBASE, PubMed, and Cochrane databases was performed in January 2022. Primary literature studies comparing biologic and synthetic meshes within the same experimental framework were included. Study quality and bias were assessed using the validated Methodological Index for Non-Randomized Studies criteria. RESULTS After duplicate removal, 109 publications were reviewed, with 12 meeting the predetermined inclusion criteria. Outcomes included common surgical complications, histological analysis, interactions with oncologic therapies, quality of life measures, and esthetic outcomes. Across all 12 studies, synthetic meshes were rated as at least equivalent to biologic meshes for every reported outcome. On average, the studies in this review tended to have moderate Methodological Index for Non-Randomized Studies scores. CONCLUSION This systematic review offers the first comprehensive evaluation of all publications comparing biologic and synthetic meshes in IBBR. The consistent finding that synthetic meshes are at least equivalent to biologic meshes across a range of clinical outcomes offers a compelling argument in favor of prioritizing the use of synthetic meshes in IBBR.
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Affiliation(s)
- Nathan Makarewicz
- From the Division of Plastic and Reconstructive Surgery, Stanford University, Stanford, CA
| | - David Perrault
- From the Division of Plastic and Reconstructive Surgery, Stanford University, Stanford, CA
| | - Ayushi Sharma
- From the Division of Plastic and Reconstructive Surgery, Stanford University, Stanford, CA
| | - Mohammed Shaheen
- From the Division of Plastic and Reconstructive Surgery, Stanford University, Stanford, CA
| | - Jessica Kim
- Loma Linda School of Medicine, Loma Linda, CA
| | - Christian Calderon
- From the Division of Plastic and Reconstructive Surgery, Stanford University, Stanford, CA
| | - Brian Sweeney
- From the Division of Plastic and Reconstructive Surgery, Stanford University, Stanford, CA
| | - Rahim Nazerali
- From the Division of Plastic and Reconstructive Surgery, Stanford University, Stanford, CA
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Lee CT, Ruth K, Patel S, Bleicher R, Sigurdson E, Weiss S, Hayes S, Anderson P, Wong JK. Factors Associated with Reconstruction Failure and Major Complications After Postmastectomy Radiation to a Reconstructed Breast. Pract Radiat Oncol 2023; 13:122-131. [PMID: 36332800 PMCID: PMC10684027 DOI: 10.1016/j.prro.2022.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 09/12/2022] [Accepted: 09/22/2022] [Indexed: 11/17/2022]
Abstract
PURPOSE Postmastectomy radiation therapy is known to increase risk of complications in the reconstruction setting. We aim to identify the variables associated with reconstruction failure and other major complications. METHODS AND MATERIALS A prospectively collected institutional database was queried for patients with up to stage IIIC breast cancer treated from 2000 to 2017, undergoing mastectomy, immediate implant or autologous tissue reconstruction, and radiation to the reconstructed breast within 1 year of surgery. Reconstruction failure was defined as complication requiring surgical revision or implant removal. Additional major complications were defined as any infection, contracture, necrosis, or fibrosis. Covariates of interest included age, body mass index, smoking status, stage, hormone receptor and HER2 status, systemic therapy timing, radiation technique, nodal irradiation, and interval between surgery and start of postmastectomy radiation therapy. Differences in complication rates were assessed with χ² or Fisher exact tests. Competing risk regression was used to estimate hazard ratios; covariates were included one at a time to avoid over adjustment. RESULTS A total of 206 reconstructed breasts in 202 patients resulted from our initial query, with 139 treated with intensity-modulated radiation therapy (IMRT) and 67 treated with conventional radiation therapy (CRT). Median follow-up was 45 months (range, 4-210 months); patient cohorts were generally similar. Eight patients were excluded from toxicity analysis for insufficient follow-up (<2 years). Overall, reconstruction failure and major complication rates were significantly lower in the IMRT group. Reconstruction failure rates were 3.0% for IMRT versus 16.4% for CRT (P = .002), and major complication rates were 6.8% for IMRT versus 24.6% for CRT (P < .001). On univariate analysis, CRT was significantly predictive of implant failure (hazard ratio, 5.54; P = .003) and increased complication rates (hazard ratio, 3.83; P = .001). Significance persisted on multivariable analysis. Survival outcomes were similar, with no difference in 2 year overall survival (P = .12) and local recurrence (P = .41). CONCLUSIONS Using IMRT may improve reconstruction outcomes over CRT, with significantly lower reconstruction failure and complication rates without compromising local control or survival.
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Affiliation(s)
- Charles T Lee
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Karen Ruth
- Department of Biostatistics and Bioinformatics, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Sameer Patel
- Department of Plastic Surgery, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Richard Bleicher
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Elin Sigurdson
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Stephanie Weiss
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Shelly Hayes
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Penny Anderson
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - J Karen Wong
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania.
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18
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Investigating the Severity of Complications following Mastectomy and Prepectoral Implant-Based versus Autologous Reconstruction. Plast Reconstr Surg 2023; 151:200e-206e. [PMID: 36332003 DOI: 10.1097/prs.0000000000009827] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Several clinical studies have reported autologous breast reconstruction (ABR) to be associated with a higher postoperative complication rate; however, few have investigated the impact of reconstructive modality on complication severity. This study examines the impact of reconstructive modality on complication severity in a matched cohort of patients who underwent ABR versus implant-based breast reconstruction (IBR). METHODS A retrospective study of patients who underwent nipple-sparing mastectomy with immediate reconstruction was performed. Propensity score matching ensured adequate matching of patients who underwent ABR and staged prepectoral IBR, respectively. Patient demographics, breast measurements, and postoperative outcomes (including the incidence and severity of complications) were analyzed. Multivariable logistic regression analysis was performed. P < 0.05 was considered significant. RESULTS One hundred twenty-eight patients (214 breast reconstructions) were included for analysis (ABR, n = 64; IBR, n = 64). No difference in overall complication rate was noted ( P = 0.61). However, a significant association of IBR with major complications was noted ( P = 0.02). In contrast, minor complications were significantly more frequent following ABR ( P = 0.04). CONCLUSIONS Although the reconstructive modality did not appear to have an effect on the overall complication rate, it did significantly affect the severity of postoperative complications, with major and minor complications being associated with IBR and ABR, respectively. These findings are relevant to patient-centered decision-making, as they provide further granularity regarding postoperative complications and address the issue of complication severity. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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19
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Stefura T, Rusinek J, Wątor J, Zagórski A, Zając M, Libondi G, Wysocki WM, Koziej M. Implant vs. autologous tissue-based breast reconstruction: A systematic review and meta-analysis of the studies comparing surgical approaches in 55,455 patients. J Plast Reconstr Aesthet Surg 2023; 77:346-358. [PMID: 36621238 DOI: 10.1016/j.bjps.2022.11.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 10/13/2022] [Accepted: 11/17/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND The choice of reconstruction type is of utmost importance in treating breast cancer. There are two major reconstructive pathways in this group of patients: autologous breast reconstruction (ABR) and implant-based breast reconstruction (IBR). The aim of this systematic review and meta-analysis was to assess and compare IBR vs. ABR. METHODS A review of studies reporting the differences between the procedures was performed. The MEDLINE/PubMed, ScienceDirect, EMBASE, BIOSIS, SciELO, Scopus, and Web of Science databases were thoroughly searched in September 2021. The data concerning group characteristics, BREAST-Q scores, complication rates, length of stay (LOS), and costs were extracted. The Cochrane risk-of-bias tool was used for randomized studies, while Newcastle-Ottawa Quality Assessment for Cohort Studies was used for other types of research. RESULTS Our meta-analysis included 32 studies (n = 55,455). We observed significantly better outcomes following ABR when it comes to esthetic satisfaction (mean difference [MD] -8.51; 95% confidence interval [CI] -10.70, -6.33; p<0.001) and satisfaction with the entire reconstructive treatment (MD -6.56; 95% CI -9.97, -3.14; p<0.001). Both methods appeared to be comparable in terms of safety, while the complication rates varied insignificantly between the groups (odds ratio [OR] 1.06; 95% CI 0.71, 1.59; p = 0.76). ABR seems to be correlated with significantly higher costs (standard mean difference [SMD] -0.69; 95% CI -1.21, -0.17; p = 0.010). CONCLUSIONS The results obtained from this evidence-based study will improve the understanding of the different clinical pathways that patients can be assigned to. The study emphasized the advantages and disadvantages of both methods.
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Affiliation(s)
| | - Jakub Rusinek
- Jagiellonian University Medical College, Cracow, Poland
| | - Julia Wątor
- Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland
| | | | - Maciej Zając
- Jagiellonian University Medical College, Cracow, Poland
| | - Guido Libondi
- Department of General, Oncological and Vascular Surgery, 5th Military Clinical Hospital in Cracow, Poland
| | - Wojciech M Wysocki
- Department of General, Oncological and Vascular Surgery, 5th Military Clinical Hospital in Cracow, Poland; Chair of Surgery, Faculty of Medicine and Health Sciences, Andrzej Frycz Modrzewski Cracow University, Cracow, Poland
| | - Mateusz Koziej
- Department of Anatomy, Jagiellonian University Medical College, Cracow, Poland.
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Emanuele Lisa AV, Salgarello M, Huscher A, Corsi F, Piovani D, Rubbino F, Andreoletti S, Papa G, Klinger F, Tinterri C, Testori A, Scorsetti M, Veronesi P, Leonardi MC, Rietjens M, Cortinovis U, Summo V, Rampino Cordaro E, Parodi PC, Persichetti P, Barone M, De Santis G, Murolo M, Riccio M, Aquinati A, Cavaliere F, Vaia N, Pagura G, Dalla Venezia E, Bassetto F, Vindigni V, Ciuffreda L, Bocchiotti MA, Sciarillo A, Renzi N, Meneghini G, Kraljic T, Loreti A, Fortunato L, Pino V, Vinci V, Klinger M. The Effect of Adjuvant Radiotherapy on One- and Two-Stage Prosthetic Breast Reconstruction and on Autologous Reconstruction: A Multicenter Italian Study among 18 Senonetwork Breast Centres. Breast J 2023; 2023:6688466. [PMID: 37205012 PMCID: PMC10188256 DOI: 10.1155/2023/6688466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Revised: 04/07/2023] [Accepted: 04/15/2023] [Indexed: 05/21/2023]
Abstract
Purpose In modern breast cancer treatment, a growing role has been observed for breast reconstruction together with an increase in clinical indications for postmastectomy radiotherapy (PMRT). Choosing the optimum type of reconstructive technique is a clinical challenge. We therefore conducted a national multicenter study to analyze the impact of PMRT on breast reconstruction. Methods We conducted a retrospective case-control multicenter study on women undergoing breast reconstruction. Data were collected from 18 Italian Breast Centres and stored in a cumulative database which included the following: autologous reconstruction, direct-to-implant (DTI), and tissue expander/immediate (TE/I). For all patients, we described complications and surgical endpoints to complications such as reconstruction failure, explant, change in type of reconstruction, and reintervention. Results From 2001 to April 2020, 3116 patients were evaluated. The risk for any complication was significantly increased in patients receiving PMRT (aOR, 1.73; 95% CI, 1.33-2.24; p < 0.001). PMRT was associated with a significant increase in the risk of capsular contracture in the DTI and TE/I groups (aOR, 2.24; 95% CI, 1.57-3.20; p < 0.001). Comparing type of procedures, the risk of failure (aOR, 1.82; 95% CI, 1.06-3.12, p=0.030), explant (aOR, 3.34; 95% CI, 3.85-7.83, p < 0.001), and severe complications (aOR, 2.54; 95% CI, 1.88-3.43, p < 0.001) were significantly higher in the group undergoing DTI reconstruction as compared to TE/I reconstruction. Conclusion Our study confirms that autologous reconstruction is the procedure least impacted by PMRT, while DTI appears to be the most impacted by PMRT, when compared with TE/I which shows a lower rate of explant and reconstruction failure. The trial is registered with NCT04783818, and the date of registration is 1 March, 2021, retrospectively registered.
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Affiliation(s)
- Andrea Vittorio Emanuele Lisa
- Reconstructive and Aesthetic Plastic Surgery School, Department of Medical Biotechnology and Translational Medicine BIOMETRA-Plastic Surgery Unit, University of Milan, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Marzia Salgarello
- Department of Plastic Surgery, Director of the Residency Program of Plastic Surgery, IRCCS Policlinico Gemelli, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Alessandra Huscher
- Department of Radiotherapy, Fondazione Poliambulanza “Guido Berlucchi” Hospital, Brescia, Italy
| | - Fabio Corsi
- Breast Unit, Department of Surgery, IRCCS Istituti Clinici Maugeri, Pavia, Italy
- Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy
| | - Daniele Piovani
- Department of Biomedical Sciences, IRCCS Humanitas University, Pieve Emanuele, Milan, Italy
- IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Federica Rubbino
- Laboratory of Molecular Gastroenterology, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Stefania Andreoletti
- Reconstructive and Aesthetic Plastic Surgery School, Department of Medical Biotechnology and Translational Medicine BIOMETRA-Plastic Surgery Unit, University of Milan, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Giovanni Papa
- Department of Plastic Surgery, UCO, University of Trieste, Trieste, Italy
| | | | - Corrado Tinterri
- Breast Unit, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Alberto Testori
- Breast Unit, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Marta Scorsetti
- Radiotherapy and Radiosurgery Department, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Paolo Veronesi
- Division of Senology, Department of Oncology and Oncohematology, IEO, IRCCS European Institute of Oncology, University of Milan, Milan, Italy
| | | | - Mario Rietjens
- Division of Plastic and Reconstructive Surgery, IEO, IRCCS European Institute of Oncology, Milan, Italy
| | - Umberto Cortinovis
- Department of Plastic Reconstructive Surgery, IRCCS National Cancer Institute, Milan, Italy
| | - Valeria Summo
- Department of Plastic Surgery, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC), Santa Maria della Misericordia Hospital, Udine, Italy
| | - Emanuele Rampino Cordaro
- Department of Plastic Surgery, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC), Santa Maria della Misericordia Hospital, Udine, Italy
| | | | | | - Mauro Barone
- Department of Plastic Surgery, Policlinico di Modena, University of Modena and Reggio, Modena, Italy
| | - Giorgio De Santis
- Department of Plastic Surgery, Policlinico di Modena, University of Modena and Reggio, Modena, Italy
| | - Matteo Murolo
- Department of Reconstructive Surgery and Hand Surgery, Azienda Ospedaliero Universitaria-Ospedali Riuniti, Ancona, Italy
| | - Michele Riccio
- Department of Reconstructive Surgery and Hand Surgery, Azienda Ospedaliero Universitaria-Ospedali Riuniti, Ancona, Italy
| | - Angelica Aquinati
- Department of Breast Surgery and Integrated Senology Centre, Belcolle Hospital, Viterbo, Italy
| | - Francesco Cavaliere
- Department of Breast Surgery and Integrated Senology Centre, Belcolle Hospital, Viterbo, Italy
| | - Nicola Vaia
- Department of Breast Surgery, AULSS 3 Veneziana, Venice, Italy
| | - Giulia Pagura
- Department of Breast Surgery, AULSS 3 Veneziana, Venice, Italy
| | - Erica Dalla Venezia
- Unit of Plastic Surgery, Department of Neurosciences, University of Padova, Padova, Italy
| | - Franco Bassetto
- Unit of Plastic Surgery, Department of Neurosciences, University of Padova, Padova, Italy
| | - Vincenzo Vindigni
- Department of Breast Surgery and Breast Unit, Casa Sollievo della Sofferenza Hospital, San Giovanni Rotondo, Foggia, Italy
| | - Luigi Ciuffreda
- Department of Breast Surgery and Breast Unit, Casa Sollievo della Sofferenza Hospital, San Giovanni Rotondo, Foggia, Italy
| | | | - Alberto Sciarillo
- Department of Plastic Surgery, ASUGI Cattinara Hospital, Trieste, Italy
| | - Nadia Renzi
- Department of Plastic Surgery, ASUGI Cattinara Hospital, Trieste, Italy
| | - Graziano Meneghini
- Functional Department Transmural Breast Surgery, AULSS 8 Berica, Vicenza, Italy
| | - Tajna Kraljic
- Department of Breast Surgery, AULSS 8 Berica, Vicenza, Italy
| | - Andrea Loreti
- Department of Plastic Surgery, San Giovanni Addolorata Hospital, Rome, Italy
| | - Lucio Fortunato
- Department of Breast Surgery and Breast Unit, San Giovanni Addolorata Hospital, Rome, Italy
| | - Valentina Pino
- Istituto di Clinica Chirurgica, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Valeriano Vinci
- Department of Biomedical Sciences, IRCCS Humanitas University, Pieve Emanuele, Milan, Italy
- IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Marco Klinger
- Reconstructive and Aesthetic Plastic Surgery School, Department of Medical Biotechnology and Translational Medicine BIOMETRA-Plastic Surgery Unit, University of Milan, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
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Oda G, Nakagawa T, Mori H, Onishi I, Fujioka T, Mori M, Kubota K, Hanazawa R, Hirakawa A, Ishikawa T, Okamoto K, Uetakesszsz H. Factors predicting upstaging from clinical N0 to pN2a/N3a in breast cancer patients. World J Clin Oncol 2022; 13:748-757. [PMID: 36212601 PMCID: PMC9537504 DOI: 10.5306/wjco.v13.i9.748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 07/25/2022] [Accepted: 09/06/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND With sentinel node metastasis in breast cancer (BC) patients, axillary lymph node (ALN) dissection is often omitted from cases with breast-conserving surgery. Omission of lymph node dissection reduces the invasiveness of surgery to the patient, but it also obscures the number of metastases to non-sentinel nodes. The possibility of finding ≥ 4 lymph nodes (pN2a/pN3a) preoperatively is important given the ramifications for postoperative treatment.
AIM To search for clinicopathological factors that predicts upstaging from N0 to pN2a/pN3a.
METHODS Patients who were sentinel lymph node (SLN)-positive and underwent ALN dissection between September 2007 and August 2018 were selected by retrospective chart review. All patients had BC diagnosed preoperatively as N0 with axillary evaluation by fluorodeoxyglucose (FDG) positron emission tomography/computed tomography and ultrasound (US) examination. When suspicious FDG accumulation was found in ALN, the presence of metastasis was reevaluated by second US. We examined predictors of upstaging from N0 to pN2a/pN3a.
RESULTS Among 135 patients, we identified 1-3 ALNs (pN1) in 113 patients and ³4 ALNs (pN2a/pN3a) in 22 patients. Multivariate analysis identified the total number of SLN metastasis, the maximal diameter of metastasis in the SLN (SLNDmax), and FDG accumulation of ALN as predictors of upstaging to pN2a/pN3a.
CONCLUSION We identified factors involved in upstaging from N0 to pN2a/pN3a. The SLNDmax and number of SLN metastasis are predictors of ≥ 4 ALNs (pN2a/pN3a) and predictors of metastasis to non-sentinel nodes, which have been reported in the past. Attention should be given to axillary accumulations of FDG, even when faint.
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Affiliation(s)
- Goshi Oda
- Department of Breast Surgery, Tokyo Medical and Dental University, Tokyo 1138519, Japan
| | - Tsuyoshi Nakagawa
- Department of Breast Surgery, Tokyo Medical and Dental University, Tokyo 1138519, Japan
| | - Hiroki Mori
- Department of Plastic and Reconstructive Surgery, Tokyo Medical and Dental University, Tokyo 1138519, Japan
| | - Iichiro Onishi
- Department of Pathology, Tokyo Medical and Dental University, Tokyo 1138519, Japan
| | - Tomoyuki Fujioka
- Department of Radiology, Tokyo Medical and Dental University, Tokyo 1138519, Japan
| | - Mio Mori
- Department of Radiology, Tokyo Medical and Dental University, Tokyo 1138519, Japan
| | - Kazunori Kubota
- Department of Radiology, Tokyo Medical and Dental University, Tokyo 1138519, Japan
| | - Ryoichi Hanazawa
- Department of Clinical Biostatistics, Tokyo Medical and Dental University, Tokyo 1138519, Japan
| | - Akihiro Hirakawa
- Department of Clinical Biostatistics, Tokyo Medical and Dental University, Tokyo 1138519, Japan
| | - Toshiaki Ishikawa
- Department of Specialized Surgeries, Tokyo Medical and Dental University, Tokyo 1138519, Japan
| | - Kentaro Okamoto
- Department of Specialized Surgeries, Tokyo Medical and Dental University, Tokyo 1138519, Japan
| | - Hiroyuki Uetakesszsz
- Department of Specialized Surgeries, Tokyo Medical and Dental University, Tokyo 1138519, Japan
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Conversion of Breast Implants into Natural Breast Reconstruction: Evaluating Lipofilled Mini Dorsi Flap. PLASTIC AND RECONSTRUCTIVE SURGERY - GLOBAL OPEN 2022; 10:e4450. [PMID: 35923995 PMCID: PMC9325333 DOI: 10.1097/gox.0000000000004450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 06/03/2022] [Indexed: 11/25/2022]
Abstract
Background: Autologous reconstruction techniques can provide a long-lasting natural breast reconstruction for patients. This study aimed to further investigate outcomes in the conversion of breast implant reconstruction into a lipofilled mini dorsi flap, focusing on reviewing its techniques, efficiency, and final results. Methods: Over 3 years, we performed a number of breast implant replacements via the lipofilled mini dorsi flap technique. The artificial implants were replaced to a deepithelized flap. The efficiency and tolerance of the technique were evaluated by the whole surgical team, and the achieved results were also analyzed by the patients in terms of postoperative pain, functional impact, and the softness of the reconstructed breast by comparing their prior condition to the lipofilled mini dorsi flap condition at least 9 months after operation. Results: Forty-seven consecutive operations were prospectively studied. The mean ± standard deviation volume of the removed implants was 348.66 ± 86.54 mL. The mean volume of fat injected was 284.13 ± 62.94 mL. The procedure’s average duration was 108.93 ± 17.65 minutes. The surgical team evaluated the results as very satisfactory in 32 cases (68.1%), satisfactory in 15 cases (31.9%), and moderately satisfactory or unsatisfactory in zero cases (0.0%). Eighteen patients (38.3%) evaluated their reconstruction as very good, while 20 patients (42.6%) considered their reconstruction as good, four (8.5%) as average, and zero (0.0%) as insufficient. Conclusion: According to our experience, the lipofilled mini dorsi flap is a simple, less invasive, and quick procedure to convert breast implants into natural breast reconstruction.
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23
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Wolter A, Fertsch S, Lisboa BW, Andree C. [Breast Reconstruction Strategies in Case of Planned Radiotherapy]. HANDCHIR MIKROCHIR P 2022; 54:279-296. [PMID: 35728602 DOI: 10.1055/a-1826-2992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION The ideal technical and chronological approach of breast reconstruction in case of planned radiotherapy after mastectomy (post-mastectomy radiotherapy, PMRT) continues to be controversially discussed. METHODS The authors analysed the MEDLINE Database PubMed for relevant studies concerning PMRT and breast reconstruction. The main theses from these publications were extracted and summarised. RESULTS An implant-based approach is the least invasive technique for immediate breast-mound formation in a PMRT setting. Reconstruction in a PMRT setting with a two-stage expander-implant technique or expander-implant-autologous procedure can provide good to excellent cosmetic outcomes. In contrast to the implant-based approach, autologous reconstruction methods provide an improved quality of life as well as haptic and sensory advantages and are usually associated with lower complication rates. PMRT after autologous reconstruction can have a negative impact on the autologous tissue. A delayed autologous approach can be advantageous and should be generally favoured in high-risk patients. CONCLUSION Factors influencing a meticulous planning of breast reconstruction including PMRT are surgical, aesthetic and patient characteristics, quality of life, preference and expectation. Ideally, PMRT is completed before autologous reconstruction to avoid radiation-associated side-effects on the final reconstructive result. If PMRT is likely, but potentially not necessary, an immediate-delayed procedure may be of advantage.
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Affiliation(s)
- Andreas Wolter
- Plastische und Ästhetische Chirurgie, Sana Krankenhaus Gerresheim, Düsseldorf, Germany.,Fakultät für Gesundheit, Universität Witten/Herdecke, Witten, Germany
| | - Sonia Fertsch
- Plastische und Ästhetische Chirurgie, Sana Krankenhaus Gerresheim, Düsseldorf, Germany.,Fakultät für Gesundheit, Universität Witten/Herdecke, Witten, Germany
| | | | - Christoph Andree
- Plastische und Ästhetische Chirurgie, Sana Krankenhaus Gerresheim, Düsseldorf, Germany
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24
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Seth I, Seth N, Bulloch G, Rozen WM, Hunter-Smith DJ. Systematic Review of Breast-Q: A Tool to Evaluate Post-Mastectomy Breast Reconstruction. BREAST CANCER (DOVE MEDICAL PRESS) 2021; 13:711-724. [PMID: 34938118 PMCID: PMC8687446 DOI: 10.2147/bctt.s256393] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Accepted: 11/29/2021] [Indexed: 12/12/2022]
Abstract
Purpose The aim of this systematic review is to update and synthesize new evidence on BREAST-Q questionnaire’s ability to reflect patient-reported outcomes in women who have undergone breast reconstruction surgery (BRS) following mastectomy. Methods PubMed, Science Direct, Google Scholar, Cochrane CENTRAL, and Clincaltrial.gov were searched for relevant studies from January 2009 to September 2021. Any interventional or observational studies that used BREAST-Q to assess patient-reported outcomes in the assessment of BRS following mastectomy were included. Results A total of 42 studies were eligible for inclusion in the review. Three were randomized controlled trials and 39 were observational studies. Compared with pre-operative scores, there was an improvement in all BREAST-Q outcome domains following BRS including ‘satisfaction with breasts’, “satisfaction with outcome” “psychosocial”, “physical”, and “sexual wellbeing”. Sexual well-being had the lowest BREAST-Q score both pre-and post-operatively (37.8–80.0 and 39.0–78.0, respectively). Autologous BRS reports higher satisfaction and overall wellbeing compared to implant-based BRS. BREAST-Q has a higher and narrow internal consistency of 0.81 to 0.96 compared with other patient-reported outcome measures (PROMs; EORTC-QLQ, FACT-B, BR-23, BCTOS). The BREAST-Q questionnaire is the only PROM which allows patients to reflect on their care, surgical outcomes, and satisfaction collectively. Conclusion This review highlights the fact that BREAST-Q can effectively and reliably measure satisfaction and wellbeing of breast cancer patients after BRS. Comparatively, sexual wellbeing shows poorer outcomes following BRS and more longitudinal studies are necessary to understand the basis for these findings. Compared to other PROMs, BREAST-Q is reliable and specific to breast cancer surgery. Overall, BREAST-Q can help clinicians improve their quality of service, understand patient experiences, and may be used as an auditing tool for surgical outcomes.
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Affiliation(s)
- Ishith Seth
- Department of Surgery, Bendigo Health, Bendigo, Victoria, 3550, Australia
| | - Nimish Seth
- Department of Surgery, The Alfred Hospital, Melbourne, Victoria, 3004, Australia
| | - Gabriella Bulloch
- Faculty of Science, Medicine and Health, University of Melbourne, Melbourne, Victoria, 3010, Australia
| | - Warren M Rozen
- Peninsula Clinical School, Central Clinical School at Monash University, The Alfred Centre, Melbourne, Victoria, 3004, Australia
| | - David J Hunter-Smith
- Peninsula Clinical School, Central Clinical School at Monash University, The Alfred Centre, Melbourne, Victoria, 3004, Australia
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25
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Régis C, Le Deley MC, Bogart E, Leguillette C, Boulanger L, Chauvet MP, Viard R, Thery J, Bosc R, Delmaire C. Functional Cerebral MRI Evaluation of Integration of Breast Reconstruction into the Body Schema. Ann Surg Oncol 2021; 29:2652-2661. [PMID: 34839425 DOI: 10.1245/s10434-021-11048-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 10/16/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND The objective of breast reconstruction (BR) is to erase the after-effects of total mastectomy by allowing patients to restore their breast shape. The aim of our study was to investigate the body map integration of different types of BR using functional magnetic resonance (fMRI). PATIENTS AND METHODS We prospectively enrolled all women undergoing BR for breast cancer to the Remasco study (NCT02553967). Participants were categorized into four groups according to the standard of care they required: immediate BR (IBR), delayed BR (DBR), flap (autologous), or implant BR. Each patient performed sensorimotor tasks during the fMRI acquisition. RESULTS Data of 38 patients were analyzed. We identified the cingulate region as the area of interest in the brain. In the case of DBR, the brain area activated during palpation of the total mastectomy scar (before BR) was different from the brain area activated during palpation of the reconstructed breast (Brodmann areas 31 versus 32). Palpation of the native breast and reconstructed breast activated the same Brodmann area 32. Comparing the brain activation signal during palpation of the native breast and the reconstructed breast did not reveal any significant difference in the overall population (P = 0.41) or in the groups: autologous (P = 0.32), implant (P = 0.10), IBR (P = 0.72), or DBR (P = 0.10). CONCLUSIONS This experimental study allowed us to describe and understand the brain plasticity processes that accompany BR. The results suggest that the reconstructed breast is integrated into the body schema, regardless of the type of BR or the timing.
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Affiliation(s)
- Claudia Régis
- Department of Surgery, Centre Oscar Lambret, 3 rue F.-Combemale, Lille cedex, France.
| | - Marie-Cécile Le Deley
- Biostatisitcs Unit, Centre Oscar Lambret, 3 rue F.-Combemale, Lille cedex, France.,Université Paris-Saclay, Universite´ Paris-Sud, UVSQ, CESP, INSERM, Villejuif, France
| | - Emilie Bogart
- Biostatisitcs Unit, Centre Oscar Lambret, 3 rue F.-Combemale, Lille cedex, France
| | - Clémence Leguillette
- Biostatisitcs Unit, Centre Oscar Lambret, 3 rue F.-Combemale, Lille cedex, France
| | - Loic Boulanger
- Department of Surgery, Centre Oscar Lambret, 3 rue F.-Combemale, Lille cedex, France
| | - Marie- Pierre Chauvet
- Department of Surgery, Centre Oscar Lambret, 3 rue F.-Combemale, Lille cedex, France
| | - Romain Viard
- University of Lille, CNRS, Inserm, CHU Lille, Institut Pasteur de Lille, US 41 - UMS 2014 - PLBS, Lille, France.,University of Lille, Inserm, CHU Lille, U1172 - LilNCog - Lille Neuroscience & Cognition, Lille, France
| | - Julien Thery
- Clinical Research and Innovation Department, Centre Oscar Lambret, Lille, France
| | - Romain Bosc
- Department of Plastic, Reconstructive, Aesthetic and maxillofacial Surgery, Henry Mondor Hospital, 51 Avenue du Maréchal de Lattre de Tassigny, Créteil, France
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26
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Barber MD, Young O, Kulkarni D, Young I, Saleem TB, Fernandez T, Revie E, Dixon JM. No evidence of benefit for laminar flow in theatre for sling-assisted, implant-based breast reconstruction. Surgeon 2021; 19:e112-e116. [DOI: 10.1016/j.surge.2020.08.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 08/18/2020] [Accepted: 08/27/2020] [Indexed: 01/25/2023]
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Oda G, Nakagawa T, Uemura N, Mori H, Mori M, Fujioka T, Onishi I, Uetake H. Immediate breast reconstruction is oncologically safe for node-positive patients: Comparison using propensity score matching. Medicine (Baltimore) 2021; 100:e27184. [PMID: 34516518 PMCID: PMC8428751 DOI: 10.1097/md.0000000000027184] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 08/23/2021] [Indexed: 11/30/2022] Open
Abstract
The oncological safety of immediate breast reconstruction (IBR) in lymph node-positive patients is unclear. In the present study, the impact of IBR on recurrence based on data of patients with axillary lymph node metastases only was examined.The subjects were 232 patients who underwent breast surgery. The patients were grouped into 2 cohorts: non-IBR patients who underwent mastectomy with axillary lymph node dissection; and IBR patients with tissue expander or flap transfer and axillary lymph node dissection. The Non-IBR group included 165 patients, and the IBR group included 67 patients. For the comparison of oncological outcomes between the 2 groups, propensity score matching was performed. The propensity scores were calculated by logistic regression analysis, including age, tumor staging, human epidermal growth factor receptor 2 status, and estrogen receptor status. There was no difference in locoregional recurrence-free survival (LRRFS) between the non-IBR and IBR groups. The 5-year LRRFS rate was 78.9% in the non-IBR group and 85.1% in the IBR group. There was no difference in recurrence-free survival (RFS) between the non-IBR and IBR groups. The 5-year RFS rate was 75.6% in the non-IBR group and 78.8% in the IBR group. In all patients, the 5-year LRRFS rate was 77.3%, and the RFS rate was 70.5%. Multivariate Cox regression analysis to identify factors affecting RFS in all patients showed that estrogen receptor status and high nuclear grade were significant prognostic factors; IBR was irrelevant.This is the first report of an analysis using propensity score matching limited to node-positive breast cancer patients, and it showed that IBR is relatively safe in such patients.
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Affiliation(s)
- Goshi Oda
- Department of Specialized Surgery, Graduate School of Medicine and Dentistry, Tokyo Medical and Dental University, Bunkyo-ku, Tokyo, Japan
| | - Tsuyoshi Nakagawa
- Department of Specialized Surgery, Graduate School of Medicine and Dentistry, Tokyo Medical and Dental University, Bunkyo-ku, Tokyo, Japan
| | - Noriko Uemura
- Department of Plastic and Reconstructive Surgery, Graduate School of Medicine and Dentistry, Tokyo Medical and Dental University, Bunkyo-ku, Tokyo, Japan
| | - Hiroki Mori
- Department of Plastic and Reconstructive Surgery, Graduate School of Medicine and Dentistry, Tokyo Medical and Dental University, Bunkyo-ku, Tokyo, Japan
| | - Mio Mori
- Department of Radiology, Graduate School of Medicine and Dentistry, Tokyo Medical and Dental University, Bunkyo-ku, Tokyo, Japan
| | - Tomoyuki Fujioka
- Department of Radiology, Graduate School of Medicine and Dentistry, Tokyo Medical and Dental University, Bunkyo-ku, Tokyo, Japan
| | - Iichiroh Onishi
- Department of Pathology, Graduate School of Medicine and Dentistry, Tokyo Medical and Dental University, Bunkyo-ku, Tokyo, Japan
| | - Hiroyuki Uetake
- Department of Specialized Surgery, Graduate School of Medicine and Dentistry, Tokyo Medical and Dental University, Bunkyo-ku, Tokyo, Japan
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Does post-mastectomy radiation therapy worsen outcomes in immediate autologous breast flap reconstruction? A systematic review and meta-analysis. J Plast Reconstr Aesthet Surg 2021; 74:3260-3280. [PMID: 34565703 DOI: 10.1016/j.bjps.2021.08.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 08/25/2021] [Indexed: 01/25/2023]
Abstract
BACKGROUND There is great uncertainty regarding the practice of immediate autologous breast reconstruction (IBR) when post-mastectomy radiotherapy (PMRT) is indicated. Plastic surgery units differ in their treatment protocols, with some recommending delayed breast reconstruction (DBR) following PMRT. IBR offers significant cosmetic and psychosocial benefits; however, the morbidity of flap exposure to radiation remains unclear. OBJECTIVE The aim of this review was to comprehensively analyze the existing literature comparing autologous flaps exposed to PMRT and flaps with no radiation exposure. METHODS A comprehensive search in MEDLINE, EMBASE and CENTRAL databases was conducted in November 2020. Primary studies comparing IBR with and without adjuvant PMRT were assessed for the following primary outcomes: clinical complications, observer-reported outcomes and patient-reported satisfaction rates. Meta-analysis was performed to obtain pooled risk ratios of individual complications. RESULTS Twenty-one articles involving 3817 patients were included. Meta-analysis of pooled data gave risk ratios for fat necrosis (RR = 1.91, p < 0.00001), secondary surgery (RR = 1.62, p = 0.03) and volume loss (RR = 8.16, p < 0.00001) favoring unirradiated flaps, but no significant difference was observed in all other reported complications. The no-PMRT group scored significantly higher in observer-reported measures. However, self-reported aesthetic and general satisfaction rates were similar between groups. CONCLUSION IBR should be offered after mastectomy to patients requiring PMRT. The higher risks of fat necrosis and contracture appear to be less clinically relevant as corroborated by positive scores from patients developing these complications. Preoperative and intraoperative measures should be taken to further optimize reconstruction and mitigate post-radiation sequel. Careful management of patients' expectations is also imperative. LEVEL OF EVIDENCE Level III.
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Meattini I, Becherini C, Bernini M, Bonzano E, Criscitiello C, De Rose F, De Santis MC, Fontana A, Franco P, Gentilini OD, Livi L, Meduri B, Parisi S, Pasinetti N, Prisco A, Rocco N. Breast reconstruction and radiation therapy: An Italian expert Delphi consensus statements and critical review. Cancer Treat Rev 2021; 99:102236. [PMID: 34126314 DOI: 10.1016/j.ctrv.2021.102236] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Revised: 05/21/2021] [Accepted: 05/24/2021] [Indexed: 02/06/2023]
Abstract
Breast conserving surgery (BCS) plus radiation therapy (RT) or mastectomy have shown comparable oncological outcomes in early-stage breast cancer and are considered standard of care treatments. Postmastectomy radiation therapy (PMRT) targeted to both the chest wall and regional lymph nodes is recommended in high-risk patients. Oncoplastic breast conserving surgery (OBCS) represents a significant recent improvement in breast surgery. Nevertheless, it represents a challenge for radiation oncologists as it triggers different decision-making strategies related to treatment volume definition and target delineation. Hence, the choice of the best combination and timing when offering RT to breast cancer patients who underwent or are planned to undergo reconstruction procedures should be carefully evaluated and based on individual considerations. We present an Italian expert Delphi Consensus statements and critical review, led by a core group of all the professional profiles involved in the management of breast cancer patients undergoing reconstructive procedures and RT. The report was structured as to consider the main recommendations on breast reconstruction and RT and analyse the current open issues deserving investigation and consensus. We used a three key-phases and a Delphi process. The final expert panel of 40 colleagues selected key topics as identified by the core group of the project. A final consensus on 26 key statements on RT and breast reconstruction after three rounds of the Delphi voting process and harmonisation was reached. An accompanying critical review of available literature was summarized. A clear communication and cooperation between surgeon and radiation oncologist is of paramount relevance both in the setting of breast reconstruction following mastectomy when PMRT is planned and when extensive glandular rearrangements as OBCS is performed. A shared-decision making, relying on outcome-based and patient-centred considerations, is essential, while waiting for higher level-of-evidence data.
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Affiliation(s)
- Icro Meattini
- Department of Experimental and Clinical Biomedical Sciences "M. Serio", University of Florence, Florence, Italy; Radiation Oncology Unit - Oncology Department, Azienda Ospedaliero Universitaria Careggi, Florence, Italy; Italian Association of Radiotherapy and Clinical Oncology (AIRO) Breast Cancer Group, Italy; Clinical Oncology Breast Cancer Group (COBCG), Italy.
| | - Carlotta Becherini
- Department of Experimental and Clinical Biomedical Sciences "M. Serio", University of Florence, Florence, Italy; Radiation Oncology Unit - Oncology Department, Azienda Ospedaliero Universitaria Careggi, Florence, Italy; Italian Association of Radiotherapy and Clinical Oncology (AIRO) Breast Cancer Group, Italy
| | - Marco Bernini
- Breast Surgery Unit - Oncology Department, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Elisabetta Bonzano
- Department of Radiation Oncology, IRCCS San Matteo Polyclinic Foundation & PhD School in Experimental Medicine, University of Pavia, Pavia, Italy; Italian Association of Radiotherapy and Clinical Oncology (AIRO) Breast Cancer Group, Italy; Clinical Oncology Breast Cancer Group (COBCG), Italy
| | - Carmen Criscitiello
- Department of Oncology and Haematology (DIPO), University of Milan & Division of Early Drug Development for Innovative Therapy, European Institute of Oncology, IRCCS, Milan, Italy
| | - Fiorenza De Rose
- Division of Radiation Oncology, Santa Chiara Hospital, Trento, Italy; Italian Association of Radiotherapy and Clinical Oncology (AIRO) Breast Cancer Group, Italy; Clinical Oncology Breast Cancer Group (COBCG), Italy
| | - Maria Carmen De Santis
- Radiation Oncology Unit 1, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy; Italian Association of Radiotherapy and Clinical Oncology (AIRO) Breast Cancer Group, Italy; Clinical Oncology Breast Cancer Group (COBCG), Italy
| | - Antonella Fontana
- Radiation Oncology Unit, Ospedale Santa Maria Goretti, Latina, Italy; Italian Association of Radiotherapy and Clinical Oncology (AIRO) Breast Cancer Group, Italy
| | - Pierfrancesco Franco
- Department of Translational Medicine, University of Eastern Piedmont & Radiation Oncology Unit, AOU "Maggiore della Carità", Novara, Italy; Italian Association of Radiotherapy and Clinical Oncology (AIRO) Breast Cancer Group, Italy; Clinical Oncology Breast Cancer Group (COBCG), Italy
| | | | - Lorenzo Livi
- Department of Experimental and Clinical Biomedical Sciences "M. Serio", University of Florence, Florence, Italy; Radiation Oncology Unit - Oncology Department, Azienda Ospedaliero Universitaria Careggi, Florence, Italy; Italian Association of Radiotherapy and Clinical Oncology (AIRO) Breast Cancer Group, Italy
| | - Bruno Meduri
- Radiation Oncology Unit, University Hospital of Modena, Modena, Italy; Italian Association of Radiotherapy and Clinical Oncology (AIRO) Breast Cancer Group, Italy; Clinical Oncology Breast Cancer Group (COBCG), Italy
| | - Silvana Parisi
- Radiation Oncology Unit, Department of Biomedical, Dental Science and Morphological and Functional Images, University of Messina, Messina, Italy; Italian Association of Radiotherapy and Clinical Oncology (AIRO) Breast Cancer Group, Italy
| | - Nadia Pasinetti
- Radiation Oncology Service, ASST Valcamonica, Esine, Italy; Italian Association of Radiotherapy and Clinical Oncology (AIRO) Breast Cancer Group, Italy; Clinical Oncology Breast Cancer Group (COBCG), Italy
| | - Agnese Prisco
- Department of Radiation Oncology, University Hospital of Udine, ASUFC, Udine, Italy; Italian Association of Radiotherapy and Clinical Oncology (AIRO) Breast Cancer Group, Italy
| | - Nicola Rocco
- Group for Reconstructive and Therapeutic Advancements (G.RE.T.A.), Milan, Naples, Catania, Italy
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