The impact of autologous breast reconstruction using DIEP flap on the oncologic efficacy of radiation therapy

Outcomes of Immediate versus Delayed Autologous Reconstruction with Postmastectomy Radiation: A Meta-Analysis

BACKGROUND

Postmastectomy autologous breast reconstruction can be immediate or delayed. The safety of performing immediate breast reconstruction (IBR) and the impact of radiation on the newly reconstructed breast is not yet validated.

METHODS

A PubMed, Embase, and Google scholar search was conducted from inception to September 17, 2023. The authors included comparative studies that assessed complications or aesthetic outcomes of IBR versus delayed breast reconstruction (DBR) in the setting of postmastectomy radiotherapy (PMRT).

RESULTS

The search identified 2693 articles. Thirteen were eligible for inclusion. A total of 565 patients underwent IBR followed by radiotherapy, whereas 699 had DBR. Mean follow-up time and age for both groups were comparable ( P > 0.1). None of the complications-revision surgery, infection, total flap failure, seroma, hematoma, dehiscence, or delayed wound healing-were significantly different across groups ( P > 0.1). IBR was found to have a higher risk of flap fibrosis (OR, 28.18; 95% CI, 5.15 to 154.12; P = 0.0001; I2 = 44%) and skin flap necrosis (OR, 6.12; 95% CI, 2.71 to 13.82; P < 0.0001; I2 = 27%) but a lower risk of partial flap failure (OR, 0.18; 95% CI, 0.06 to 0.58; P = 0.004; I2 = 0%) when compared with DBR. Results of fat necrosis should be interpreted with caution. Patient-reported and objective aesthetic outcomes were mostly comparable between groups.

CONCLUSIONS

IBR in the setting of PMRT is increasingly being performed and poses a specific set of challenges that surgeons usually consider. The choice between IBR or DBR in the setting of PMRT should be an individualized decision based on patient risk factors and desires.

The Effects of Radiotherapy on the Sequence and Eligibility of Breast Reconstruction: Current Evidence and Controversy

Immediate breast reconstruction (IBR) following a mastectomy, combined with radiotherapy, presents a multifaceted approach to breast cancer treatment, balancing oncological safety and aesthetic outcomes. IBR, typically involving the use of implants or autologous tissue, aims to restore breast morphology directly after a mastectomy, minimizing the psychological and physical impacts. However, integrating radiotherapy with IBR is complex due to the potential adverse effects on reconstructed tissues. Radiotherapy, essential for reducing local recurrence, can induce fibrosis, capsular contracture, and compromised aesthetic results. This narrative review covers the current trends in the sequencing of breast reconstruction and radiotherapy. We discuss patient selection, timing of radiotherapy, and reconstructive techniques, with special attention paid to quality-of-life outcomes that are increasingly reported in clinical trials. Emerging evidence supports the feasibility of IBR with careful patient selection and tailored therapeutic approaches, although ongoing research is necessary to refine protocols and enhance outcomes. Overall, IBR in the context of radiotherapy remains a promising but intricate treatment modality, requiring a nuanced balance between cancer control and aesthetic restoration.

Impact of Prepectoral vs. Subpectoral Tissue Expander Placement on Post-mastectomy Radiation Therapy Delivery: A Retrospective Cohort Study

Background

Implant-based reconstruction is the most common method of postmastectomy reconstruction. Many patients require postmastectomy radiation (PMRT). Tissue expanders (TEs), typically inserted as a first stage, have historically been placed subpectorally. More recently, prepectoral reconstruction has gained popularity, but its impact on PMRT is unknown. Prior studies focus on complication rates and aesthetic outcomes. This study examines whether there is a difference in radiation dosimetry among patients undergoing prepectoral versus subpectoral TE reconstruction.

Methods

Electronic medical records and radiation plans of 50 patients (25 prepectoral, 25 subpectoral) who underwent mastectomy with immediate TE reconstruction at our institution or affiliate site were reviewed. Pectoralis major muscle and chest wall structures were contoured and mean percentage volumes of these structures receiving less than 95%, 100%, and more than 105% target radiation dose were calculated, as were heart and ipsilateral lung doses. Welch two sample t test, Fisher exact test, and Pearson chi-squared tests were performed.

Results

The groups had comparable patient and tumor characteristics and underwent similar ablative and reconstructive procedures and radiation dosimetry. Subpectoral patients had larger mean areas receiving less than 95% target dose ("cold spots"); prepectoral patients had larger mean areas receiving greater than 105% ("hot spots") and 100% target doses. There were no differences in chest wall, heart, and lung doses.

Conclusions

Our results demonstrate an increased mean percentage area of pectoralis cold spots with subpectoral reconstruction and increased area of hot spots and 100% dose delivery to the pectoralis in prepectoral patients. Larger studies should analyze long-term effects of prepectoral reconstruction on radiation dosing and recurrence rates.

Breast cancer recurrence after immediate and delayed postmastectomy breast reconstruction-A systematic review and meta-analysis

BACKGROUND

Oncological safety of different types and timings of PMBR after breast cancer remains controversial. Lack of stratified risk assessment in literature makes current clinical and shared decision-making complex. This is the first systematic review and meta-analysis to evaluate differences in oncological outcomes after immediate versus delayed postmastectomy breast reconstruction (PMBR) for autologous and implant-based PMBR separately.

METHODS

A systematic literature search was performed in MEDLINE, Cochrane Library, and Embase. The Cochrane Collaboration Handbook and Meta-analysis Of Observational Studies in Epidemiology checklist were followed for data abstraction. Variability in point estimates attributable to heterogeneity was assessed using I2 -statistic. (Loco)regional breast cancer recurrence rates, distant metastasis rates, and overall breast cancer recurrence rates were pooled in generalized linear mixed models using random effects.

RESULTS

Fifty-five studies, evaluating 14,217 patients, were included. When comparing immediate versus delayed autologous PMBR, weighted average proportions were: 0.03 (95% confidence interval [CI], 0.02-0.03) versus 0.02 (95% CI, 0.01-0.04), respectively, for local recurrences, 0.02 (95% CI, 0.01-0.03) versus 0.02 (95% CI, 0.01-0.03) for regional recurrences, and 0.04 (95% CI, 0.03-0.06) versus 0.01 (95% CI, 0.00-0.03) for locoregional recurrences. No statistically significant differences in weighted average proportions for local, regional and locoregional recurrence rates were observed between immediate and delayed autologous PMBR. Data did not allow comparing weighted average proportions of distant metastases and total breast cancer recurrences after autologous PMBR, and of all outcome measures after implant-based PMBR.

CONCLUSIONS

Delayed autologous PMBR leads to similar (loco)regional breast cancer recurrence rates compared to immediate autologous PMBR. This study highlights the paucity of strong evidence on breast cancer recurrence after specific types and timings of PMBR.

LAY SUMMERY

Oncologic safety of different types and timings of postmastectomy breast reconstruction (PMBR) remains controversial. Lack of stratified risk assessment in literature makes clinical and shared decision-making complex. This meta-analysis showed that delayed autologous PMBR leads to similar (loco)regional recurrence rates as immediate autologous PMBR. Data did not allow comparing weighted average proportions of distant metastases and total breast cancer recurrence after autologous PMBR, and of all outcome measures after implant-based PMBR. Based on current evidence, oncological concerns do not seem a valid reason to withhold patients from certain reconstructive timings or techniques, and patients should equally be offered all reconstructive options they technically qualify for.

Oncoplastic breast surgery: A guide to good practice

Oncoplastic Breast Surgery has become standard of care in the management of Breast Cancer patients. These guidelines written by an Expert Advisory Group; convened by the Association of Breast Surgery (ABS) and the British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS), are designed to provide all members of the breast cancer multidisciplinary team (MDT) with guidance on the best breast surgical oncoplastic and reconstructive practice at each stage of a patient's journey, based on current evidence. It is hoped they will also be of benefit to the wide range of professionals and service commissioners who are involved in this area of clinical practice.

"Systematic review and meta-analysis of immediate versus delayed autologous breast reconstruction in the setting of post-mastectomy adjuvant radiation therapy"

BACKGROUND

Immediate post-mastectomy autologous breast reconstruction in breast cancer patients requiring post-mastectomy radiation therapy (PMRT) minimizes the number of operations that patients must undergo and alleviates the psychological impact of living without a breast. However, the safety and impact of radiation on the reconstructed breast remains to be established. This study aimed to compare immediate versus delayed autologous reconstruction in the setting of PMRT to determine the optimal sequencing of reconstruction and adjuvant radiation.

METHODS

A systematic review of the literature identified 292 studies meeting criteria for full-text review, 44 of which underwent meta-analysis. This represented data on 1,927 immediate reconstruction (IR) patients and 1,546 delayed reconstruction (DR) patients (3,473 total patients). Early complications included flap loss, fat necrosis, thrombosis, seroma, hematoma, infection, and skin dehiscence. Late complications included fibrosis or contracture, severe asymmetry, hyperpigmentation, and decreased flap volume.

RESULTS

Immediate breast reconstruction did not demonstrate significantly increased complication rates. Reported mean complication rates in IR versus DR groups, respectively, were fat necrosis 14.91% and 8.12% (p = 0.076), flap loss 0.99% and 1.80% (p = 0.295), hematoma 1.91% and 1.14% (p = 0.247), infection 11.66% and 4.68% (p = 0.155), and thrombosis 1.51% and 3.36% (p = 0.150). Seroma rates were significantly lower in the immediate cohort at 2.69% versus 10.57% in the delayed cohort (p = 0.042).

CONCLUSION

Complication rates are comparable between immediate and delayed breast reconstruction in the setting of PMRT. Given the patient benefits incurred by an IR algorithm, immediate autologous breast reconstruction should be considered as a viable treatment option in patients requiring PMRT.

A Meta-Analysis of Autologous Microsurgical Breast Reconstruction and Timing of Adjuvant Radiation Therapy

BACKGROUND

 Postmastectomy radiation therapy (PMRT) decreases loco-regional recurrence and improves survival in patients with locally advanced breast cancer. Autologous free flap reconstruction, while more durable in the setting of radiation than alloplastic reconstruction, is still susceptible to radiation-induced fibrosis, contracture, fat necrosis, volume loss, and distortion of breast shape. Options for reconstruction timing (immediate vs. delayed) have been discussed to mitigate these effects, but a clear optimum is not known.

METHODS

 A systematic review of the literature was conducted according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines using search terms "breast reconstruction AND (radiation OR irradiation OR radiotherapy)" were used. Inclusion criteria consisted of studies reporting complications for free flap breast reconstruction in the setting of PMRT. Patients who underwent PMRT were pooled into two groups: those who underwent immediate free flap reconstruction prior to PMRT and those who underwent delayed reconstruction after PMRT.

RESULTS

 Out of the 23 studies, 12 focused on immediate reconstruction, seven focused on delayed reconstruction, and four studies included both groups. Overall, 729 patients underwent immediate reconstruction, while 868 underwent delayed reconstruction. Complete and partial flap loss rates were significantly higher in patients undergoing delayed reconstruction, while infection and wound-healing complication rates were higher in those undergoing immediate reconstructions. Rates of unplanned reoperations, vascular complications, hematoma/seroma, and fat necrosis did not differ significantly between the two groups. However, rates of planned revision surgeries were higher in the delayed reconstruction group.

CONCLUSION

 Immediate free flap breast reconstruction is associated with superior flap survival compared with delayed reconstruction. Rates of complications are largely comparable, and rates of revision surgeries are equivalent. The differences in long-term aesthetic outcomes are not, however, clearly assessed by the available literature. Even in the face of PMRT, immediate free flap breast reconstruction is an effective approach.

Long-Term Outcomes of Immediate Autologous Breast Reconstruction for Breast Cancer Patients

BACKGROUND

There is limited information on the oncological outcomes of immediate autologous breast reconstruction in the Asian population. This study aimed to evaluate the oncological outcomes of immediate one-stage autologous breast reconstruction using a free perforator flap for breast cancer patients at a single institution in Japan.

METHODS

We retrospectively reviewed 239 patients who underwent immediate one-stage autologous breast reconstruction using a free perforator flap after skin- or nipple-sparing mastectomy. The whole breast was pathologically analyzed in 5-mm sections. Clinical and pathological data were collected from medical records.

RESULTS

For tumor stage among the 239 patients, 101 (42.3%) had stage 0, 127 (53.1%) had stage I and II, and 11 (4.6%) had stage III. Twenty-three patients (9.6%) had margin involvement in the surgical specimen. Adjuvant chemotherapy was performed in 75 patients (30%), and endocrine therapy was administered in 153 patients (64%). Radiation therapy was performed in 15 patients (6.3%) because of multiple lymph node metastases or margin involvement. With a median follow-up time of 73 mo, local recurrence was found in 3.3%, distant metastases in 2.5%, and contralateral breast cancer in 3.7%. All patients with local recurrence did not receive radiation therapy as adjuvant treatment.

CONCLUSIONS

Among the patients who underwent immediate one-stage autologous reconstruction after breast surgery, 3.3% had local recurrence. For patients with margin involvement, radiation therapy is a promising option.

Comparison of survival outcomes of locally advanced breast cancer patients receiving post-mastectomy radiotherapy with and without immediate breast reconstruction: a population-based analysis

Objective

To compare the survival outcomes in locally advanced breast cancer (LABC) patients receiving post-mastectomy radiotherapy (PMRT) with and without immediate breast reconstruction.

Methods

We used the Surveillance, Epidemiology, and End Results program to include LABC patients who were treated/not treated with immediate breast reconstruction followed by PMRT between 2003 and 2010. Statistical analysis was performed using the chi-squared test, Kaplan–Meier survival analysis, and Cox regression analysis. A 1:1 propensity score matching method was performed to decrease the selection bias.

Results

We identified 1,732 patient-pairs that were completely matched. In the unmatched population, 8,198 and 1,802 patients received mastectomy only and immediate breast reconstruction, respectively. Patients who received immediate breast reconstruction had better breast cancer-specific survival (BCSS) (hazard ratio [HR] 0.880, 95% CI 0.783–0.989, P = 0.032) and overall survival (OS) (HR 0.846, 95% CI 0.758–0.943, P = 0.003) than patients who underwent mastectomy alone. However, in the matched population, there was comparable BCSS and OS between patients who received immediate breast reconstruction and mastectomy alone. Subset analysis in the matched population found that immediate breast reconstruction was associated with better BCSS (HR 0.750, 95% CI 0.614–0.917, P = 0.005) and OS (HR 0.779, 95% CI 0.644–0.942, P = 0.010) compared to patients aged <50 years who received mastectomy alone.

Conclusion

There are comparable survival outcomes in LABC patients who received immediate breast reconstruction or mastectomy alone followed by PMRT. However, patients aged <50 years had a survival advantage after immediate breast reconstruction.