Multicentre study of patient-reported and clinical outcomes following immediate and delayed Autologous Breast Reconstruction And Radiotherapy (ABRAR study)

Visual Perception of Breast Free Flap Size Is Influenced by Radiation Changes of Surrounding Tissue

BACKGROUND

 Microsurgical reconstruction for bilateral mastectomy defects after unilateral radiation often results in asymmetry, despite both flap tissues never being radiated.

METHODS

 Photos of 16 patients who received prior radiation to one breast and underwent bilateral abdominal free flap reconstruction were taken postoperatively. Layperson and expert assessment were attained via online crowdsourcing and a panel of attending surgeons and senior residents. Stratification by interflap weight differences was done for subanalysis.

RESULTS

 A total of 399 laypersons responded, with the majority (57.3%) reporting that the radiated breast appeared smaller than the nonradiated breast. When the photos were stratified by interflap weight differences, the photos with the radiated side flap weight over 3% more than nonradiated side were significantly more likely to be perceived by laypersons as the same size (odds ratio [OR] = 2.7; p < 0.001) and of similar aesthetic (OR = 1.9; p < 0.001) when compared with photos with same-sized flaps. Of the expert responses (n = 16), the radiated side was perceived as smaller 72.3% of the time and the nonradiated side appeared more aesthetic 52.7% of the time. Contrary to layperson responses, the experts tend to report the radiated side as smaller despite varying flap weight. Interestingly, expert raters were significantly more likely to rate the flaps of equal aesthetics when the radiated side has a flap larger by 3% or more (OR = 3.6; p < 0.001).

CONCLUSION

 Higher aesthetic scores were noted when larger flaps were inset to the radiated envelope by both laypersons and experts, suggesting potential technical refinement in reconstructive outcomes.

A Scoping Review of the Application of BREAST-Q in Surgical Research

Background

Collection of patient-reported outcome (PRO) data can facilitate cost-effective, evidence-based, and patient-centered care. The BREAST-Q has become the gold standard tool to measure PRO data in breast surgery. The last review of its application indicated that it was underutilized. Considering the evolution in breast surgery, the purpose of this study was to perform a scoping review of BREAST-Q application since 2015 and identify emerging trends and potential persistent gaps to guide patient-centered practice and future research in breast surgery.

Methods

We performed an electronic literature review to identify publications published in English that used the BREAST-Q to assess patient outcomes. We excluded validation studies, review papers, conference abstracts, discussions, comments, and/or responses to previously published papers.

Results

We identified 270 studies that met our inclusion criteria. Specific data was extracted to examine the evolution of the BREAST-Q application and examine clinical trends and research gaps.

Discussion

Despite a significant increase in BREAST-Q studies, gaps in the understanding of the patient experience remain. The BREAST-Q is uniquely designed to measure quality of life and satisfaction with outcome and care. The prospective collection of center-specific data for every type of breast surgery will generate important information for the provision of patient-centered and evidence-based care.

Trends and issues in clinical research on satisfaction and quality of life after mastectomy and breast reconstruction: a 5-year scoping review

Breast reconstruction (BR) aims to improve the satisfaction and quality of life (QOL) of breast cancer survivors. Clinical studies using patient-reported outcomes (PROs) can therefore provide relevant information to the patients and support decision-making. This scoping review was conducted to analyze recent trends in world regions, methods used, and factors investigated. The literature search was conducted in August 2022. Databases of PubMed, MEDLINE, and CINAHL were searched for relevant English-language studies published from 2017 to 2022. Studies involving women with breast cancer who underwent BR after mastectomy and investigated PROs after BR using BR-specific scales were included. Data on the country, publication year, study design, PRO measures (PROMs) used, time points of surveys, and research themes were collected. In total, 147 articles met the inclusion criteria. BREAST-Q was the most widely used, contributing to the increase in the number and diversification of studies in this area. Such research has been conducted mainly in North America and Europe and is still developing in Asia and other regions. The research themes involved a wide range of clinical and patient factors in addition to surgery, which could be influenced by research methods, time since surgery, and even cultural differences. Recent BR-specific PROMs have led to a worldwide development of research on factors that affect satisfaction and QOL after BR. PRO after BR may be influenced by local cultural and social features, and it would be necessary to accumulate data in each region to draw clinically useful conclusion.

Prospective Longitudinal Patient-Reported Satisfaction and Health-Related Quality of Life following DIEP Flap Breast Reconstruction: Effects of Reconstruction Timing

BACKGROUND

Without reconstruction, mastectomy alone can produce significant detrimental effects on health-related quality of life. The magnitude of quality-of-life benefits following breast reconstruction may be unique based on timing of reconstruction. Facilitated by the BREAST-Q questionnaire, characterization of how reconstruction timing differentially affects patient-reported quality of life is essential for improved evidence-based clinical practice.

METHODS

Consecutive DIEP flap breast reconstruction patients prospectively completed BREAST-Q questionnaires preoperatively and at two different time intervals postoperatively. The first (postoperative time point A) and second (postoperative time point B) postoperative questionnaires were completed 1 month postoperatively and following breast revision/symmetry procedures, respectively. Postoperative flap and donor-site complications were recorded prospectively. Stratified by timing (immediate versus delayed) of reconstruction, preoperative clinical data, operative morbidity, and BREAST-Q scores were compared at all time points.

RESULTS

Between July of 2012 and August of 2016, 73 patients underwent 130 DIEP flap breast reconstructions. Collectively, breast satisfaction, psychosocial well-being, and sexual well-being scores significantly (p < 0.001) increased postoperatively versus baseline. Chest and abdominal physical well-being scores returned to baseline levels by postoperative time point B. Preoperatively, patients undergoing delayed breast reconstruction reported significantly (p < 0.05) lower breast satisfaction, psychosocial well-being, and sexual well-being scores compared to immediate reconstruction patients. Postoperatively, delayed and immediate reconstruction patients reported similar quality-of-life scores. Outcome satisfaction and flap and donor-site morbidity were similar between groups irrespective of timing of reconstruction.

CONCLUSIONS

In this prospective study, patient-reported outcomes demonstrate significant improvements in breast satisfaction, psychosocial well-being, and sexual well-being among patients following DIEP flap reconstruction. Moreover, preoperative differences in quality-of-life scores among delayed/immediate reconstruction patients were eliminated postoperatively.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, II.

Breast Reconstruction-Prospective Follow up on Breast Cancer Patients' Health-Related Quality of Life

Background

Analysing the results of breast reconstruction is important both in terms of oncological safety and health-related quality of life (HRQoL). Immediate breast reconstruction (IBR) is thought to be prone to complications and heavy for patients with no time to adapt to having cancer. Delayed reconstruction (DR) is an option after primary surgery and oncological treatments, but requires patients to go through two recovery periods after surgery.

Methods

A prospective study of 1065 breast cancer patients with repeated measurement of HRQoL with both generic (15D) and disease specific (EORTC QLQ C-30 BR23) measuring tools included 51 IBR patients and 41 DR patients. These patients’ HRQoL and reconstruction methods were studied in more detail alongside with clinical data to determine HRQoL levels for patients with IBR and those with mastectomy and DR during a 24-month follow-up. Measuring points were baseline, 3, 6, 12 and 24 months.

Results

Most frequent techniques used were abdominal flaps (IBR n = 16, DR n = 14), latissimus dorsi flaps (LD) (IBR n = 19, DR n = 10), implants (IBR n = 12) and fat grafting (DR n = 6). Smaller groups were excluded from group comparisons. Approximately one third of the patients encountered complications. Symptom scores did not differ between reconstruction methods. DR patients had better overall HRQoL at 12 months, but at 24 months the situation had changed in favour of IBR. Both approaches of reconstructive surgery produced good HRQoL with no significant differences between the approaches studied.

Does post-mastectomy radiation therapy worsen outcomes in immediate autologous breast flap reconstruction? A systematic review and meta-analysis

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.

The Effect of Previous Irradiation for Patients With Prosthetic Breast Reconstruction: A Meta-Analysis

BACKGROUND

Results regarding immediate prosthetic breast reconstruction after postmastectomy radiation therapy (PMRT) have been inconsistent.

OBJECTIVES

The authors aimed to assess the efficacy and safety of PMRT before immediate prosthetic breast reconstruction for patients with breast cancer.

METHODS

Electronic databases (PubMed, EmBase, and the Cochrane Library) were systematically searched to identify eligible studies from their inception until March 2020. The pooled odds ratio (OR) with 95% confidence intervals (CIs) was applied as an effect estimate and calculated using the random-effects model.

RESULTS

Nineteen studies including a total of 6757 patients were selected for final meta-analysis. The pooled OR showed that PMRT was associated with a higher incidence of reconstruction failure (OR = 2.57; 95% CI =1.55-4.26; P < 0.001), capsular contracture (OR = 5.99; 95% CI = 3.12-11.47; P < 0.001), and overall complications (OR = 2.52; 95% CI = 1.68-3.79; P < 0.001). It was also associated with a lower incidence of patient satisfaction (OR = 0.29; 95% CI = 0.16-0.52; P < 0.001) and good aesthetic results (OR = 0.25; 95% CI = 0.12-0.52; P < 0.001) compared with those who did not undergo PMRT. These significant associations could be affected by study design, mean age, stage of immediate breast reconstruction, follow-up, and study quality.

CONCLUSIONS

Although PMRT is the standard adjuvant therapy for mastectomy patients treated with immediate implant-based breast reconstruction, PMRT for patients undergoing immediate implant-based breast reconstruction has been associated with high risks of reconstruction failure, capsular contracture, and overall complications as well as low incidences of patient satisfaction and good aesthetic results.

LEVEL OF EVIDENCE: 4

Effects of radiation on toxicity, complications, revision surgery and aesthetic outcomes in breast reconstruction: An argument about timing and techniques

BACKGROUND

Radiotherapy (RT) combined with breast reconstruction can reduce the risk of cancer recurrence and increase the survival rate. However, this approach seems to worsen aesthetic outcomes and increase complication rates. The impact of breast reconstruction timing and techniques on clinical outcomes, however, remains unclear. For this reason, we aimed to perform a more comprehensive analysis of a series of patients undergoing RT and breast reconstruction.

METHODS

Patients were divided into 4 groups according to the timing of reconstruction (before RT and after RT) and surgical technique (heterologous reconstruction and autologous reconstruction (AR)). The median time between RT and reconstruction, number of revision surgeries, incidence of complications, toxicity, aesthetics and associated clinical risk factors were used to assess the clinical outcomes. An objective system of skin toxicity evaluation was performed.

RESULTS

Ninety-five patients were included in this study. No significant differences in the median time between RT and reconstruction, incidence of complications, toxicity or aesthetics were noted between different timings or techniques of reconstruction. Patients undergoing AR needed more revision surgeries to complete reconstruction. However, the total number of surgical procedures was similar between the groups. In a comparison between the treated and untreated breasts by an objective system, RT produced an increase in erythema and pigmentation and a decrease in elasticity in the treated breast (p<0.05 for all parameters). On multivariate analysis, smoking was a significant predictor associated with complications.

CONCLUSIONS

Combined breast reconstruction and RT seem to be successful regardless of the order of treatment or the type of reconstruction.

Breast reconstruction and radiation therapy: An Italian expert Delphi consensus statements and critical review

Breast conserving surgery (BCS) plus radiation therapy (RT) or mastectomy have shown comparable oncological outcomes in early-stage breast cancer and are considered standard of care treatments. Postmastectomy radiation therapy (PMRT) targeted to both the chest wall and regional lymph nodes is recommended in high-risk patients. Oncoplastic breast conserving surgery (OBCS) represents a significant recent improvement in breast surgery. Nevertheless, it represents a challenge for radiation oncologists as it triggers different decision-making strategies related to treatment volume definition and target delineation. Hence, the choice of the best combination and timing when offering RT to breast cancer patients who underwent or are planned to undergo reconstruction procedures should be carefully evaluated and based on individual considerations. We present an Italian expert Delphi Consensus statements and critical review, led by a core group of all the professional profiles involved in the management of breast cancer patients undergoing reconstructive procedures and RT. The report was structured as to consider the main recommendations on breast reconstruction and RT and analyse the current open issues deserving investigation and consensus. We used a three key-phases and a Delphi process. The final expert panel of 40 colleagues selected key topics as identified by the core group of the project. A final consensus on 26 key statements on RT and breast reconstruction after three rounds of the Delphi voting process and harmonisation was reached. An accompanying critical review of available literature was summarized. A clear communication and cooperation between surgeon and radiation oncologist is of paramount relevance both in the setting of breast reconstruction following mastectomy when PMRT is planned and when extensive glandular rearrangements as OBCS is performed. A shared-decision making, relying on outcome-based and patient-centred considerations, is essential, while waiting for higher level-of-evidence data.

"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.

Fat-Augmented Latissimus Dorsi versus Deep Inferior Epigastric Perforator Flap: Comparative Study in Delayed Autologous Breast Reconstruction

BACKGROUND

 The use of autologous tissues is considered the mainstay for delayed breast reconstruction. Aside the free abdominal flaps, which are most commonly used, the fat-augmented latissimus-dorsi (FALD) flap has been recently shown a reliable alternative option for pure autologous breast reconstruction. In this retrospective study, we aim to compare outcomes of autologous breast reconstructions using the extended FALD and deep inferior epigastric perforator flap (DIEP) flap, with an emphasis on patients' characteristics, demographic data, complications, and patients' satisfaction after a minimum 12-month follow-up.

METHODS

 Our series consists of 135 women who underwent a delayed postmastectomy unilateral autologous breast reconstruction from 2011 to 2017: 36 patients (Group A) had an extended FALD flap and 99 (Group B) a free DIEP flap performed by the same surgeons. Demographic data, breast volume, medical history, smoking, complications, and patients' satisfaction were recorded and analyzed. Student's t-test for independent variables, Mann-Whitney U-test, and Chi-squared test were used to compare the reported variables.

RESULTS

 Patients' age, body mass index (BMI), and pregnancy history were statistically different between groups (p < 0.001, p = 0.004, p < 0.001, respectively); younger age (35.1 vs. 41.2 years), lower BMI (25.6 vs. 28.4), and fewer pregnancies were recorded in Group A. Breast volume was also found significantly smaller in Group A patients (p = 0.009). Past medical history using the ASA physical status classification score, previous radiation therapy, history of smoking, and incidence of overall complications were similar in both groups. Overall satisfaction scores were found slightly higher, but not statistically significant, in the free-flap group (p = 0.442).

CONCLUSION

 The use of the FALD flap may provide comparable outcome to the DIEP flap in delayed breast reconstruction in terms of complications and patients' satisfaction; it should be considered a good reconstructive option for young and thin nulliparous patients, with small to medium size opposite breast.

Implant-based immediate breast reconstruction: failure rate when radiating the tissue expander or the permanent implant-a meta-analysis

Background

Implant-based immediate approach remains to be a first line option for reconstruction of mastectomy defects. When combined with post-mastectomy radiation therapy (PMRT) two different schemas are possible: radiating the temporary tissue expander (TTE) or the permanent implant (PI). The present article intends to be the biggest cohort meta-analysis to the date comparing reconstructive failure (RF) rate in these two scenarios: PMRT to TE compared with PMRT to PI.

Methods

A systematic search of the literature was performed on PUBMED/MEDLINE. The following key words were chosen: Breast Reconstruction AND Implant based AND Immediate. The time limit applied was from January 2008 to January 2019. We selected ten articles (n=1,130) to perform a meta-analysis due to the similarity of their approaches. Secondly, we did a simple literature review in order to identify some variables possibly working as predicting factors for RF.

Results

Previous meta-analysis are analysed. Some variables possibly working as risk factors for RF are summarized. We performed a meta-analysis in two scenarios: a fixed-effect model and a random effect model. For the random effect model an OR of 1.85 was obtained (0.96, 3.57; P=0.067). A funnel plot is performed showing no publication bias exists.

Conclusions

There is a tendency towards a higher RF rate when the TTE is irradiated compared with the irradiation of the PI. Further studies trying to elucidate the influence of the suggested risk factors for RF have to be performed to stablish a consensus about the indications and contraindications of this reconstructive modality.

Long-term outcomes of immediate autologous breast reconstruction after definite adjuvant therapy in intermediate and locally advanced breast cancer

Background

To analyze oncologic outcomes and reconstruction quality in locally advanced stage breast cancer after performing immediate autologous breast reconstruction (IABR).

Methods

From 2007 to 2014, data of patients aged ≤70 years old with stage II-III breast cancer who received total mastectomy (TM) were extracted from medical records. Exclusion criteria were: previous contralateral breast cancer, follow-up loss before adjuvant therapy completion, and artificial reconstruction. Patients were divided into two groups: (I) TM alone, and (II) TM + IABR. Overall survival (OS) and loco-regional recurrence free survival (LRRFS) were calculated. Times of minor revision, abnormal image findings in breast, and change of breast height were observed.

Results

Sixty-one of 188 patients received IABR after TM. Stage IIIB-C was the most important prognostic factor for OS (P<0.001) and LRRFS (P<0.001). For stage II, five-year TM and TM + IABR OS rates were 96.8% and 100% (P=0.324), respectively. For stage IIIB-C, five-year TM and TM + IABR OS rates were 57.6% and 62.5% (P=0.544), respectively. For stage II, five-year TM and TM + IABR LRRFS were 98.1% and 95.7% (P=0.998), respectively. For stage IIIB-C, five-year TM and TM + IABR LRRFS were 70.8% and 62.5% (P=0.378), respectively. Two major complications were observed after IABR. Minor revisions, abnormal image findings, and change of breast height were common without showing significant relation with adjuvant radiotherapy or tumor stage.

Conclusions

IABR showed feasible oncologic outcomes in 5-year follow-up. Adjuvant radiotherapy had little effect on quality of reconstruction. However, IABR in advanced stage should be cautiously applied considering expected survival and minor problems after IABR.

Delayed breast reconstruction with transverse latissimus dorsi myocutaneous flap using Becker expander implants in patients submitted to radiotherapy: A series of cases

BACKGROUND

Breast reconstruction with a latissimus dorsi myocutaneous flap associated with a breast implant is a well-established procedure. However, there are few published articles regarding latissimus association with expanders and radiotherapy. This study assess data of breast reconstructions using a latissimus dorsi myocutaneous flap associated with Becker expander implant (TLDMF/E) in patients submitted to radiotherapy.

METHODS

This is a descriptive study consisting of a series of cases. Inclusion criteria were patients who underwent mastectomy, radiotherapy, and delayed LDMF/E breast reconstruction. A minimum 6-month follow-up period was established, and descriptive variables were analyzed.

RESULTS

One hundred twenty-three patients were selected. The mean age of the patients was 45.1 years. Contralateral breast procedures were performed in 68 patients to achieve symmetry with substitution of the expander for an implant, with the majority of patients with an implant larger than the expander (74.0%) The nipple-areola complex was reconstructed in 77 patients (62.6%). In the donor site area, 116 patients (94.3%) had no complications. Minor complications were seroma in one patient and partial dehiscence in another patient. In the reconstructed breast, 11 patients (8.9%) had minor complications such as hematomas, partial necrosis of the native irradiated breast skin (3 cm or smaller), local infections, and partial exposition of the injection port. Major complications in the reconstructed breast were necrosis (larger than 3-5 cm) of the native irradiated breast skin in 5 patients (4.0%) who needed repair to avoid exposure of the expander. One patient needed expander removal due to a larger exposition.

CONCLUSIONS

Delayed breast reconstruction with TLDMF/E is a reliable option to selected patients with mastectomy and radiotherapy sequel.

Objective assessment of flap volume changes and aesthetic results after adjuvant radiation therapy in patients undergoing immediate autologous breast reconstruction

BACKGROUND

The use of immediate breast reconstruction and adjuvant radiation therapy is increasing in breast cancer patients. This study aimed to analyze the aesthetic outcome and changes in flap volume in patients with breast cancer undergoing radiation therapy of the surgical site after immediate autologous tissue reconstruction.

METHODS

Immediate abdominal free flap breast reconstruction following unilateral mastectomy was performed in 42 patients; 21 patients received adjuvant radiation (study group) and 21 patients did not (control group). To compare flap volume, three-dimensional computed tomography (CT) was performed before and after radiation. Also, aesthetic analysis was performed in both groups to evaluate shape changes.

RESULTS

There was a 12.3% flap volume reduction after the completion of radiation in the experimental group that was significantly greater than the 2.6% volume reduction observed in the non-radiation group (P<0.01). There was no significant difference in the short- and long-term aesthetic results between the groups.

CONCLUSIONS

When performing immediate autologous breast reconstruction, 14% volume overcorrection is recommended for patients in whom adjuvant radiation therapy is anticipated to improve aesthetic outcomes.