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Belkacemi Y, Moran MS, Ozden BC, Masannat Y, Geara F, Albashir M, To NH, Debbi K, El Tamer M. Post-mastectomy radiation therapy after breast reconstruction: from historic dogmas to practical expert agreements based on a large literature review of surgical and radiation therapy considerations. Crit Rev Oncol Hematol 2024; 200:104421. [PMID: 38876160 DOI: 10.1016/j.critrevonc.2024.104421] [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: 12/10/2023] [Revised: 06/08/2024] [Accepted: 06/10/2024] [Indexed: 06/16/2024] Open
Abstract
Breast reconstruction (BR) after mastectomy is important to consider for a woman's body image enhancement and psychological well-being. Although post-mastectomy radiation (PMRT) significantly improves the outcome of patients with high-risk breast cancer (BC), PMRT after BR may affect cosmetic outcomes and may compromise the original goal of improving quality of life (QoL). With the lack of practical guidelines, it seems essential to work on a consensus and provide some "expert agreements" to offer patients the best option for PMRT after BR. We report a global "expert agreement" that results from a critical review of the literature on BR and PMRT during the 6th international multidisciplinary breast conference in March 2023.
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Affiliation(s)
- Yazid Belkacemi
- AP-HP, Department of Radiation Oncology and Henri Mondor Breast Center, Henri Mondor University Hospital. University of Paris Est Creteil (UPEC), France; Institut Mondor de Recherche Biomédicale (IMRB), INSERM U955, i-Biot, UPEC, Créteil, France.
| | - Meena S Moran
- Smilow Cancer Center, Yale University School of Medicine. Department of Therapeutic Radiology, New Haven, CT, USA
| | | | - Yazan Masannat
- Broomfield Hospital, Mid and South Essex NHS Trust, England, UK
| | - Fady Geara
- Department of Radiation Oncology, Oncology Institute, Cleveland Clinic Abu Dhabi, United Arab Emirates
| | - Mohamed Albashir
- Levantine Medical Center, Ain Alkhaleej Hospital and Burjeel Royal Hospital, Alain, United Arab Emirates
| | - Nhu Hanh To
- AP-HP, Department of Radiation Oncology and Henri Mondor Breast Center, Henri Mondor University Hospital. University of Paris Est Creteil (UPEC), France; Institut Mondor de Recherche Biomédicale (IMRB), INSERM U955, i-Biot, UPEC, Créteil, France
| | - Kamel Debbi
- AP-HP, Department of Radiation Oncology and Henri Mondor Breast Center, Henri Mondor University Hospital. University of Paris Est Creteil (UPEC), France; Institut Mondor de Recherche Biomédicale (IMRB), INSERM U955, i-Biot, UPEC, Créteil, France
| | - Mahmoud El Tamer
- Memorial Sloan Kettering Cancer Center and Weill Medical College at Cornell University, New York, USA
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Thiem DGE, Siegberg F, Vinayahalingam S, Blatt S, Krüger M, Lethaus B, Al-Nawas B, Zimmerer R, Kämmerer PW. The Perfect Timing-Immediate versus Delayed Microvascular Reconstruction of the Mandible. Cancers (Basel) 2024; 16:974. [PMID: 38473338 DOI: 10.3390/cancers16050974] [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: 01/18/2024] [Revised: 02/18/2024] [Accepted: 02/23/2024] [Indexed: 03/14/2024] Open
Abstract
In this retrospective study, the clinical and economic implications of microvascular reconstruction of the mandible were assessed, comparing immediate versus delayed surgical approaches. Utilizing data from two German university departments for oral and maxillofacial surgery, the study included patients who underwent mandibular reconstruction following continuity resection. The data assessed included demographic information, reconstruction details, medical history, dental rehabilitation status, and flap survival rates. In total, 177 cases (131 male and 46 females; mean age: 59 years) of bony free flap reconstruction (72 immediate and 105 delayed) were included. Most patients received adjuvant treatment (81% with radiotherapy and 51% combined radiochemotherapy), primarily for tumor resection. Flap survival was not significantly influenced by the timing of reconstruction, radiotherapy status, or the mean interval (14.5 months) between resection and reconstruction. However, immediate reconstruction had consumed significantly fewer resources. The rate of implant-supported masticatory rehabilitation was only 18% overall. This study suggests that immediate jaw reconstruction is economically advantageous without impacting flap survival rates. It emphasizes patient welfare as paramount over financial aspects in clinical decisions. Furthermore, this study highlights the need for improved pathways for masticatory rehabilitation, as evidenced by only 18% of patients with implant-supported dentures, to enhance quality of life and social integration.
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Affiliation(s)
- Daniel G E Thiem
- Department of Oral and Maxillofacial Surgery, Facial Plastic Surgery, University Medical Centre Mainz, Augustusplatz 2, 55131 Mainz, Germany
| | - Fabia Siegberg
- Department of Oral and Maxillofacial Surgery, Facial Plastic Surgery, University Medical Centre Mainz, Augustusplatz 2, 55131 Mainz, Germany
| | - Shankeeth Vinayahalingam
- Department of Oral and Maxillofacial Surgery, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands
| | - Sebastian Blatt
- Department of Oral and Maxillofacial Surgery, Facial Plastic Surgery, University Medical Centre Mainz, Augustusplatz 2, 55131 Mainz, Germany
| | - Maximilian Krüger
- Department of Oral and Maxillofacial Surgery, Facial Plastic Surgery, University Medical Centre Mainz, Augustusplatz 2, 55131 Mainz, Germany
| | - Bernd Lethaus
- Department of Oral and Maxillofacial Surgery, Facial Plastic Surgery, University Medical Centre Tübingen, Osianderstr. 2-8, 72076 Tübingen, Germany
| | - Bilal Al-Nawas
- Department of Oral and Maxillofacial Surgery, Facial Plastic Surgery, University Medical Centre Mainz, Augustusplatz 2, 55131 Mainz, Germany
| | - Rüdiger Zimmerer
- Department of Oral and Maxillofacial Surgery, Facial Plastic Surgery, University Medical Centre Tübingen, Osianderstr. 2-8, 72076 Tübingen, Germany
- Department of Oral and Maxillofacial Surgery, Facial Plastic Surgery, University Medical Centre Leipzig, Liebigstraße 12, 04103 Leipzig, Germany
| | - Peer W Kämmerer
- Department of Oral and Maxillofacial Surgery, Facial Plastic Surgery, University Medical Centre Mainz, Augustusplatz 2, 55131 Mainz, Germany
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Zhang H, Song D, Xie L, Zhan N, Xie W, Zhang J. Postmastectomy radiotherapy in breast reconstruction: Current controversies and trends. CANCER INNOVATION 2024; 3:e104. [PMID: 38948530 PMCID: PMC11212305 DOI: 10.1002/cai2.104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 09/11/2023] [Accepted: 09/13/2023] [Indexed: 07/02/2024]
Abstract
Breast cancer is the most common cancer among women worldwide. Postmastectomy radiotherapy (PMRT) is an essential component of combined therapy for early-stage, high-risk breast cancer. Breast reconstruction (BR) is often considered for patients with breast cancer who have undergone mastectomy. There has been a considerable amount of discussion about the optimal approach to combining PMRT with BR in the treatment of breast cancer. PMRT may increase the risk of complications and prevent good aesthetic results after BR, while BR may increase the complexity of PMRT and the radiation dose to surrounding normal tissues. The purpose of this review is to give a broad overview and summary of the current controversies and trends in PMRT and BR in the context of the most recent literature available.
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Affiliation(s)
- Honghong Zhang
- Department of Radiation Oncology, Xiang'an Hospital of Xiamen University, Cancer Research Center, School of MedicineXiamen University, Xiang'anXiamenFujianChina
| | - Dandan Song
- Department of Radiation Oncology, Xiang'an Hospital of Xiamen University, Cancer Research Center, School of MedicineXiamen University, Xiang'anXiamenFujianChina
| | - Liangxi Xie
- Department of Radiation Oncology, Xiang'an Hospital of Xiamen University, Cancer Research Center, School of MedicineXiamen University, Xiang'anXiamenFujianChina
| | - Ning Zhan
- Department of Radiation Oncology, Xiang'an Hospital of Xiamen University, Cancer Research Center, School of MedicineXiamen University, Xiang'anXiamenFujianChina
| | - Wenjia Xie
- Department of Radiation Oncology, Xiang'an Hospital of Xiamen University, Cancer Research Center, School of MedicineXiamen University, Xiang'anXiamenFujianChina
| | - Jianming Zhang
- Fujian Provincial Key Laboratory of Intelligent Identification and Control of Complex Dynamic System, Quanzhou Institute of Equipment Manufacturing, Haixi InstitutesChinese Academy of SciencesQuanzhouFujianChina
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4
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Parmeshwar N, Barnes L, Martins D, Nicholas C, Piper M. The impact of post-mastectomy radiation timing on overall outcomes of autologous free-flap breast reconstruction. Microsurgery 2024; 44:e31091. [PMID: 37469230 DOI: 10.1002/micr.31091] [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: 04/21/2023] [Revised: 06/07/2023] [Accepted: 07/06/2023] [Indexed: 07/21/2023]
Abstract
BACKGROUND The optimal timing of post-mastectomy radiation therapy (PMRT) in autologous breast reconstruction is controversial. Our study compares overall reconstructive outcomes in patients who received post-mastectomy radiation therapy either before or after the autologous flap. METHODS A single-center retrospective review was performed for patients who underwent free flap breast reconstruction and post-mastectomy radiation from January 2004 through January 2021. Demographic, intraoperative, and post-operative variables were recorded. RESULTS A total of 452 free flaps were identified, and 82 underwent PMRT. 59.8% were radiated with an expander prior to free flap surgery (PreFlap), and 40.2% flaps underwent PMRT (PostFlap). PostFlap patients were significantly younger (43.0 vs. 47.9 years, p = .016). There were no significant differences in free flap outcomes between the two cohorts including thrombosis, venous congestion, flap loss, takebacks, fat necrosis, seroma, or infection. Mastectomy skin flap necrosis was significantly higher in the PostFlap cohort (9.1% vs. 0%, p = .032), but nipple necrosis rates did not differ. There were no significant differences in number or need for revision surgeries, fat necrosis, or fat grafting between groups. However, there were significantly more total reconstructive complications, including infection and wound breakdown, experienced by the PreFlap cohort (46.9% vs. 24.2%, p = .038). CONCLUSIONS Timing of PMRT did not impact free flap outcomes, but those who had the expander radiated experienced significantly more complications overall. For the 34.7% of patients in the preFlap group who planned for autologous reconstruction form initial consultation, radiation after the flap may have improved their overall outcomes. As added complications cause delays in cancer therapy and final reconstruction, our results suggest that PMRT of the flap when possible may improve the overall experience for breast cancer patients.
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Affiliation(s)
- Nisha Parmeshwar
- Division of Plastic and Reconstructive Surgery, University of California San Francisco, San Francisco, California, USA
| | - Laura Barnes
- Division of Plastic and Reconstructive Surgery, University of California San Francisco, San Francisco, California, USA
| | - Deborah Martins
- Division of Plastic and Reconstructive Surgery, University of California San Francisco, San Francisco, California, USA
| | - Catherine Nicholas
- School of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Merisa Piper
- Division of Plastic and Reconstructive Surgery, University of California San Francisco, San Francisco, California, USA
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Huang N, Liu L, Qin Y, Xie Y. Effect of radiation therapy during surgery on postoperative wound complications after breast reconstruction in patients with breast cancer: A meta-analysis. Int Wound J 2023; 21:e14473. [PMID: 37905575 PMCID: PMC10828528 DOI: 10.1111/iwj.14473] [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: 10/09/2023] [Revised: 10/17/2023] [Accepted: 10/17/2023] [Indexed: 11/02/2023] Open
Abstract
Breast remodelling is a major therapeutic choice in radical mastectomy. Breast reconstruction is regarded as a promising option for the treatment of breast cancer. The purpose of this meta-analysis was to investigate the effect of Post mastectomy radiotherapy (PMRT) on postoperative wound complications in breast carcinoma. A comprehensive review of documents was conducted between the date of establishment and the 28th of August 2023. In all of the trials, patients were treated with breast cancer. The researchers chose 11 publications out of 8068 related studies. Two researchers examined these publications to satisfy the inclusion criteria. Among the 516 patients who had received radiation therapy in the course of the operation, 1772 had not received radiation therapy. The impact of radiation therapy and non-radiation therapy in breast cancer patients after breast reconstruction was reported in 8 studies, and the incidence of postoperative wound infection in non-radiation group was significantly lower (OR, 1.95; 95% CI, 1.26-3.02 p = 0.003). In nine studies, There is not considered to have achieved statistical significance between radiation therapy and non-radiation treatment for post-operation wound dehiscence in breast cancer patients who had received chemotherapy (OR, 1.61; 95% CI, 0.70-3.72 p = 0.27). The results of six trials demonstrated that radiation therapy and non-radiation therapy had no statistical significance on post-operation haemorrhage in breast cancer patients (OR, 1.02; 95% CI, 0.42-2.47 p = 0.96). The results of 7 trials demonstrated that radiation therapy and non-radiation therapy had no significant impact on the post-operation of skin necrosis (OR, 1.22; 95% CI, 0.66-2.28 p = 0.53). Two trials demonstrated that those without radiation therapy were less likely than those who received radiation therapy in skin contracture in patients (OR, 7.24; 95% CI, 1.80-29.10 p = 0.005). Regarding the incidence of wound infection and cutaneous contraction was higher in the radiation group.
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Affiliation(s)
- Na Huang
- Department of Radiotherapy, Radiation Oncology Key Laboratory of Sichuan Province, Sichuan Clinical Research Center for Cancer, Sichuan Cancer Hospital & Institute, Sichuan Cancer CenterAffiliated Cancer Hospital of University of Electronic Science and Technology of ChinaChengduChina
| | - Lihao Liu
- Department of Radiotherapy, Radiation Oncology Key Laboratory of Sichuan Province, Sichuan Clinical Research Center for Cancer, Sichuan Cancer Hospital & Institute, Sichuan Cancer CenterAffiliated Cancer Hospital of University of Electronic Science and Technology of ChinaChengduChina
| | - Yuan Qin
- Department of Radiotherapy, Radiation Oncology Key Laboratory of Sichuan Province, Sichuan Clinical Research Center for Cancer, Sichuan Cancer Hospital & Institute, Sichuan Cancer CenterAffiliated Cancer Hospital of University of Electronic Science and Technology of ChinaChengduChina
| | - Yao Xie
- Department of obstetrics and gynaecology, Sichuan Provincial People's Hospital, School of MedicineUniversity of Electronic Science and Technology of ChinaChengduChina
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Hou PY, Hsieh CH, Hsu CX, Kuo DY, Lu YF, Shueng PW. Impact of Varying Chest Wall Target Volume Delineation on Postmastectomy Radiation Therapy Outcomes in Breast Cancer Patients with Implant-Based Reconstruction. J Clin Med 2023; 12:6882. [PMID: 37959348 PMCID: PMC10650648 DOI: 10.3390/jcm12216882] [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: 09/25/2023] [Revised: 10/24/2023] [Accepted: 10/30/2023] [Indexed: 11/15/2023] Open
Abstract
BACKGROUND The target volume for post-mastectomy radiation therapy (PMRT) in breast cancer patients with reconstruction has been a subject of debate. Traditionally, the RT chest wall (CW) volume encompasses the entire implant. For patients with retropectoral implants, the deep lymphatic plexus dorsal part of the implant is no longer considered high risk and can be omitted. This study aimed to assess the radiation dose distribution and treatment outcomes associated with different CW delineation according to ESTRO ACROP guideline for patients who have undergone implant-based reconstruction. METHODS We conducted a retrospective review of breast cancer patients who underwent a mastectomy followed by two-stage implant-based breast reconstruction and adjuvant radiation therapy (RT) between 2007 and 2022. The expanders/implants were positioned retropectorally. The chest wall target volumes were categorized into two groups: the prepectoral group, which excluded the deep lymphatic plexus, and the whole expander group. RESULTS The study included 26 patients, with 15 in the prepectoral group and 11 in the whole expander group. No significant differences were observed in normal organ exposure between the two groups. There was a trend toward a lower ipsilateral lung mean dose in the prepectoral group (10.2 vs. 11.1 Gy, p = 0.06). Both groups exhibited limited instances of reconstruction failure and local recurrence. CONCLUSIONS For patients undergoing two-stage expander/implant retropectoral breast reconstruction and PMRT, our data provided comparable outcomes and normal organ exposure for those omitting the deep lymphatic plexus.
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Affiliation(s)
- Pei-Yu Hou
- Department of Radiation Oncology, Far Eastern Memorial Hospital, New Taipei 220216, Taiwan; (P.-Y.H.); (C.-H.H.); (C.-X.H.); (D.-Y.K.); (Y.-F.L.)
- School of Nursing, Yuan Ze University, Taoyuan 320315, Taiwan
| | - Chen-Hsi Hsieh
- Department of Radiation Oncology, Far Eastern Memorial Hospital, New Taipei 220216, Taiwan; (P.-Y.H.); (C.-H.H.); (C.-X.H.); (D.-Y.K.); (Y.-F.L.)
- School of Nursing, Yuan Ze University, Taoyuan 320315, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei 112304, Taiwan
- Institute of Traditional Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei 112304, Taiwan
| | - Chen-Xiong Hsu
- Department of Radiation Oncology, Far Eastern Memorial Hospital, New Taipei 220216, Taiwan; (P.-Y.H.); (C.-H.H.); (C.-X.H.); (D.-Y.K.); (Y.-F.L.)
| | - Deng-Yu Kuo
- Department of Radiation Oncology, Far Eastern Memorial Hospital, New Taipei 220216, Taiwan; (P.-Y.H.); (C.-H.H.); (C.-X.H.); (D.-Y.K.); (Y.-F.L.)
| | - Yueh-Feng Lu
- Department of Radiation Oncology, Far Eastern Memorial Hospital, New Taipei 220216, Taiwan; (P.-Y.H.); (C.-H.H.); (C.-X.H.); (D.-Y.K.); (Y.-F.L.)
| | - Pei-Wei Shueng
- Department of Radiation Oncology, Far Eastern Memorial Hospital, New Taipei 220216, Taiwan; (P.-Y.H.); (C.-H.H.); (C.-X.H.); (D.-Y.K.); (Y.-F.L.)
- School of Medicine, National Yang Ming Chiao Tung University, Taipei 112304, Taiwan
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7
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Polotto S, Pedrazzi G, Bergamini M, D'Abbiero N, Cattelani L. ADM-Assisted Direct-to-Implant Prepectoral Breast Reconstruction in Postmastectomy Radiation Therapy Setting: Long-Term Results. Clin Breast Cancer 2023; 23:704-711. [PMID: 37479666 DOI: 10.1016/j.clbc.2023.06.011] [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: 03/22/2023] [Revised: 06/18/2023] [Accepted: 06/27/2023] [Indexed: 07/23/2023]
Abstract
BACKGROUND Postmastectomy radiotherapy (PMRT) on immediate breast reconstruction historically involved a marked increase in complication rate (up to 50%). Prepectoral breast reconstruction (PPBR) has shown promising early postoperative results. This study aims to evaluate PPBR long-term results in PMRT setting. MATERIALS AND METHODS This is a retrospective monocentric analysis of 485 PPBR (439 patients) undergoing Acellular-Dermal-Matrix assisted direct-to-implant reconstruction (46 bilateral procedures) between January 2015 and December 2020 (mean FU:35.6 months). Group 1 comprised 401 PPBR not submitted to PMRT, and 84 reconstructions receiving PMRT in Group 2. Patients' characteristics, postoperative complication and revisional surgery rate were examined. PMRT characteristics and subcutaneous tissue thickness, measured in Group 2 by CT scan, were also evaluated. RESULTS Long-term complication rate was 11.2% in Group 1 vs. 21.4% in Group 2 (P-value = .019). Capsular contracture represented the only complication associated to a statistically significant difference between the 2 groups (P-value < .001). In Group 2, only 4.8% implant loss and 8.3% severe capsular contracture rate was found. In patients who underwent PMRT, 38.9% of complications settled with no consequences, and only 4.8% of patients needed revisional surgery in the long-term FU. According to multivariate analysis, drug intake and PMRT were significantly associated with postoperative complications. In Group 2, a thinner subcutaneous tissue was linked to a higher complication risk. CONCLUSION In our series, patients treated with PPBR who underwent PMRT, presented a low complication rate and minimal need for revisional surgery in the long-term follow-up, suggesting that this technique is feasible and safe also in PMRT context.
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Affiliation(s)
- Susanna Polotto
- Nottingham Breast Institute, Nottingham University Hospitals NHS Trust, Nottingham Breast Institute, Nottingham, UK; Breast Surgery Unit, University Hospital of Parma, Parma (PR), Italy.
| | - Giuseppe Pedrazzi
- Neuroscience Unit, Department of Medicine and Surgery, University of Parma, Parma (PR), Italy
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Kim PJ, Yuan M, Wu J, Gallo L, Uhlman K, Voineskos SH, O’Neill A, Hofer SO. "Spin" in Observational Studies in Deep Inferior Epigastric Perforator Flap Breast Reconstruction: A Systematic Review. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e5095. [PMID: 37351115 PMCID: PMC10284325 DOI: 10.1097/gox.0000000000005095] [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: 01/24/2023] [Accepted: 04/26/2023] [Indexed: 06/24/2023]
Abstract
The deep inferior epigastric artery perforator (DIEP) flap is widely used in autologous breast reconstruction. However, the technique relies heavily on nonrandomized observational research, which has been found to have high risk of bias. "Spin" can be used to inappropriately present study findings to exaggerate benefits or minimize harms. The primary objective was to assess the prevalence of spin in nonrandomized observational studies on DIEP reconstruction. The secondary objectives were to determine the prevalence of each spin category and strategy. Methods MEDLINE and Embase databases were searched from January 1, 2015, to November 15, 2022. Spin was assessed in abstracts and full-texts of included studies according to criteria proposed by Lazarus et al. Results There were 77 studies included for review. The overall prevalence of spin was 87.0%. Studies used a median of two spin strategies (interquartile range: 1-3). The most common strategies identified were causal language or claims (n = 41/77, 53.2%), inadequate extrapolation to larger population, intervention, or outcome (n = 27/77, 35.1%), inadequate implication for clinical practice (n = 25/77, 32.5%), use of linguistic spin (n = 22/77, 28.6%), and no consideration of the limitations (n = 21/77, 27.3%). There were no significant associations between selected study characteristics and the presence of spin. Conclusions The prevalence of spin is high in nonrandomized observational studies on DIEP reconstruction. Causal language or claims are the most common strategy. Investigators, reviewers, and readers should familiarize themselves with spin strategies to avoid misinterpretation of research in DIEP reconstruction.
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Affiliation(s)
- Patrick J. Kim
- From the Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Morgan Yuan
- Division of Plastic, Reconstructive and Aesthetic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Jeremy Wu
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Lucas Gallo
- Division of Plastic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Kathryn Uhlman
- Division of Plastic, Reconstructive and Aesthetic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Sophocles H. Voineskos
- Division of Plastic, Reconstructive and Aesthetic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Anne O’Neill
- Division of Plastic, Reconstructive and Aesthetic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Stefan O.P. Hofer
- Division of Plastic, Reconstructive and Aesthetic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
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9
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Godden AR, Micha A, O'Connell RL, Mohammed K, Kirby AM, Thiruchelvam PTR, Leff DR, MacNeill FA, Rusby JE. Pre-operative Radiotherapy And Deep Inferior Epigastric Artery Perforator (DIEP) flAp study (PRADA): Aesthetic outcome and patient satisfaction at one year. J Plast Reconstr Aesthet Surg 2023; 78:19-28. [PMID: 36764040 DOI: 10.1016/j.bjps.2022.11.040] [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: 06/13/2022] [Revised: 10/03/2022] [Accepted: 11/17/2022] [Indexed: 01/21/2023]
Abstract
INTRODUCTION The optimal combination of radiotherapy and breast reconstruction has not yet been defined. Post-mastectomy radiotherapy (PMRT) has deleterious effects on breast reconstruction, leading to caution amongst surgeons. Pre-operative radiotherapy (PRT) is a growing area of interest, is demonstrated to be safe, and spares autologous flaps from radiotherapy. This study evaluates the aesthetic outcome of PRT and deep inferior epigastric artery perforator (DIEP) flap reconstruction within the Pre-operative Radiotherapy And Deep Inferior Epigastric artery Perforator (DIEP) flAp (PRADA) cohort. METHODS PRADA was an observational cohort study designed to evaluate the feasibility and safety of PRT for women undergoing neoadjuvant chemotherapy and DIEP reconstruction. Panel evaluation of 3D surface images (3D-SIs) and patient-reported outcome measures (BREAST-Q) for a subset of women in the study were compared with those of a DIEP-PMRT cohort who had undergone DIEP reconstruction and PMRT. RESULTS Seventeen out of 33 women from the PRADA study participated in this planned substudy. Twenty-eight women formed the DIEP-PMRT cohort (median follow-up 23 months). The median (inter-quartile range [IQR]) 'satisfaction with breasts' score at 12 months for the PRADA cohort was significantly better than the DIEP-PMRT cohort (77 [72-87] versus 64 [54-71], respectively), p=0.01). Median [IQR] panel evaluation (5-point scale) was also significantly better for the PRADA cohort than for the DIEP-PMRT cohort (4.3 [3.9-4.6] versus 3.6 [2.8-4] p=0.003). CONCLUSIONS Aesthetic outcome for the PRADA cohort was reported to be 'good' or 'excellent' in 93% of cases using a bespoke panel assessment with robust methodology. Patient satisfaction at one year is encouraging and superior to DIEP-PMRT at 23 months. Switching surgery-radiotherapy sequencing leads to similar breast aesthetic outcomes and warrants further large-scale, multi-centre evaluation in a randomised trial.
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Affiliation(s)
- Amy R Godden
- The Royal Marsden NHS Foundation Trust, United Kingdom; Institute of Cancer Research, United Kingdom
| | | | - Rachel L O'Connell
- The Royal Marsden NHS Foundation Trust, United Kingdom; Institute of Cancer Research, United Kingdom
| | | | - Anna M Kirby
- The Royal Marsden NHS Foundation Trust, United Kingdom; Institute of Cancer Research, United Kingdom
| | | | - Daniel R Leff
- Imperial College Healthcare NHS Trust, London, United Kingdom
| | | | - Jennifer E Rusby
- The Royal Marsden NHS Foundation Trust, United Kingdom; Institute of Cancer Research, United Kingdom.
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10
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Yehia ZA, Punglia RS, Wong J. Integration of Radiation and Reconstruction After Mastectomy. Semin Radiat Oncol 2022; 32:237-244. [DOI: 10.1016/j.semradonc.2022.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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11
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Enhanced Recovery Pathway Reduces Hospital Stay and Opioid Use in Microsurgical Breast Reconstruction: A Single-Center, Private Practice Experience. Plast Reconstr Surg 2022; 150:13e-21e. [PMID: 35500278 DOI: 10.1097/prs.0000000000009179] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND This study aimed to determine benefits of the Enhanced Recovery After Surgery (ERAS) pathway implementation in free flap breast reconstruction related to postoperative narcotic use and health care resource utilization. METHODS A retrospective analysis of consecutive patients undergoing deep inferior epigastric perforator flap breast reconstruction from November of 2015 to April of 2018 was performed before and after implementation of the ERAS protocol. RESULTS Four hundred nine patients met inclusion criteria. The pre-ERAS group comprised 205 patients, and 204 patients were managed through the ERAS pathway. Mean age, laterality, timing of reconstruction, and number of previous abdominal surgical procedures were similar ( p > 0.05) between groups. Mean operative time between both groups (450.1 ± 92.7 minutes versus 440.7 ± 93.5 minutes) and complications were similar ( p > 0.05). Mean intraoperative (58.9 ± 32.5 versus 31.7 ± 23.4) and postoperative (129.5 ± 80.1 versus 90 ± 93.9) morphine milligram equivalents used were significantly ( p < 0.001) higher in the pre-ERAS group. Mean length of stay was significantly ( p < 0.001) longer in the pre-ERAS group (4.5 ± 0.8 days versus 3.2 ± 0.6 days). Bivariate linear regression analysis demonstrated that operative time was positively associated with total narcotic requirements ( p < 0.001) and length of stay ( p < 0.001). CONCLUSIONS ERAS pathways in microsurgical breast reconstruction promote reduction in intraoperative and postoperative narcotic utilization with concomitant decrease in hospital length of stay. In this study, patients managed through ERAS pathways required 46 percent less intraoperative and 31 percent less postoperative narcotics and had a 29 percent reduction in hospital length of stay. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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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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Letsiou E, Tsakatikas S, Vakis G, Tsapakidis K, Charalampakis N, Diamantis A, Poultsidi A, Michelakis D, de Bree E, Mauri D, Tsoukalas N, Antoniades C, Tolia M. Radiotherapy and Breast Reconstruction: What Is the Ideal Timing? A Narrative Review. Rev Recent Clin Trials 2022; 17:73-85. [PMID: 35289255 DOI: 10.2174/1574887117666220314161609] [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: 09/22/2021] [Revised: 11/13/2021] [Accepted: 12/24/2021] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Women undergoing mastectomy choose to pursue breast reconstruction (BR) in order to reduce their body image distress.Adjuvant chest wall irradiation is associated with a negative cosmetic outcome. The aim of our review was to identify the optimal timing of BR relating to radiotherapy delivery. MATERIALS AND METHODS Using Cochrane Library, Embase, PubMed, Springer, Wanfang and CNKI, we performed a non-systematic review of articles published up to August 2021. RESULTS There is no hard evidence in favor of immediate, delayed or 2-stage BR when post-mastectomy radiation is indicated. Immediate and 2-stage BR seem to be valid alternatives to delayed BR. CONCLUSIONS Further research is essential in order to assess clinician and patient reported aesthetic outcomes and determine the optimal timing of BR in view of post-mastectomy radiotherapy, in breast cancer survivors.
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Affiliation(s)
| | - Sergios Tsakatikas
- Department of Medical Oncology, Metaxa Cancer Hospital, 185 37 Athens, Greece
| | - George Vakis
- Plastic Surgery Clinic, Evangelismos General Hospital, Ipsilantou 45-47, 106 76, Athens, Greece
| | - Konstantinos Tsapakidis
- Department of Oncology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Biopolis, 41500, Larisa, Greece
| | | | - Alexandros Diamantis
- Department of Surgery, Medical School, University of Thessaly, 415 00 Larissa, Greece
| | - Antigoni Poultsidi
- Department of Surgery, Medical School, University of Thessaly, 415 00 Larissa, Greece
| | - Dimosthenis Michelakis
- Department of Surgical Oncology, Medical School of Crete University Hospital, 711 10 Heraklion, Greece
| | - Eelco de Bree
- Department of Surgical Oncology, Medical School of Crete University Hospital, 711 10 Heraklion, Greece
| | - Davide Mauri
- Faculty of Medicine, School of Health Sciences, University of Ioannina, Ioannina, Greece.,Department of Medical, Oncology, Greece Society for Study of Clonal Heterogeneity of Neoplasia (EMEKEN), University Hospital of Ioannina, Ioannina, Greece
| | - Nikolaos Tsoukalas
- Department of Oncology, 401 General Military Hospital of Athens, 115 25, Athens, Greece
| | - Chrysostomos Antoniades
- Department of Radiotherapy, School of Medicine, University of Crete, 711 10, Heraklion, Greece
| | - Maria Tolia
- Department of Radiotherapy, School of Medicine, University of Crete, 711 10, Heraklion, Greece
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14
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Klifto KM, Tecce MG, Serletti JM, Kovach SJ. Comparison of nine methods of immediate breast reconstruction after resection of localized breast cancer: A cost-effectiveness Markov decision analysis of prospective studies. Microsurgery 2022; 42:401-427. [PMID: 35355320 DOI: 10.1002/micr.30882] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Revised: 01/08/2022] [Accepted: 03/10/2022] [Indexed: 11/10/2022]
Abstract
BACKGROUND Women undergoing immediate breast reconstruction without radiation therapy have reconstruction methods available with uncertain long-term costs associated with complications requiring surgery and revisions. We evaluated cost-effectiveness of nine methods of immediate breast reconstruction for women with localized breast cancer. METHODS Markov modeling was performed over 10-years for unilateral/bilateral breast reconstructions from healthcare/societal perspectives. PubMed, Embase, Cochrane, Scopus, and CINAHL were searched to derive data from 13,744 patients in 79 prospective studies. Complications requiring surgery (mastectomy necrosis, total/partial flap necrosis, seroma, hematoma, infection, wound dehiscence, abdominal hernia, implant removal/explantation) and revisions (fat necrosis, capsular contracture, asymmetry, scars/redundant tissue, implant rupture/removal, fat grafting) were evaluated over yearly cycles. Reconstructions included: direct-to-implant (DTI), tissue expander-to-implant (TEI), latissimus dorsi flap-to-implant (LDI), latissimus dorsi (LD), pedicled transverse rectus abdominis myocutaneous (TRAM), free TRAM, deep inferior epigastric perforator/superficial inferior epigastric artery (DIEP/SIEA), thigh-based, or gluteal based flaps. Outcomes were incremental cost-effectiveness ratios (ICER) and net monetary benefits (NMB). Willingness-to-pay thresholds were $50,000 and $100,000. RESULTS From a healthcare perspective for unilateral reconstruction, compared to LD, the ICER for DTI was -$42,109.35/quality-adjusted life-years (QALY), LDI was -$25,300.83/QALY, TEI was -$22,036.02/QALY, DIEP/SIEA was $8307.65/QALY, free TRAM was $8677.26/QALY, pedicled TRAM was $13,021.44/QALY, gluteal-based was $17,698.99/QALY, and thigh-based was $23,447.82/QALY. NMB of DIEP/SIEA was $404,523.47, free TRAM was $403,821.40, gluteal-based was $392,478.64, thigh-based was $387,691.70, pedicled TRAM was $376,901.83, LD was $370,646.93, DTI was $339,668.77, LDI was $334,350.30, and TEI was $329,265.84. CONCLUSIONS All nine methods of immediate breast reconstruction were considered cost-effective from healthcare/societal perspectives. LD provided the lowest costs, while DIEP/SIEA provided the greatest effectiveness and NMB.
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Affiliation(s)
- Kevin M Klifto
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Missouri School of Medicine, Columbia, Missouri, USA.,Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Michael G Tecce
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Joseph M Serletti
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Stephen J Kovach
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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Metz G, Snook K, Sood S, Baron-Hay S, Spillane A, Lamoury G, Carroll S. Breast Radiotherapy after Oncoplastic Surgery—A Multidisciplinary Approach. Cancers (Basel) 2022; 14:cancers14071685. [PMID: 35406457 PMCID: PMC8996843 DOI: 10.3390/cancers14071685] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 03/02/2022] [Accepted: 03/21/2022] [Indexed: 11/16/2022] Open
Abstract
Simple Summary This article aims to review and summarize the current evidence for the role of oncoplastic breast surgery and the implications this may have on other therapies, such as radiotherapy and chemotherapy. Abstract Oncoplastic breast surgery encompasses a range of techniques used to provide equitable oncological outcomes compared with standard breast surgery while, simultaneously, prioritizing aesthetic outcomes. While the outcomes of oncoplastic breast surgery are promising, it can add an extra complexity to the treatment paradigm of breast cancer and impact on decision-making surrounding adjuvant therapies, like chemotherapy and radiotherapy. As such, early discussions at the multidisciplinary team meeting with surgeons, medical oncologists, and radiation oncologists present, should be encouraged to facilitate best patient care.
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Affiliation(s)
- Gabrielle Metz
- Northern Sydney Cancer Centre, Royal North Shore Hospital, Sydney, NSW 2065, Australia; (S.S.); (S.B.-H.); (G.L.); (S.C.)
- Correspondence:
| | - Kylie Snook
- Sydney Medical School, University of Sydney, Sydney, NSW 2006, Australia; (K.S.); (A.S.)
- Breast and Surgical Oncology, The Poche Centre, Sydney, NSW 2060, Australia
- The Mater Hospital, Sydney, NSW 2060, Australia
| | - Samriti Sood
- Northern Sydney Cancer Centre, Royal North Shore Hospital, Sydney, NSW 2065, Australia; (S.S.); (S.B.-H.); (G.L.); (S.C.)
- Sydney Medical School, University of Sydney, Sydney, NSW 2006, Australia; (K.S.); (A.S.)
- Breast and Surgical Oncology, The Poche Centre, Sydney, NSW 2060, Australia
- The Mater Hospital, Sydney, NSW 2060, Australia
- Breast and Melanoma Surgery Unit, Royal North Shore Hospital, Sydney, NSW 2065, Australia
| | - Sally Baron-Hay
- Northern Sydney Cancer Centre, Royal North Shore Hospital, Sydney, NSW 2065, Australia; (S.S.); (S.B.-H.); (G.L.); (S.C.)
| | - Andrew Spillane
- Sydney Medical School, University of Sydney, Sydney, NSW 2006, Australia; (K.S.); (A.S.)
- Breast and Surgical Oncology, The Poche Centre, Sydney, NSW 2060, Australia
- The Mater Hospital, Sydney, NSW 2060, Australia
- Breast and Melanoma Surgery Unit, Royal North Shore Hospital, Sydney, NSW 2065, Australia
| | - Gillian Lamoury
- Northern Sydney Cancer Centre, Royal North Shore Hospital, Sydney, NSW 2065, Australia; (S.S.); (S.B.-H.); (G.L.); (S.C.)
- Sydney Medical School, University of Sydney, Sydney, NSW 2006, Australia; (K.S.); (A.S.)
- The Mater Hospital, Sydney, NSW 2060, Australia
| | - Susan Carroll
- Northern Sydney Cancer Centre, Royal North Shore Hospital, Sydney, NSW 2065, Australia; (S.S.); (S.B.-H.); (G.L.); (S.C.)
- Sydney Medical School, University of Sydney, Sydney, NSW 2006, Australia; (K.S.); (A.S.)
- The Mater Hospital, Sydney, NSW 2060, Australia
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16
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Comparison of Autologous Breast Reconstruction Complications by Type of Neoadjuvant Chemotherapy Regimen. Plast Reconstr Surg 2021; 148:1186-1196. [PMID: 34644277 DOI: 10.1097/prs.0000000000008505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Neoadjuvant chemotherapy before mastectomy helps reduce tumor burden and pathologic response in breast cancer. Limited evidence exists regarding how neoadjuvant chemotherapy impacts outcomes following microvascular breast reconstruction. This study examines the effects of neoadjuvant chemotherapy regimens and schedules on microvascular breast reconstruction complication rates and also assesses the effects of neoadjuvant chemotherapy on circulating immune cells related to wound healing. METHODS Patients who underwent neoadjuvant chemotherapy and microvascular breast reconstruction at Yale New Haven Hospital between 2013 and 2018 were identified. Demographic variables, oncologic history, chemotherapy regimens, and complication profiles were collected. Chemotherapy regimens were stratified by inclusion of anthracycline and order of taxane administration. Chi-square, Fisher's exact, and t tests were used for univariate analysis. Multivariate binary logistic regression was used to control for covariates. RESULTS One hundred patients met inclusion criteria. On multivariate analysis, the administration of taxane first in an anthracycline-containing chemotherapy sequence was associated with increased complications (OR, 3.521; p = 0.012), particularly fat necrosis (OR, 2.481; p = 0.040). In the logistic regression model evaluating the effect of the taxane-first regimen on complication rates, the area under the curve was estimated to be 0.760 (p < 0.0001), particularly fat necrosis 0.635 (p < 0.05). The dosage of chemotherapy, number of days between neoadjuvant chemotherapy completion and surgery, and number of circulating immune cells did not significantly differ among patients who experienced complications. CONCLUSIONS Taxane-first, anthracycline-containing neoadjuvant chemotherapy regimens were associated with increased complications, particularly fat necrosis. The increased postreconstruction complication risk must be weighed against the benefits of taxane-first regimens in improving tumor outcome. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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Goel A, Agarwal VK, Nayak V, Yogsrivas R, Gulia A. Surgical Management of Locoregional Recurrence in Breast Cancer. Indian J Surg Oncol 2021; 12:616-623. [PMID: 34658592 DOI: 10.1007/s13193-021-01342-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 04/29/2021] [Indexed: 11/27/2022] Open
Abstract
Locoregional recurrences from breast cancer represent a heterogeneous group of disease that poses a therapeutic challenge and needs a multidisciplinary team management. The incidence of local recurrence after breast conservation surgery ranges from 10 to 22% and 5-15% after mastectomy at 10-year follow-up. Management of locoregional recurrence depends on tumor biology, stage at presentation, and prior local and systemic therapy. With improvements in diagnostic, pathological, and surgical techniques, radiation and systemic therapy approach, outcomes in these patients have improved. In this review, we discuss the risk factors, prognostic factors, surgical and reconstruction options, re-irradiation, and role of systemic therapy to define a reasonable treatment approach without compromising oncologic safety and achieve good cosmetic and survival outcomes.
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Affiliation(s)
- Ashish Goel
- Department of Surgical and Radiation Oncolgy, Jaypee Hospital, Noida, India
| | | | - Vikash Nayak
- Department of Surgical and Radiation Oncolgy, Jaypee Hospital, Noida, India
| | - Rekha Yogsrivas
- Department of Surgical and Radiation Oncolgy, Jaypee Hospital, Noida, India
| | - Abhishek Gulia
- Department of Surgical and Radiation Oncolgy, Jaypee Hospital, Noida, India
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18
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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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19
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Optimizing Breast Reconstruction through Integration of Plastic Surgery and Radiation Oncology. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3577. [PMID: 33977003 PMCID: PMC8104197 DOI: 10.1097/gox.0000000000003577] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Accepted: 03/15/2021] [Indexed: 11/27/2022]
Abstract
Post-mastectomy radiation therapy (PMRT) is an important adjunct to improve oncologic outcomes and survival in select breast cancer patients at increased risk for local recurrence. As recommendations for PMRT broaden, an increasing number of patients will have it included as part of their breast cancer treatment plan.
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Ly CL, Khetpal S, Heller DR, Higgins SA, Killelea B, Alperovich M, Avraham T. Comparing complications in irradiated and non-irradiated free-flaps in patients with bilateral immediate breast reconstruction and unilateral post-mastectomy radiotherapy. Microsurgery 2021; 41:615-621. [PMID: 33886127 DOI: 10.1002/micr.30747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 03/27/2021] [Accepted: 04/09/2021] [Indexed: 11/11/2022]
Abstract
BACKGROUND Numerous studies have evaluated the effect of post-mastectomy radiotherapy (PMRT) on autologous breast reconstruction, but the variability of PMRT regimens and inadequate controls have made results difficult to interpret. Therefore, in this study, irradiated free-flaps are compared to non-irradiated internal controls in patients who underwent immediate bilateral reconstruction followed by unilateral PMRT to better delineate the effect of PMRT. The role of regional nodal irradiation (RNI) is also specifically assessed. METHODS Appropriate patients were identified through retrospective review. Complications such as fat necrosis, fibrosis, infection, delayed healing, and flap loss, as well as revision surgeries, among the irradiated free-flaps were compared to those on the contralateral non-irradiated side. Additional analyses were performed to evaluate the effect of patient demographics and treatment characteristics, such as RNI, on complications involving the irradiated free-flaps. RESULTS Seventy-three women were included. There was no significant difference between complication rates for the irradiated and non-irradiated free-flaps (39.7% vs. 38.4%, p = .78), although irradiated free-flaps were more likely to have fibrosis (17.0% vs. 0.0%; p < .0001) and multiple complications (9.6% vs. 0.0%; p = .02). Both groups underwent a similar number of revision surgeries (42.5% vs. 41.1%; p = .29). Looking at the irradiated free-flaps, internal mammary node (IMN) irradiation was the only factor predictive of complications (IRR 3.80, CI 1.32-10.97; p = .01). CONCLUSIONS PMRT may contribute to free-flap fibrosis, but does not appear to affect the overall risk of complications or revision surgeries. However, additional counseling is warranted if IMN irradiation is likely, as it is potentially associated with increased complications.
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Affiliation(s)
- Catherine L Ly
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Yale University, School of Medicine, New Haven, Connecticut, USA
| | - Sumun Khetpal
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Yale University, School of Medicine, New Haven, Connecticut, USA
| | - Danielle R Heller
- Department of Surgery, Yale University, School of Medicine, New Haven, Connecticut, USA
| | - Susan A Higgins
- Department of Therapeutic Radiology, Yale University, School of Medicine, New Haven, Connecticut, USA
| | - Brigid Killelea
- Department of Surgery, Yale University, School of Medicine, New Haven, Connecticut, USA
| | - Michael Alperovich
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Yale University, School of Medicine, New Haven, Connecticut, USA
| | - Tomer Avraham
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Yale University, School of Medicine, New Haven, Connecticut, USA
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21
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Hershenhouse KS, Bick K, Shauly O, Kondra K, Ye J, Gould DJ, Patel KM. "Systematic review and meta-analysis of immediate versus delayed autologous breast reconstruction in the setting of post-mastectomy adjuvant radiation therapy". J Plast Reconstr Aesthet Surg 2020; 74:931-944. [PMID: 33423976 DOI: 10.1016/j.bjps.2020.11.027] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Revised: 11/03/2020] [Accepted: 11/22/2020] [Indexed: 01/29/2023]
Abstract
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.
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Affiliation(s)
| | - Katherine Bick
- Keck School of Medicine of USC, Los Angeles, California, USA
| | - Orr Shauly
- Keck School of Medicine of USC, Los Angeles, California, USA
| | - Katelyn Kondra
- Department of Surgery, Keck Hospital of USC, Los Angeles, California, USA
| | - Jason Ye
- Radiation Oncology, Keck School of Medicine of USC, Los Angeles, California, USA
| | | | - Ketan M Patel
- Department of Plastic and Reconstructive Surgery, Keck Hospital of USC, Los Angeles, California, USA.
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22
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Heiman AJ, Gabbireddy SR, Kotamarti VS, Ricci JA. A Meta-Analysis of Autologous Microsurgical Breast Reconstruction and Timing of Adjuvant Radiation Therapy. J Reconstr Microsurg 2020; 37:336-345. [PMID: 32957153 DOI: 10.1055/s-0040-1716846] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
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.
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Affiliation(s)
- Adee J Heiman
- Division of Plastic Surgery, Albany Medical Center, Albany, New York
| | | | | | - Joseph A Ricci
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Montefiore Medical Center, Bronx, New York
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23
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Shumway DA, Momoh AO, Sabel MS, Jagsi R. Integration of Breast Reconstruction and Postmastectomy Radiotherapy. J Clin Oncol 2020; 38:2329-2340. [PMID: 32442071 DOI: 10.1200/jco.19.02850] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
- Dean A Shumway
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | - Adeyiza O Momoh
- Section of Plastic Surgery, University of Michigan, Ann Arbor, MI
| | - Michael S Sabel
- Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Reshma Jagsi
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI
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24
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A Clinical Algorithm for Breast Cancer Patients: Exploring Reconstructive Options after Radiation. CURRENT BREAST CANCER REPORTS 2019. [DOI: 10.1007/s12609-019-00344-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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25
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Long-Term Outcomes After Autologous or Tissue Expander/Implant–Based Breast Reconstruction and Postmastectomy Radiation for Breast Cancer. Pract Radiat Oncol 2019; 9:e497-e505. [DOI: 10.1016/j.prro.2019.06.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 06/07/2019] [Accepted: 06/11/2019] [Indexed: 01/03/2023]
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26
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Nava MB, Benson JR, Audretsch W, Blondeel P, Catanuto G, Clemens MW, Cordeiro PG, De Vita R, Hammond DC, Jassem J, Lozza L, Orecchia R, Pusic AL, Rancati A, Rezai M, Scaperrotta G, Spano A, Winters ZE, Rocco N. International multidisciplinary expert panel consensus on breast reconstruction and radiotherapy. Br J Surg 2019; 106:1327-1340. [PMID: 31318456 DOI: 10.1002/bjs.11256] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Revised: 12/11/2018] [Accepted: 05/06/2019] [Indexed: 11/06/2022]
Abstract
BACKGROUND Conflicting evidence challenges clinical decision-making when breast reconstruction is considered in the context of radiotherapy. Current literature was evaluated and key statements on topical issues were generated and discussed by an expert panel at the International Oncoplastic Breast Surgery Meeting in Milan 2017. METHODS Studies on radiotherapy and breast reconstruction (1985 to September 2017) were screened using MEDLINE, Embase and CENTRAL. The literature review yielded 30 controversial key questions. A set of key statements was derived and the highest levels of clinical evidence (LoE) for each of these were summarized. Nineteen panellists convened for dedicated discussions at the International Oncoplastic Breast Surgery Meeting to express agreement, disagreement or abstention for the generated key statements. RESULTS The literature review identified 1522 peer-reviewed publications. A list of 22 key statements was produced, with the highest LoE recorded for each statement. These ranged from II to IV, with most statements (11 of 22, 50 per cent) supported by LoE III. There was full consensus for nine (41 per cent) of the 22 key statements, and more than 75 per cent agreement was reached for half (11 of 22). CONCLUSION Poor evidence exists on which to base patient-informed consent. Low-quality studies are conflicting with wide-ranging treatment options, precluding expert consensus regarding optimal type and timing of breast reconstruction in the context of radiotherapy. There is a need for high-quality evidence from prospective registries and randomized trials in this field.
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Affiliation(s)
- M B Nava
- Department of Plastic Surgery, University of Milan, Milan, Italy
| | - J R Benson
- Cambridge Breast Unit, Addenbrooke's Hospital, Cambridge, UK.,School of Medicine, Anglia Ruskin University, Cambridge and Chelmsford, UK
| | - W Audretsch
- Department of Senology and Breast Surgery, Heinrich Heine University, Dusseldorf, Germany
| | - P Blondeel
- Department of Plastic Surgery, University Hospital Ghent, Ghent, Belgium
| | - G Catanuto
- Multidisciplinary Breast Unit, Azienda Ospedaliera Cannizzaro, Catania, Italy
| | - M W Clemens
- Plastic and Reconstructive Surgery Unit, MD Anderson Cancer Center, Houston, Texas
| | - P G Cordeiro
- Department of Plastic and Reconstructive Surgery, Weill Cornell Medicine and.,Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, USA
| | - R De Vita
- Department of Plastic Surgery, National Cancer Institute 'Regina Elena', Rome, Italy
| | - D C Hammond
- Partners in Plastic Surgery of West Michigan, Grand Rapids, Michigan, USA
| | - J Jassem
- Department of Oncology and Radiotherapy, Medical University of Gdansk, Gdansk, Poland
| | - L Lozza
- Radiotherapy Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - R Orecchia
- Department of Radiotherapy, European Institute of Oncology, Milan, Italy
| | - A L Pusic
- Division of Plastic and Reconstructive Surgery, Brigham and Women's Hospital, Harvard University, Boston, Massachusetts, USA
| | - A Rancati
- Oncoplastic Surgery, Instituto Henry Moore, University of Buenos Aires, Buenos Aires, Argentina
| | - M Rezai
- European Breast Centre, Dusseldorf, Germany
| | - G Scaperrotta
- Radiology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - A Spano
- Plastic Surgery Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Z E Winters
- Division of Surgery and Interventional Science, Faculty of Medical Sciences, University College London, London, UK
| | - N Rocco
- Department of Clinical Medicine and Surgery, University of Naples 'Federico II', Naples, Italy
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Abstract
Purpose: The optimal approach to the integration of postmastectomy reconstruction and radiation therapy is not well-established. This review will summarize current literature pertaining to the most common types of reconstruction in the setting of postmastectomy radiation therapy (PMRT). Data Sources: Literature from PubMed was reviewed from 2000 to 2016. Study Selection: Studies were selected with relevance to “postmastectomy breast reconstruction,” “breast reconstruction,” and “breast reconstructive methods and PMRT.” Surgical outcomes, patient satisfaction, and cost-effectiveness were examined. Data Extraction: Data from publications was extracted, summarized, and converted to a table. Results of Data Synthesis: Implant-based techniques are on the rise, in the setting of PMRT. Implant-based methods are more affordable in the short term and result in immediate breast-mound formation compared to autologous methods. When compared to implant-based reconstruction with PMRT, autologous reconstruction with PMRT results in better quality of life (QoL) and sensory recovery as well as fewer complications and failures. Among autologous flaps, deep inferior epigastric perforator flaps are considered superior to transverse rectus abdominal muscle (TRAM) pedicled flaps and may be more suitable for PMRT. Latissimus dorsi and muscle-sparing free TRAM flaps are also viable options. In delayed autologous, which may be advantageous for high-risk patients, the optimal timing to delay surgery after radiation therapy is unknown. Reconstruction with a 2-stage tissue expander-implant technique offers good to excellent cosmetic outcomes in the setting of PMRT, although there may be complications in this 2-stage process. Conclusion: Surgical, cosmetic, quality of life, and life expectancy must be taken into account when selecting the way to integrate breast reconstruction and PMRT.
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Affiliation(s)
- Johanna H Yun
- 1 Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Roberto Diaz
- 2 Department of Radiation Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Amber G Orman
- 2 Department of Radiation Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
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Noninvasive Flap Preconditioning by Foam-Mediated External Suction Improves the Survival of Fasciocutaneous Axial-Pattern Flaps in a Type 2 Diabetic Murine Model. Plast Reconstr Surg 2018; 142:872e-883e. [DOI: 10.1097/prs.0000000000005038] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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29
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Three-dimensional Analysis of How Radiation Affects Deep Inferior Epigastric Perforator (DIEP) Flap Volume, Projection, and Position in Breast Cancer Reconstruction. Ann Plast Surg 2018; 81:235-239. [DOI: 10.1097/sap.0000000000001462] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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30
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Adam H, Docherty Skogh AC, Edsander Nord Å, Schultz I, Gahm J, Hall P, Frisell J, Halle M, de Boniface J. Risk of recurrence and death in patients with breast cancer after delayed deep inferior epigastric perforator flap reconstruction. Br J Surg 2018; 105:1435-1445. [PMID: 29683203 PMCID: PMC6174948 DOI: 10.1002/bjs.10866] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Accepted: 02/22/2018] [Indexed: 12/14/2022]
Abstract
Background Postmastectomy reconstruction using a deep inferior epigastric perforator (DIEP) flap is increasingly being performed in patients with breast cancer. The procedure induces extensive tissue trauma, and it has been hypothesized that the release of growth factors, angiogenic agonists and immunomodulating factors may reactivate dormant micrometastasis. The aim of the present study was to estimate the risk of breast cancer recurrence in patients undergoing DIEP flap reconstruction compared with that in patients treated with mastectomy alone. Methods Each patient who underwent delayed DIEP flap reconstruction at Karolinska University Hospital, Sweden, between 1999 and 2013, was compared with up to four controls with breast cancer who did not receive a DIEP flap. The control patients were selected using incidence density matching with respect to age, tumour and nodal status, neoadjuvant therapy and year of mastectomy. The primary endpoint was breast cancer‐specific survival. Survival analysis was carried out using Kaplan–Meier survival estimates and Cox proportional hazard regression analysis. Results The analysis included 250 patients who had 254 DIEP flap reconstructions and 729 control patients. Median follow‐up was 89 and 75 months respectively (P = 0·053). Breast cancer recurrence developed in 50 patients (19·7 per cent) in the DIEP group and 174 (23·9 per cent) in the control group (P = 0·171). The 5‐year breast cancer‐specific survival rate was 92·0 per cent for patients with a DIEP flap and 87·9 per cent in controls (P = 0·032). Corresponding values for 5‐year overall survival were 91·6 and 84·7 per cent (P < 0·001). After adjustment for tumour and patient characteristics and treatment, patients without DIEP flap reconstruction had significantly lower overall but not breast cancer‐specific survival. Conclusion The present findings do not support the hypothesis that patients with breast cancer undergoing DIEP flap reconstruction have a higher rate of breast cancer recurrence than those who have mastectomy alone. Deep inferior epigastric perforator is safe
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Affiliation(s)
- H Adam
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - A C Docherty Skogh
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Department of Reconstructive Plastic Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Å Edsander Nord
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Department of Reconstructive Plastic Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - I Schultz
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Department of Reconstructive Plastic Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - J Gahm
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Department of Reconstructive Plastic Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - P Hall
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.,Department of Oncology, South General Hospital, Stockholm, Sweden
| | - J Frisell
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Department of Breast and Endocrine Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - M Halle
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Department of Reconstructive Plastic Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - J de Boniface
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Department of Surgery, Breast Unit, Capio St Göran's Hospital, Stockholm, Sweden
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Pu Y, Mao TC, Zhang YM, Wang SL, Fan DL. The role of postmastectomy radiation therapy in patients with immediate prosthetic breast reconstruction: A meta-analysis. Medicine (Baltimore) 2018; 97:e9548. [PMID: 29419662 PMCID: PMC5944685 DOI: 10.1097/md.0000000000009548] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVE The controversy remains as to whether immediate prosthetic breast reconstruction with postmastectomy radiation therapy (PMRT) is associated with acceptable complications and aesthetic outcomes. The aim of this meta-analysis was to provide a pooled analysis of comparative clinical studies that evaluated breast cancer patients who were treated with a mastectomy and an immediate prosthetic breast reconstruction to compare the complications and satisfaction of those who underwent or did not undergo PMRT. METHODS According to the recommendations of the Cochrane Collaboration, we established a rigorous study protocol. We performed a systematic electronic search of the PubMed and Embase databases to identify articles for inclusion in our meta-analysis. Reconstruction failure, overall complications, capsular contracture, and patient satisfaction were analyzed individually. RESULTS Fifteen controlled trials were included, comprising 5314 patients (1069 PMRT vs 4245 non-PMRT). Primary outcomes revealed a statistically significant increase in overall complications [odds ratio (OR) 3.45; 95% confidence interval (95% CI) 2.62-4.54; P < .00001], reconstruction failure (OR: 2.59; 95% CI 1.46-4.62; P = .001), and capsular contracture (OR: 5.26, 95% CI: 2.73-10.13, P < .00001) after receiving PMRT. CONCLUSION Our review found that PMRT for patients who underwent immediate implant-based breast reconstruction led to higher risks of reconstruction failure, overall complications, and capsular contracture. However, it is still the standard adjuvant therapy for mastectomy patients who have opted for immediate implant-based breast reconstruction.
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Abstract
With the indications for radiation therapy in the treatment of breast cancer continuing to expand, many patients present for reconstruction having previously had radiation or having a high likelihood of requiring radiation following mastectomy. Both situations are challenging for the plastic surgeon, with different variables impacting the surgical outcome. To date, multiple studies have been performed examining prosthetic and autologous reconstruction in this setting. The purpose of this article was to provide a general platform for understanding the literature as it relates to reconstruction and radiation through an examination of recent systematic reviews and relevant recent publications. We examined this with a focus on the timing of the radiation, and within this context, examined the data from the traditional surgical outcomes standpoint as well as from a patient-reported outcomes perspective. The data provided within will aid in patient counseling and the informed consent process.
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See MSF, Farhadi J. Radiation Therapy and Immediate Breast Reconstruction: Novel Approaches and Evidence Base for Radiation Effects on the Reconstructed Breast. Clin Plast Surg 2017; 45:13-24. [PMID: 29080655 DOI: 10.1016/j.cps.2017.08.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Patients who undergo breast reconstruction experience higher complication rates if they have had a history of radiotherapy. However, implant-based reconstruction confers significantly higher complication and reconstruction failure rates compared with autologous reconstruction. This article analyses the factors that contribute to the complications of the different breast reconstruction modalities and the strategies described to mitigate these problems.
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Affiliation(s)
- Marlene Sue-Fen See
- Department of Plastic Surgery, St. Thomas' Hospital, Guy's and St. Thomas' Hospitals NHS Foundation Trust, Westminster Bridge Road, London SE1 7EH, UK.
| | - Jian Farhadi
- Department of Plastic Surgery, St. Thomas' Hospital, Guy's and St. Thomas' Hospitals NHS Foundation Trust, Westminster Bridge Road, London SE1 7EH, UK; Reconstructive and Aesthetic Surgery, University of Basel, Petersplatz 1, 4001 Basel, Switzerland; Centre for Plastic Surgery, Klinik Pyramide am See, Bellerivestrasse 34, 8034 Zürich, Switzerland
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34
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Immediate Breast Reconstruction with Abdominal Free Flap and Adjuvant Radiotherapy. Plast Reconstr Surg 2017; 140:681-690. [DOI: 10.1097/prs.0000000000003664] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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35
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Cooke AL, Diaz-Abele J, Hayakawa T, Buchel E, Dalke K, Lambert P. Radiation Therapy Versus No Radiation Therapy to the Neo-breast Following Skin-Sparing Mastectomy and Immediate Autologous Free Flap Reconstruction for Breast Cancer: Patient-Reported and Surgical Outcomes at 1 Year—A Mastectomy Reconstruction Outcomes Consortium (MROC) Substudy. Int J Radiat Oncol Biol Phys 2017; 99:165-172. [DOI: 10.1016/j.ijrobp.2017.05.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Revised: 04/19/2017] [Accepted: 05/01/2017] [Indexed: 11/12/2022]
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Should Immediate Autologous Breast Reconstruction Be Considered in Women Who Require Postmastectomy Radiation Therapy? A Prospective Analysis of Outcomes. Plast Reconstr Surg 2017; 139:1279-1288. [PMID: 28198770 DOI: 10.1097/prs.0000000000003331] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND In women who require postmastectomy radiation therapy, immediate autologous breast reconstruction is often discouraged. The authors prospectively evaluated postoperative morbidity and satisfaction reported by women undergoing delayed or immediate autologous breast reconstruction in the setting of postmastectomy radiation therapy. METHODS Patients enrolled in the Mastectomy Reconstruction Outcomes Consortium study, who received postmastectomy radiotherapy and underwent immediate or delayed free abdominally based autologous breast reconstruction, were identified. Postoperative complications at 1 and 2 years after reconstruction were assessed. Patient-reported outcomes were evaluated using the BREAST-Q questionnaire preoperatively and at 1 and 2 years postoperatively. Bivariate analyses and mixed-effects regression models were used to compare outcomes. RESULTS A total of 175 patients met the authors' inclusion criteria. Immediate reconstructions were performed in 108 patients and delayed reconstructions in 67 patients; 93.5 percent of immediate reconstructions were performed at a single center. Overall complication rates were similar based on reconstructive timing (25.9 percent immediate and 26.9 percent delayed at 1 year; p = 0.54). Patients with delayed reconstruction reported significantly lower prereconstruction scores (p < 0.0001) for Satisfaction with Breasts and Psychosocial and Sexual Well-being than did patients with immediate reconstruction. At 1 and 2 years postoperatively, both groups reported comparable levels of satisfaction in assessed BREAST-Q domains. CONCLUSIONS From this prospective cohort, immediate autologous breast reconstruction in the setting of postmastectomy radiation therapy appears to be a safe option that may be considered in select patients and centers. Breast aesthetics and quality of life, evaluated from the patient's perspective, were not compromised by flap exposure to radiation therapy. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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37
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Immediate tissue expander or implant-based breast reconstruction does not compromise the oncologic delivery of post-mastectomy radiotherapy (PMRT). Breast Cancer Res Treat 2017; 164:237-244. [DOI: 10.1007/s10549-017-4241-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Accepted: 04/08/2017] [Indexed: 12/25/2022]
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Sacotte R, Fine N, Kim JY, Alghoul M, Bethke K, Hansen N, Khan SA, Kulkarni S, Strauss J, Hayes JP, Donnelly ED. Assessing long-term complications in patients undergoing immediate postmastectomy breast reconstruction and adjuvant radiation. Pract Radiat Oncol 2017; 7:e91-e97. [DOI: 10.1016/j.prro.2016.10.017] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2016] [Revised: 10/14/2016] [Accepted: 10/26/2016] [Indexed: 11/16/2022]
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39
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Erdmann-Sager J, Wu LC. Advances in Immediate Breast Reconstruction and Reconstruction after Breast Conservation. CURRENT SURGERY REPORTS 2016. [DOI: 10.1007/s40137-016-0153-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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40
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Assessment and planning for oncoplastic and reconstructive breast surgery: a review and a proposed chart. EUROPEAN JOURNAL OF PLASTIC SURGERY 2016. [DOI: 10.1007/s00238-016-1221-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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