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Thai JN, Sodagari F, Colwell AS, Winograd JM, Revzin MV, Mahmoud H, Mozayan S, Chou SHS, Destounis SV, Butler RS. Multimodality Imaging of Postmastectomy Breast Reconstruction Techniques, Complications, and Tumor Recurrence. Radiographics 2024; 44:e230070. [PMID: 38573814 DOI: 10.1148/rg.230070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2024]
Abstract
For women undergoing mastectomy, breast reconstruction can be performed by using implants or autologous tissue flaps. Mastectomy options include skin- and nipple-sparing techniques. Implant-based reconstruction can be performed with saline or silicone implants. Various autologous pedicled or free tissue flap reconstruction methods based on different tissue donor sites are available. The aesthetic outcomes of implant- and flap-based reconstructions can be improved with oncoplastic surgery, including autologous fat graft placement and nipple-areolar complex reconstruction. The authors provide an update on recent advances in implant reconstruction techniques and contemporary expanded options for autologous tissue flap reconstruction as it relates to imaging modalities. As breast cancer screening is not routinely performed in this clinical setting, tumor recurrence after mastectomy and reconstruction is often detected by palpation at physical examination. Most local recurrences occur within the skin and subcutaneous tissue. Diagnostic breast imaging continues to have a critical role in confirmation of disease recurrence. Knowledge of the spectrum of benign and abnormal imaging appearances in the reconstructed breast is important for postoperative evaluation of patients, including recognition of early and late postsurgical complications and breast cancer recurrence. The authors provide an overview of multimodality imaging of the postmastectomy reconstructed breast, as well as an update on screening guidelines and recommendations for this unique patient population. ©RSNA, 2024 Test Your Knowledge questions for this article are available in the supplemental material.
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Affiliation(s)
- Janice N Thai
- From the Department of Radiology, Division of Breast Imaging (J.N.T., F.S., S.H.S.C.); and Department of Surgery, Division of Plastic and Reconstructive Surgery (A.S.C., J.M.W.), Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114; Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT (M.V.R., R.S.B.); Yale New Haven Health, Bridgeport Hospital, Bridgeport, CT (H.M., S.M.); and Elizabeth Wende Breast Care, Rochester, NY (S.V.D.)
| | - Faezeh Sodagari
- From the Department of Radiology, Division of Breast Imaging (J.N.T., F.S., S.H.S.C.); and Department of Surgery, Division of Plastic and Reconstructive Surgery (A.S.C., J.M.W.), Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114; Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT (M.V.R., R.S.B.); Yale New Haven Health, Bridgeport Hospital, Bridgeport, CT (H.M., S.M.); and Elizabeth Wende Breast Care, Rochester, NY (S.V.D.)
| | - Amy S Colwell
- From the Department of Radiology, Division of Breast Imaging (J.N.T., F.S., S.H.S.C.); and Department of Surgery, Division of Plastic and Reconstructive Surgery (A.S.C., J.M.W.), Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114; Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT (M.V.R., R.S.B.); Yale New Haven Health, Bridgeport Hospital, Bridgeport, CT (H.M., S.M.); and Elizabeth Wende Breast Care, Rochester, NY (S.V.D.)
| | - Jonathan M Winograd
- From the Department of Radiology, Division of Breast Imaging (J.N.T., F.S., S.H.S.C.); and Department of Surgery, Division of Plastic and Reconstructive Surgery (A.S.C., J.M.W.), Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114; Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT (M.V.R., R.S.B.); Yale New Haven Health, Bridgeport Hospital, Bridgeport, CT (H.M., S.M.); and Elizabeth Wende Breast Care, Rochester, NY (S.V.D.)
| | - Margarita V Revzin
- From the Department of Radiology, Division of Breast Imaging (J.N.T., F.S., S.H.S.C.); and Department of Surgery, Division of Plastic and Reconstructive Surgery (A.S.C., J.M.W.), Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114; Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT (M.V.R., R.S.B.); Yale New Haven Health, Bridgeport Hospital, Bridgeport, CT (H.M., S.M.); and Elizabeth Wende Breast Care, Rochester, NY (S.V.D.)
| | - Hagar Mahmoud
- From the Department of Radiology, Division of Breast Imaging (J.N.T., F.S., S.H.S.C.); and Department of Surgery, Division of Plastic and Reconstructive Surgery (A.S.C., J.M.W.), Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114; Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT (M.V.R., R.S.B.); Yale New Haven Health, Bridgeport Hospital, Bridgeport, CT (H.M., S.M.); and Elizabeth Wende Breast Care, Rochester, NY (S.V.D.)
| | - Sara Mozayan
- From the Department of Radiology, Division of Breast Imaging (J.N.T., F.S., S.H.S.C.); and Department of Surgery, Division of Plastic and Reconstructive Surgery (A.S.C., J.M.W.), Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114; Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT (M.V.R., R.S.B.); Yale New Haven Health, Bridgeport Hospital, Bridgeport, CT (H.M., S.M.); and Elizabeth Wende Breast Care, Rochester, NY (S.V.D.)
| | - Shinn-Huey S Chou
- From the Department of Radiology, Division of Breast Imaging (J.N.T., F.S., S.H.S.C.); and Department of Surgery, Division of Plastic and Reconstructive Surgery (A.S.C., J.M.W.), Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114; Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT (M.V.R., R.S.B.); Yale New Haven Health, Bridgeport Hospital, Bridgeport, CT (H.M., S.M.); and Elizabeth Wende Breast Care, Rochester, NY (S.V.D.)
| | - Stamatia V Destounis
- From the Department of Radiology, Division of Breast Imaging (J.N.T., F.S., S.H.S.C.); and Department of Surgery, Division of Plastic and Reconstructive Surgery (A.S.C., J.M.W.), Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114; Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT (M.V.R., R.S.B.); Yale New Haven Health, Bridgeport Hospital, Bridgeport, CT (H.M., S.M.); and Elizabeth Wende Breast Care, Rochester, NY (S.V.D.)
| | - Reni S Butler
- From the Department of Radiology, Division of Breast Imaging (J.N.T., F.S., S.H.S.C.); and Department of Surgery, Division of Plastic and Reconstructive Surgery (A.S.C., J.M.W.), Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114; Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT (M.V.R., R.S.B.); Yale New Haven Health, Bridgeport Hospital, Bridgeport, CT (H.M., S.M.); and Elizabeth Wende Breast Care, Rochester, NY (S.V.D.)
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Machado LB, Brody MB, Rotenberg SE, Stachelek GC, Fernandez JG. Breast Cancer Tumor Board: A Radiologist's Guide to Postmastectomy Radiation Therapy. Radiographics 2023; 43:e220086. [PMID: 36795596 DOI: 10.1148/rg.220086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
Radiation therapy represents a pillar in the current management of breast cancer. Historically, postmastectomy radiation therapy (PMRT) has been administered only in patients with locally advanced disease and a poor prognosis. These included patients with large primary tumors at diagnosis and/or more than three metastatic axillary lymph nodes. However, during the past few decades, several factors have prompted a shift in perspective, and recommendations for PMRT have become more fluid. Guidelines for PMRT in the United States are outlined by the National Comprehensive Cancer Network and the American Society for Radiation Oncology. Because evidence to support performing PMRT is frequently discordant, the decision to offer radiation therapy often requires team discussion. These discussions are usually held in multidisciplinary tumor board meetings in which radiologists play a pivotal role by providing critical information such as the location and extent of disease. Breast reconstruction after mastectomy is optional and is safe in cases in which the patient's clinical status allows it. The preferred method in the setting of PMRT is autologous reconstruction. If this is not possible, then a two-step implant-based reconstruction is recommended. Radiation therapy does involve a risk of toxicity. Complications can be seen in acute and chronic settings and range from fluid collections and fractures to radiation-induced sarcomas. Radiologists have a key role in detecting these and other clinically relevant findings and should be prepared to recognize, interpret, and address them. © RSNA, 2023 Quiz questions for this article are available in the supplemental material.
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Affiliation(s)
- Laura B Machado
- From the Departments of Radiology (L.B.M., M.B.B., S.E.R.) and Radiation Oncology (G.C.S.), Mercy Catholic Medical Center, 1500 Lansdowne Ave, Darby, PA 19023-1200; and Department of Plastic and Reconstructive Surgery, St Mary's Medical Center, Langhorne, PA (J.G.F.)
| | - Marion B Brody
- From the Departments of Radiology (L.B.M., M.B.B., S.E.R.) and Radiation Oncology (G.C.S.), Mercy Catholic Medical Center, 1500 Lansdowne Ave, Darby, PA 19023-1200; and Department of Plastic and Reconstructive Surgery, St Mary's Medical Center, Langhorne, PA (J.G.F.)
| | - Scott E Rotenberg
- From the Departments of Radiology (L.B.M., M.B.B., S.E.R.) and Radiation Oncology (G.C.S.), Mercy Catholic Medical Center, 1500 Lansdowne Ave, Darby, PA 19023-1200; and Department of Plastic and Reconstructive Surgery, St Mary's Medical Center, Langhorne, PA (J.G.F.)
| | - Gregory C Stachelek
- From the Departments of Radiology (L.B.M., M.B.B., S.E.R.) and Radiation Oncology (G.C.S.), Mercy Catholic Medical Center, 1500 Lansdowne Ave, Darby, PA 19023-1200; and Department of Plastic and Reconstructive Surgery, St Mary's Medical Center, Langhorne, PA (J.G.F.)
| | - John G Fernandez
- From the Departments of Radiology (L.B.M., M.B.B., S.E.R.) and Radiation Oncology (G.C.S.), Mercy Catholic Medical Center, 1500 Lansdowne Ave, Darby, PA 19023-1200; and Department of Plastic and Reconstructive Surgery, St Mary's Medical Center, Langhorne, PA (J.G.F.)
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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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García-Solbas S, Lorenzo-Liñán MÁ, Castro-Luna G. Long-Term Quality of Life (BREAST-Q) in Patients with Mastectomy and Breast Reconstruction. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:9707. [PMID: 34574627 PMCID: PMC8472119 DOI: 10.3390/ijerph18189707] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 09/12/2021] [Accepted: 09/13/2021] [Indexed: 11/20/2022]
Abstract
(1) Background: Mastectomy is the surgical treatment of choice in 20-30% of women with breast cancer. In addition, more women are undergoing risk-reducing mastectomies. It is necessary to study these women's quality of life and satisfaction after surgery, as studies report high percentages of dissatisfaction with the results. The publication of the BREAST-Q© questionnaire in 2009 provided a valuable tool to measure these results. (2) Methods: Descriptive, cross-sectional study of 70 patients who underwent mastectomy and breast reconstruction, both therapeutic and prophylactic, in the last 10 years to whom the BREAST-Q© 2.0-Reconstruction Module questionnaire was provided for completion. (3) Results: The sexual satisfaction scale was the lowest score of the entire questionnaire (51.84 ± 21.13), while the highest score was obtained on the satisfaction with the surgeon scale (91.86 ± 18.11). The satisfaction with care scales showed the importance of the evaluation of these items for future studies. More than half of the patients of the study (51.5%) underwent at least one reoperation after the first surgery, with an average of one (1.15) intervention per patient and a maximum of five. (4) Conclusions: Mastectomy and breast reconstruction have a high negative impact on the sexual well-being of patients. The high percentage of reoperations is a factor to consider because of its possible influence on these patients' quality of life and satisfaction.
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Affiliation(s)
- Silvia García-Solbas
- Department of Obstetrics and Gynaecology, Hospital Vithas Virgen del Mar, 04120 Almería, Spain
| | | | - Gracia Castro-Luna
- Department of Nursing, Physiotherapy and Medicine, University of Almería, 04120 Almería, Spain;
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5
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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: 5] [Impact Index Per Article: 1.3] [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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Fuertes V, Francés M, Casarrubios JM, Fernández-Palacios J, González JM, Loro-Ferrer JF. Implant-based immediate breast reconstruction: failure rate when radiating the tissue expander or the permanent implant-a meta-analysis. Gland Surg 2020; 9:209-218. [PMID: 32420244 DOI: 10.21037/gs.2020.01.20] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
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.
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Affiliation(s)
- Víctor Fuertes
- Department of Plastic Surgery, Vancouver General Hospital, Vancouver, Canada
| | - Mónica Francés
- Department of Plastic Surgery, University Hospital Dr. Negrín, Las Palmas de Gran Canaria, Spain
| | - José M Casarrubios
- Department of Plastic Surgery, University Hospital Dr. Negrín, Las Palmas de Gran Canaria, Spain
| | | | - Jesús María González
- Research Department, University Hospital Dr. Negrín, Las Palmas de Gran Canaria, Spain
| | - Juan Francisco Loro-Ferrer
- Clinical Pharmacology, Medicine School-University of Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Spain
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Risk communication in a patient decision aid for radiotherapy in breast cancer: How to deal with uncertainty? Breast 2020; 51:105-113. [PMID: 32298961 PMCID: PMC7375609 DOI: 10.1016/j.breast.2020.04.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 03/13/2020] [Accepted: 04/01/2020] [Indexed: 12/21/2022] Open
Abstract
Background and aim Patient decision aids for oncological treatment options, provide information on the effect on recurrence rates and/or survival benefit, and on side-effects and/or burden of different treatment options. However, often uncertainty exists around the probability estimates for recurrence/survival and side-effects which is too relevant to be ignored. Evidence is lacking on the best way to communicate these uncertainties. The aim of this study is to develop a method to incorporate uncertainties in a patient decision aid for breast cancer patients to support their decision on radiotherapy. Methods Firstly, qualitative interviews were held with patients and health care professionals. Secondly, in the development phase, thinking aloud sessions were organized with four patients and 12 health care professionals, individual and group-wise. Results Consensus was reached on a pictograph illustrating the whole range of uncertainty for local recurrence risks, in combination with textual explanation that a more exact personalized risk would be given by their own physician. The pictograph consisted of 100 female icons in a 10 x 10 array. Icons with a stepwise gradient color indicated the uncertainty margin. The prevalence and severity of possible side-effects were explained using verbal labels. Conclusions We developed a novel way of visualizing uncertainties in recurrence rates in a patient decision aid. The effect of this way of communicating risk uncertainty is currently being tested in the BRASA study (NCT03375801). There exists uncertainty around local recurrence risks for breast cancer patients. Little is known on how to communicate uncertainty to patients. Patient decision aids can help communicating risks and uncertainty. We developed pictographs to communicate numerical uncertainty in recurrence risks. The effect of the pictographs is currently being tested in the BRASA study.
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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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Postmastectomy Radiation Therapy (PMRT) before and after 2-Stage Expander-Implant Breast Reconstruction: A Systematic Review. ACTA ACUST UNITED AC 2019; 55:medicina55060226. [PMID: 31146506 PMCID: PMC6630203 DOI: 10.3390/medicina55060226] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 04/26/2019] [Accepted: 05/21/2019] [Indexed: 01/12/2023]
Abstract
Background: In those undergoing treatment for breast cancer, evidence has demonstrated a significant improvement in survival, and a reduction in the risk of local recurrence in patients who undergo postmastectomy radiation therapy (PMRT). There is uncertainty about the optimal timing of PMRT, whether it should be before or after tissue expander or permanent implant placement. This study aimed to summarize the data reported in the literature on the effect of the timing of PMRT, both preceding and following 2-stage expander-implant breast reconstruction (IBR), and to statistically analyze the impact of timing on infection rates and the need for explantation. Methods: A comprehensive systematic review of the literature was conducted using the PubMed/Medline, Ovid, and Cochrane databases without timeframe limitations. Articles included in the analysis were those reporting outcomes data of PMRT in IBR published from 2009 to 2017. Chi-square statistical analysis was performed to compare infection and explantation rates between the two subgroups at p < 0.05. Results: A total of 11 studies met the inclusion criteria for this study. These studies reported outcomes data for 1565 total 2-stage expander-IBR procedures, where PMRT was used (1145 before, and 420 after, implant placement). There was a statistically significant higher likelihood of infection following pre-implant placement PMRT (21.03%, p = 0.000079), compared to PMRT after implant placement (9.69%). There was no difference in the rate of explantation between pre-implant placement PMRT (12.93%) and postimplant placement PMRT (11.43%). Conclusion: This study suggests that patients receiving PMRT before implant placement in 2-stage expander–implant based reconstruction may have a higher risk of developing an infection.
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Fredman R, Wu C, Rapolti M, Luckett D, Fine J, McGuire K, Gallagher K, Roughton M. Prepectoral Direct-to-Implant Breast Reconstruction: Early Outcomes and Analysis of Postoperative Pain. Aesthet Surg J Open Forum 2019; 1:ojz006. [PMID: 33791602 PMCID: PMC7984832 DOI: 10.1093/asjof/ojz006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Direct-to-implant (DTI) breast reconstruction provides high-quality aesthetic results in appropriate candidates. Most commonly, implants are placed in the subpectoral space which can lead to pain and breast animation. Surgical and technological advances have allowed for successful prepectoral implant placement which may eliminate these trade-offs. OBJECTIVES Here we present early outcomes from 153 reconstructions in 94 patients who underwent prepectoral DTI. We sought to determine whether these patients have less postoperative pain and narcotic use than subpectoral implant or expander placement. METHODS A retrospective review was performed for all prepectoral DTI reconstructions at our institution from 2015 to 2016. Data were collected on postoperative pain and narcotic use while in hospital. RESULTS The average follow-up time was 8.5 months (range, 3-17 months) and the overall complication rate was 27% (n = 41) with the most common complications being skin necrosis (9%, n = 13) and infection (7%, n = 11). No statistically significant difference in complications was found in patients who underwent postmastectomy radiation therapy. Patients who underwent prepectoral DTI reconstruction did not have a statistically significant difference in postoperative pain and narcotic use while in-hospital compared with other techniques. CONCLUSION Prepectoral DTI reconstruction provides good results with similar complication rates to subpectoral techniques. Prepectoral DTI eliminates the problem of breast animation. Although our series did not reach statistical significance in pain scores or requirement for postoperative narcotics, we believe that it is an important preliminary result and with larger numbers we anticipate a more definitive conclusion. LEVEL OF EVIDENCE 4
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Affiliation(s)
- Rafi Fredman
- Division of Plastic and Reconstructive Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Cindy Wu
- Division of Plastic and Reconstructive Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Mihaela Rapolti
- Division of Plastic and Reconstructive Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Daniel Luckett
- Division of Plastic and Reconstructive Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Jason Fine
- Division of Plastic and Reconstructive Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Kandace McGuire
- Division of Plastic and Reconstructive Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Kristalyn Gallagher
- Division of Plastic and Reconstructive Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Michelle Roughton
- Division of Plastic and Reconstructive Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC
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