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Nag S, Berlin L, Hunter K, Bonawitz SC. Effects of Neoadjuvant Chemotherapy on Autologous and Implant-Based Breast Reconstruction: A Systematic Review and Meta-Analysis of the Literature. Clin Breast Cancer 2024; 24:184-190. [PMID: 38228449 DOI: 10.1016/j.clbc.2023.12.004] [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: 08/29/2023] [Revised: 11/30/2023] [Accepted: 12/14/2023] [Indexed: 01/18/2024]
Abstract
Neoadjuvant chemotherapy (NAC) is a standard modality of treatment for breast cancer. The exposure of patients to drugs that effect the cells and processes involved in healing prior to reconstructive surgical procedures is a source of concern for reconstructive surgeons. The reported effects of NAC on autologous and tissue expander to implant-based breast reconstruction vary from study to study and have not been comprehensively reviewed on a large scale. There is also significant variation from study to study regarding which outcomes are evaluated. The primary aim of this systematic review and meta-analysis is to evaluate the effect of neoadjuvant chemotherapy (NAC) on common and significant outcomes including total complication, reconstruction loss, and SSI (Surgical Site Infection) rates in breast reconstruction. The second aim of this study is to evaluate whether NAC has differing effects on implant-based reconstruction compared with autologous flap reconstruction. A systematic review of the literature published from 1991 to 2019 in the PubMed and Scopus library database was performed to identify studies reporting outcomes of breast reconstruction in patients receiving NAC. A meta-analysis was then performed. Primary outcomes reviewed included overall complication rates, SSI rates, and total loss of reconstruction (flap necrosis or premature tissue expander or implant removal). Outcomes were analyzed using a random effects model and chi-square statistical test. Our literature search yielded 22 manuscripts with a total of 3680 patients that fit our inclusion criteria, of which 12 reported on reconstruction loss, 14 reported on SSI rates, and 10 reported on overall complication rates. There was no significant difference in overall breast reconstruction loss rate (OR 1.30, P = .35), complication rate (OR 1.21, P = .06), and rate of SSI (OR 1.28, P = .85) between NAC vs. non-NAC groups. In patients undergoing autologous flap reconstruction there were no significant differences in complication (23.4% vs. 17.7%, P = 0.076), loss of reconstruction (3.1% vs. 4.4%, P = .393), or SSI (5.3% vs. 3.4%, P = .108) rates in patients who were treated with NAC compared to those who were not. Likewise, in patients undergoing TE/implant-based reconstruction there were no significant differences in complication (19.6 vs. 24.2 P = .069), loss of reconstruction (17.4% vs. 13.3%, P = .072), or SSI (7.9% vs. 5.1%, P = .073) rates in patients who were treated with NAC compared to those who were not. NAC was not associated with any significant differences in overall complication, reconstruction loss, or SSI rates in patients receiving implant-based or autologous flap breast reconstruction. Additionally, the lack of effect of NAC on overall complication, reconstruction loss or SSI rates did not differ with or depend on the type of reconstruction.
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Affiliation(s)
- Shayoni Nag
- Department of Plastic and Reconstructive Surgery, Cooper University Healthcare, Camden, NJ; Hackensack University Medical Center, Hackensack, NJ
| | - Levana Berlin
- Department of Plastic and Reconstructive Surgery, Cooper University Healthcare, Camden, NJ
| | | | - Steven C Bonawitz
- Department of Plastic and Reconstructive Surgery, Cooper University Healthcare, Camden, NJ; Cooper Medical School of Rowan University, Camden, NJ.
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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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Gao RW, Mullikin TC, Aziz KA, Afzal A, Smith NL, Routman DM, Gergelis KR, Harmsen WS, Remmes NB, Tseung HSWC, Shiraishi SS, Boughey JC, Ruddy KJ, Harless CA, Garda AE, Waddle MR, Park SS, Shumway DA, Corbin KS, Mutter RW. Postmastectomy Intensity Modulated Proton Therapy: 5-Year Oncologic and Patient-Reported Outcomes. Int J Radiat Oncol Biol Phys 2023; 117:846-856. [PMID: 37244627 DOI: 10.1016/j.ijrobp.2023.05.036] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 05/10/2023] [Accepted: 05/19/2023] [Indexed: 05/29/2023]
Abstract
PURPOSE To report oncologic, physician-assessed, and patient-reported outcomes (PROs) for a group of women homogeneously treated with modern, skin-sparing multifield optimized pencil-beam scanning proton (intensity modulated proton therapy [IMPT]) postmastectomy radiation therapy (PMRT). METHODS AND MATERIALS We reviewed consecutive patients who received unilateral, curative-intent, conventionally fractionated IMPT PMRT between 2015 and 2019. Strict constraints were applied to limit the dose to the skin and other organs at risk. Five-year oncologic outcomes were analyzed. Patient-reported outcomes were evaluated as part of a prospective registry at baseline, completion of PMRT, and 3 and 12 months after PMRT. RESULTS A total of 127 patients were included. One hundred nine (86%) received chemotherapy, among whom 82 (65%) received neoadjuvant chemotherapy. The median follow-up was 4.1 years. Five-year locoregional control was 98.4% (95% CI, 93.6-99.6), and overall survival was 87.9% (95% CI, 78.7-96.5). Acute grade 2 and 3 dermatitis was seen in 45% and 4% of patients, respectively. Three patients (2%) experienced acute grade 3 infection, all of whom had breast reconstruction. Three late grade 3 adverse events occurred: morphea (n = 1), infection (n = 1), and seroma (n = 1). There were no cardiac or pulmonary adverse events. Among the 73 patients at risk for PMRT-associated reconstruction complications, 7 (10%) experienced reconstruction failure. Ninety-five patients (75%) enrolled in the prospective PRO registry. The only metrics to increase by >1 point were skin color (mean change: 5) and itchiness (2) at treatment completion and tightness/pulling/stretching (2) and skin color (2) at 12 months. There was no significant change in the following PROs: bleeding/leaking fluid, blistering, telangiectasia, lifting, arm extension, or bending/straightening the arm. CONCLUSIONS With strict dose constraints to skin and organs at risk, postmastectomy IMPT was associated with excellent oncologic outcomes and PROs. Rates of skin, chest wall, and reconstruction complications compared favorably to previous proton and photon series. Postmastectomy IMPT warrants further investigation in a multi-institutional setting with careful attention to planning techniques.
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Affiliation(s)
- Robert W Gao
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Trey C Mullikin
- Department of Radiation Oncology, Duke Cancer Center, Durham, North Carolina
| | - Khaled A Aziz
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Arslan Afzal
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Na L Smith
- Sanford Cancer Center, Sioux Falls, South Dakota
| | - David M Routman
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | | | - William S Harmsen
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | | | | | | | - Judy C Boughey
- Division of Breast and Melanoma Surgical Oncology, Mayo Clinic, Rochester, Minnesota
| | - Kathryn J Ruddy
- Division of Medical Oncology, Mayo Clinic, Rochester, Minnesota
| | | | - Allison E Garda
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Mark R Waddle
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Sean S Park
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Dean A Shumway
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | | | - Robert W Mutter
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota.
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Levitin R, Salari K, Squires BS, Hazy AJ, Maywood MJ, Thrasher P, Delise AP, Almahariq MF, Dekhne N, Oliver L, Chen PY, Walters KJ, Dudley D, Dilworth JT. Near-Surface Dose Correlates With Moist Desquamation and Unplanned Reconstructive Surgery in Patients With Implant-Based Reconstruction Receiving Postmastectomy Radiation Therapy. Adv Radiat Oncol 2023; 8:101283. [PMID: 37492779 PMCID: PMC10363637 DOI: 10.1016/j.adro.2023.101283] [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: 04/06/2023] [Accepted: 05/12/2023] [Indexed: 07/27/2023] Open
Abstract
Purpose Postmastectomy radiation therapy (PMRT) reduces disease recurrence in appropriately selected patients but may compromise implant-based reconstruction. We investigated whether near-surface dose correlates with radiation-related toxic effects in these patients. Methods and Materials Patients receiving PMRT at a single institution from 2016 to 2019 were retrospectively reviewed. Patient demographics and treatment information were collected. Three near-surface structures were retrospectively generated, bound by the chest wall tangent beam as well as the skin surface and the skin-3 mm contour (SR3), skin surface and skin-5 mm contour (SR5), or skin-5 and skin-10 mm contours. Dosimetric analysis of these near-surface contours was performed in 2 Gy intervals. Univariate and multivariate analyses were used to identify predictors of moist desquamation, grade 2+ chest wall pain, use of opiate pain medication, unplanned reconstructive surgery, and implant failure. Logistic regression for each outcome and near-surface contour was performed for receiver-operator area under the curve (AUC) analysis and the Youden J Statistic was used to determine the optimal threshold for each dosimetric parameter. Results Of 126 patients reviewed, 109 met the study's eligibility criteria. Median follow-up was 2.3 years. Twenty-five patients (23%) underwent unplanned reconstructive surgery, and 10 (9.2%) experienced implant failure. Among clinical variables, low body mass index and history of smoking predicted unplanned surgery on univariate and multivariate analyses, and moist desquamation predicted grade 2+ chest wall pain. The top dosimetric parameters by AUC for moist desquamation, grade 2+ chest wall pain, use of opiates, unplanned reconstructive surgery, and implant failure were SR5 D10 cc (AUC = 0.701, optimal threshold 57.8 Gy, P < .001), SR3 D10 cc (AUC = 0.600, optimal threshold 56.8 Gy, P = .079), SR5 D10 cc (AUC = 0.642, optimal threshold 57.3 Gy, P = .041), SR3 V44 Gy (AUC = 0.711, optimal threshold 81%, P = .001), and SR3 V44 Gy (AUC = 0.688, optimal threshold 82%, P = .052), respectively. Conclusions Near-surface dose correlates with moist desquamation and unplanned reconstructive surgery after PMRT. Further evaluation of prospective optimization of dosimetric parameters related to SR3 and SR5 should be considered.
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Affiliation(s)
- Ronald Levitin
- Department of Radiation Oncology, Corewell Health William Beaumont University Hospital, Royal Oak, Michigan
| | - Kamran Salari
- Department of Radiation Oncology, Corewell Health William Beaumont University Hospital, Royal Oak, Michigan
| | - Bryan S. Squires
- Radiation oncology, Huron River Radiation Oncology Specialists, Ypsilanti, Michigan
| | - Allison J. Hazy
- Department of Radiation Oncology, Corewell Health William Beaumont University Hospital, Royal Oak, Michigan
| | - Michael J. Maywood
- Department of Ophthalmology, Corewell Health William Beaumont University Hospital, Royal Oak, Michigan
| | - Patrick Thrasher
- Oakland University William Beaumont School of Medicine, Rochester, Michigan
| | - Anthony P. Delise
- Department of Family Medicine, Corewell Health William Beaumont University Hospital, Royal Oak, Michigan
| | - Muayad F. Almahariq
- Department of Radiation Oncology, Corewell Health Dearborn Hospital, Dearborn, Michigan
| | - Nayana Dekhne
- Department of Breast Surgery, Corewell Health William Beaumont University Hospital, Royal Oak, Michigan
| | - Lauren Oliver
- Department of Plastic Surgery, Corewell Health William Beaumont University Hospital, Royal Oak, Michigan
| | - Peter Y. Chen
- Department of Radiation Oncology, Corewell Health William Beaumont University Hospital, Royal Oak, Michigan
| | - Kailee J. Walters
- Department of Radiation Oncology, Corewell Health William Beaumont University Hospital, Royal Oak, Michigan
| | - Diane Dudley
- Department of Radiation Oncology, Corewell Health William Beaumont University Hospital, Royal Oak, Michigan
| | - Joshua T. Dilworth
- Department of Radiation Oncology, Corewell Health William Beaumont University Hospital, Royal Oak, Michigan
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5
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Mutter RW, Giri S, Fruth BF, Remmes NB, Boughey JC, Harless CA, Ruddy KJ, McGee LA, Afzal A, Gao RW, Shumway DA, Vern-Gross TZ, Villarraga HR, Kenison SL, Kang Y, Wong WW, Stish BJ, Merrell KW, Yan ES, Park SS, Corbin KS, Vargas CE. Conventional versus hypofractionated postmastectomy proton radiotherapy in the USA (MC1631): a randomised phase 2 trial. Lancet Oncol 2023; 24:1083-1093. [PMID: 37696281 PMCID: PMC10591844 DOI: 10.1016/s1470-2045(23)00388-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 07/26/2023] [Accepted: 08/02/2023] [Indexed: 09/13/2023]
Abstract
BACKGROUND Proton therapy is under investigation in breast cancer as a strategy to reduce radiation exposure to the heart and lungs. So far, studies investigating proton postmastectomy radiotherapy (PMRT) have used conventional fractionation over 25-28 days, but whether hypofractionated proton PMRT is feasible is unclear. We aimed to compare conventional fractionation and hypofractionation in patients with indications for PMRT, including those with immediate breast reconstruction. METHODS We did a randomised phase 2 trial (MC1631) at Mayo Clinic in Rochester (MN, USA) and Mayo Clinic in Arizona (Phoenix, AZ, USA) comparing conventional fractionated (50 Gy in 25 fractions of 2 Gy [relative biological effectiveness of 1·1]) and hypofractionated (40·05 Gy in 15 fractions of 2·67 Gy [relative biological effectiveness of 1·1]) proton PMRT. All patients were treated with pencil-beam scanning. Eligibility criteria included age 18 years or older, an Eastern Cooperative Oncology Group performance status of 0-2, and breast cancer resected by mastectomy with or without immediate reconstruction with indications for PMRT. Patients were randomly assigned (1:1) to either conventional fractionation or hypofractionation, with presence of immediate reconstruction (yes vs no) as a stratification factor, using a biased-coin minimisation algorithm. Any patient who received at least one fraction of protocol treatment was evaluable for the primary endpoint and safety analyses. The primary endpoint was 24-month complication rate from the date of first radiotherapy, defined as grade 3 or worse adverse events occurring from 90 days after last radiotherapy or unplanned surgical interventions in patients with immediate reconstruction. The inferiority of hypofractionation would not be ruled out if the upper bound of the one-sided 95% CI for the difference in 24-month complication rate between the two groups was greater than 10%. This trial is registered with ClinicalTrials.gov, NCT02783690, and is closed to accrual. FINDINGS Between June 2, 2016, and Aug 23, 2018, 88 patients were randomly assigned (44 to each group), of whom 82 received protocol treatment (41 in the conventional fractionation group and 41 in the hypofractionation group; median age of 52 years [IQR 44-64], 79 [96%] patients were White, two [2%] were Black or African American, one [1%] was Asian, and 79 [96%] were not of Hispanic ethnicity). As of data cutoff (Jan 30, 2023), the median follow-up was 39·3 months (IQR 37·5-61·2). The median mean heart dose was 0·54 Gy (IQR 0·30-0·72) for the conventional fractionation group and 0·49 Gy (0·25-0·64) for the hypofractionation group. Within 24 months of first radiotherapy, 14 protocol-defined complications occurred in six (15%) patients in the conventional fractionation group and in eight (20%) patients in the hypofractionation group (absolute difference 4·9% [one-sided 95% CI 18·5], p=0·27). The complications in the conventionally fractionated group were contracture (five [12%] of 41 patients]) and fat necrosis (one [2%] patient) requiring surgical intervention. All eight protocol-defined complications in the hypofractionation group were due to infections, three of which were acute infections that required surgical intervention, and five were late infections, four of which required surgical intervention. All 14 complications were in patients with immediate expander or implant-based reconstruction. INTERPRETATION After a median follow-up of 39·3 months, non-inferiority of the hypofractionation group could not be established. However, given similar tolerability, hypofractionated proton PMRT appears to be worthy of further study in patients with and without immediate reconstruction. FUNDING The Department of Radiation Oncology, Mayo Clinic, Rochester, MN, the Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, USA, and the US National Cancer Institute.
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Affiliation(s)
- Robert W Mutter
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA.
| | - Sharmila Giri
- Division of Clinical Trials and Biostatistics, Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
| | - Briant F Fruth
- Division of Clinical Trials and Biostatistics, Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
| | | | | | | | - Kathryn J Ruddy
- Division of Medical Oncology, Mayo Clinic, Rochester, MN, USA
| | - Lisa A McGee
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, USA
| | - Arslan Afzal
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | - Robert W Gao
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | - Dean A Shumway
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | | | | | | | - Yixiu Kang
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, USA
| | - William W Wong
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, USA
| | - Bradley J Stish
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | | | - Elizabeth S Yan
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | - Sean S Park
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | | | - Carlos E Vargas
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, USA
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Ochoa O, Chrysopoulo MT. Preoperative Assessment of the Breast Reconstruction Patient. Clin Plast Surg 2023; 50:201-210. [PMID: 36813398 DOI: 10.1016/j.cps.2022.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Through a multidisciplinary approach, as well as, a nuanced appreciation of patient goals and setting appropriate expectations, breast reconstruction can significantly improve the quality of life following mastectomy. A thorough review of the patient medical and surgical history in addition to oncologic treatments will facilitate discussion and recommendations for an individualized shared decision-making reconstructive process. Alloplastic reconstruction, although a highly popular modality, has important limitations. On the contrary, autologous reconstruction is more flexible but requires more thorough consideration.
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Affiliation(s)
- Oscar Ochoa
- PRMA Plastic Surgery, 9635 Huebner Road, San Antonio, TX 78240, USA.
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Laughlin BS, Bhangoo RS, Niska JR, Thorpe CS, Girardo ME, Anderson JD, Kosiorek HE, McGee LA, Hartsell WF, Chang JH, Rossi CJ, Tsai HK, Choi IJ, Vargas CE. Proton therapy for isolated local regional recurrence of breast cancer after mastectomy alone. Front Oncol 2022; 12:925078. [DOI: 10.3389/fonc.2022.925078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 11/10/2022] [Indexed: 11/29/2022] Open
Abstract
Purpose/ObjectivesTo assess adverse events (AEs) and disease-specific outcomes after proton therapy for isolated local-regional recurrence (LRR) of breast cancer after mastectomy without prior radiotherapy (RT).Materials/MethodsPatients were identified from a multi-institutional prospective registry and included if diagnosed with invasive breast cancer, initially underwent mastectomy without adjuvant RT, experienced an LRR, and subsequently underwent salvage treatment, including proton therapy. Follow-up and cancer outcomes were measured from the date of RT completion.ResultsNineteen patients were included. Seventeen patients were treated with proton therapy to the chest wall and comprehensive regional lymphatics (17/19, 90%). Maximum grade AE was grade 2 in 13 (69%) patients and grade 3 in 4 (21%) patients. All patients with grade 3 AE received > 60 GyE (p=0.04, Spearman correlation coefficient=0.5). At the last follow-up, 90% of patients were alive with no LRR or distant recurrence.ConclusionsFor breast cancer patients with isolated LRR after initial mastectomy without adjuvant RT, proton therapy is well-tolerated in the salvage setting with excellent loco-regional control. All grade 3 AEs occurred in patients receiving > 60 GyE.
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Naoum GE, Ioakeim MI, Shui AM, Salama L, Colwell A, Ho AY, Taghian AG. Radiation Modality (Proton/Photon), Timing, and Complication Rates in Patients With Breast Cancer Receiving 2-Stages Expander/Implant Reconstruction. Pract Radiat Oncol 2022; 12:475-486. [PMID: 35989216 PMCID: PMC9637758 DOI: 10.1016/j.prro.2022.05.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 05/26/2022] [Accepted: 05/31/2022] [Indexed: 11/28/2022]
Abstract
PURPOSE Our purpose is to explore the effect of postmastectomy radiation therapy (PMRT) modality and timing on complication rates in breast cancer patients receiving immediate 2-stages expander/implant. METHODS AND MATERIALS We reviewed the charts of 661 patients who underwent immediate 2-stages expander/implant with/without PMRT at our institution from 2000 to 2019. Patients were divided into 3 cohorts: no radiation, PMRT to expanders (RTE), and PMRT to implants after expander exchange (RTI). PMRT was delivered either with 3-dimensional conformal photon with or without chest wall boost (CWB) or proton therapy. Reconstruction complications were defined as infection/necrosis requiring debridement, capsular-contracture requiring capsulotomy, and reconstruction failure requiring prothesis removal. Logistic regression and Cox models were used to assess the effect of different radiation therapy modalities on complication rates and local control. RESULTS Among 661 patients, 309 (46.7%) received PMRT, 220 of the 309 (71.2%) received RTE before exchange, and 89 (28.8%) received RTI after exchange. Seventeen out of 309 (5.5%) patients received proton therapy. The complications among RTE versus RTI cohorts were 22.7% versus 15.7% for infection/necrosis, 13.6% versus 19.1% for capsular-contracture, and 39.5% versus 31.5% for overall reconstruction failure, respectively. Among proton patients, 8/17 (47%) developed capsular contracture compared with 16.4% (24/146) and 10.3% (15/146) in CWB and non-CWB groups, respectively. Adjusted multivariable analysis showed no significant difference between RTI and RTE in terms of infection/necrosis and capsular contracture. Yet, RTE significantly increased overall reconstruction failure compared with RTI (39.5% vs 31.5%; odds ratio [OR], 2.11; P = .02). Protons significantly increased capsular contracture compared with both CWB and non-CWB groups (OR, 5.4; P = .01 and OR, 10.9; P < .001, respectively). Moreover, proton significantly increased overall reconstruction failure. The 5-year local control rates were 95.3% and 97.7% for RTE and RTI, respectively (hazard ratio, 1.2; P = .7). CONCLUSIONS Early radiation to the expander before the exchange to implant significantly increased overall reconstruction failure without improving local control. Protons significantly increased capsular contracture rates and overall reconstruction failure leading to more revision surgeries.
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Affiliation(s)
- George E Naoum
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachussetts; Current Affiliation: Department of Radiation Oncology, Northwestern University Memorial Hospital, Chicago, Illinois.
| | - Myrsini Ioannidou Ioakeim
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachussetts
| | - Amy M Shui
- Biostatistics Center, Massachusetts General Hospital, Boston, Massachussetts
| | - Laura Salama
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachussetts; Current Affiliation: Brown University Medical Center, Providence, Rhode Island
| | - Amy Colwell
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachussetts
| | - Alice Y Ho
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachussetts
| | - Alphonse G Taghian
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachussetts.
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9
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Optimal timing of postmastectomy radiotherapy in two-stage prosthetic breast reconstruction: An updated meta-analysis. Int J Surg 2022; 105:106814. [PMID: 35977650 DOI: 10.1016/j.ijsu.2022.106814] [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: 02/25/2022] [Revised: 07/07/2022] [Accepted: 07/27/2022] [Indexed: 10/15/2022]
Abstract
BACKGROUND There is no consensus on the timing of postmastectomy radiotherapy (PMRT) in relation to the exchange procedure in breast cancer patients undergoing the immediate two-stage prosthetic breast reconstruction. This meta-analysis investigated the reconstruction failure, complications, and cosmesis between PMRT to the tissue expander (TE) and PMRT to the permanent implant (PI). METHODS A literature search was conducted in PubMed and Embase databases until February 2022. Studies presenting at least one aspect relating to reconstruction failure, complications, and cosmesis between two cohorts were included. Newcastle-Ottawa Scale (NOS) was used to assess the risk of bias in included studies. RESULTS Eleven studies presenting 1447 patients were enrolled. Three studies were prospective controlled research. The risk for implant loss was higher in PMRT to TE cohort (RR 1.75; 95% CI, 1.03 to 2.98; p = 0.04); meanwhile, the PMRT to TE cohort had a significantly lower risk of capsular contracture (RR 0.47; 95% CI, 0.29 to 0.78; p = 0.003). However, the synthesized result should be interpreted sensibly due to heterogeneity in statistical methods and definitions. CONCLUSION Delivering PMRT to PI may reduce the risk of implant loss, while delivering PMRT to TE can reduce the risk of severe capsular contracture. More high-quality studies are warranted for the refinement of clinical practice.
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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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Optimal Timing of Expander-to-Implant Exchange after Irradiation in Immediate Two-Stage Breast Reconstruction. Plast Reconstr Surg 2022; 149:185e-194e. [PMID: 35077405 DOI: 10.1097/prs.0000000000008712] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Time intervals for expander-to-implant exchange from radiation therapy have been reported to reduce device failure. This study investigated the optimal timing of expander-to-implant exchange after irradiation in terms of short- and long-term outcomes. METHODS This retrospective review enrolled consecutive patients who underwent immediate two-stage breast reconstruction and radiation therapy to tissue expanders from 2010 to 2019. Receiver operating characteristic curves and the Youden index were used to estimate the optimal time from radiation therapy to implant placement in terms of 49-day (early) and 2-year (late) complications. Logistic regression analysis was performed to identify the risk factors for each complication. RESULTS Of the 1675 patients, 133 were included. The 49-day and 2-year complication rates were 8.3 percent and 29.7 percent, respectively. Capsular contracture was the most common 2-year complication. The Youden index indicated that implant placement at 131 days after radiation therapy was most effective in reducing the 49-day complications, but that the 2-year complication was less significant, with lower sensitivity and area under the curve. Modified radical mastectomy, expander fill volume at radiation therapy, and size of permanent implant increased the odds of 49-day complications; none of them was associated with the odds of 2-year complications. CONCLUSIONS To reduce short-term complications, the best time point for permanent implant placement was 131 days after radiation therapy. However, there was no significant time interval for reducing long-term complications. Capsular contracture was an irreversible complication of radiation injury that was not modified by postirradiation variables including the time from irradiation or size of permanent implant. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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Citgez B, Yigit B, Bas S. Oncoplastic and Reconstructive Breast Surgery: A Comprehensive Review. Cureus 2022; 14:e21763. [PMID: 35251834 PMCID: PMC8890601 DOI: 10.7759/cureus.21763] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/31/2022] [Indexed: 12/13/2022] Open
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Immediate breast reconstruction has no impact on the oncologic outcomes of patients treated with post-mastectomy radiation therapy: a comparative analysis based on propensity score matching. Breast Cancer Res Treat 2022; 192:101-112. [PMID: 35034242 DOI: 10.1007/s10549-021-06483-2] [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: 06/21/2021] [Accepted: 12/03/2021] [Indexed: 11/02/2022]
Abstract
PURPOSE To investigate the impact of immediate breast reconstruction (iBR) on patients treated with post-mastectomy radiation therapy (PMRT) using propensity score matching (PSM). METHODS After a retrospective review of patients treated with PMRT between 2008 and 2017, we included 153 patients who underwent iBR and 872 patients who did not undergo iBR. Among the 153 patients who underwent iBR, 34 received one-stage iBR with autologous tissue and 119 received two-stage iBR. Conventional fractionated PMRT with a total dose of 50-50.4 Gy in 25-28 fractions was performed in all patients. Propensity scores were calculated via logistic regression. RESULTS Patients who underwent iBR were younger, had early stage disease, and had more frequent hormone receptor-positive tumor than those who did not undergo iBR. After PSM, 127 patients from each group with well-balanced characteristics were selected. With a median follow-up of 67.5 months, iBR led to better 6-year disease-free survival rates compared to no iBR before PSM (84.8% vs. 71.4%, p = 0.003); after PSM, there was no significant difference (84.8% vs. 75.5%, p = 0.130). On multivariable analysis in the matched cohort, iBR was not associated with inferior disease-free survival (hazard ratio, 0.67; p = 0.175). In the sensitivity analysis, iBR was not associated with a lower disease-free survival across all prognostic groups. The 5-year cumulative incidence of iBR failure was 15.0%. CONCLUSION In patients with adverse pathologic factors planning to receive PMRT, iBR did not compromise oncologic outcomes. In addition, iBR can be considered in patients treated with PMRT with several clinicopathologic risk factors.
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Naoum GE, Ho AY, Shui A, Salama L, Goldberg S, Arafat W, Winograd J, Colwell A, Smith BL, Taghian AG. Risk of Developing Breast Reconstruction Complications: A Machine-Learning Nomogram for Individualized Risk Estimation with and without Postmastectomy Radiation Therapy. Plast Reconstr Surg 2022; 149:1e-12e. [PMID: 34758003 DOI: 10.1097/prs.0000000000008635] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND The purpose of this study was to create a nomogram using machine learning models predicting risk of breast reconstruction complications with or without postmastectomy radiation therapy. METHODS Between 1997 and 2017, 1617 breast cancer patients undergoing mastectomy and breast reconstruction were analyzed. Those with autologous, tissue expander/implant, and single-stage direct-to-implant reconstruction were included. Postmastectomy radiation therapy was delivered either with three-dimensional conformal photon or proton therapy. Complication endpoints were defined based on surgical reintervention operative notes as infection/necrosis requiring débridement. For implant-based patients, complications were defined as capsular contracture requiring capsulotomy and implant failure. For each complication endpoint, least absolute shrinkage and selection operator-penalized regression was used to select the subset of predictors associated with the smallest prediction error from 10-fold cross-validation. Nomograms were built using the least absolute shrinkage and selection operator-selected predictors, and internal validation using cross-validation was performed. RESULTS Median follow-up was 6.6 years. Among 1617 patients, 23 percent underwent autologous reconstruction, 39 percent underwent direct-to-implant reconstruction, and 37 percent underwent tissue expander/implant reconstruction. Among 759 patients who received postmastectomy radiation therapy, 8.3 percent received proton-therapy to the chest wall and nodes and 43 percent received chest wall boost. Internal validation for each model showed an area under the receiver operating characteristic curve of 73 percent for infection, 75 percent for capsular contracture, 76 percent for absolute implant failure, and 68 percent for overall implant failure. Periareolar incisions and complete implant muscle coverage were found to be important predictors for infection and capsular contracture, respectively. In a multivariable analysis, we found that protons compared to no postmastectomy radiation therapy significantly increased capsular contracture risk (OR, 15.3; p < 0.001). This was higher than the effect of photons with electron boost versus no postmastectomy radiation therapy (OR, 2.5; p = 0.01). CONCLUSION Using machine learning, these nomograms provided prediction of postmastectomy breast reconstruction complications with and without radiation therapy. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, III.
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Affiliation(s)
- George E Naoum
- From the Departments of Radiation Oncology, Plastic Surgery, and Surgery and the Biostatistics Center, Massachusetts General Hospital, Harvard Medical School; and Department of Clinical Oncology, Alexandria University
| | - Alice Y Ho
- From the Departments of Radiation Oncology, Plastic Surgery, and Surgery and the Biostatistics Center, Massachusetts General Hospital, Harvard Medical School; and Department of Clinical Oncology, Alexandria University
| | - Amy Shui
- From the Departments of Radiation Oncology, Plastic Surgery, and Surgery and the Biostatistics Center, Massachusetts General Hospital, Harvard Medical School; and Department of Clinical Oncology, Alexandria University
| | - Laura Salama
- From the Departments of Radiation Oncology, Plastic Surgery, and Surgery and the Biostatistics Center, Massachusetts General Hospital, Harvard Medical School; and Department of Clinical Oncology, Alexandria University
| | - Saveli Goldberg
- From the Departments of Radiation Oncology, Plastic Surgery, and Surgery and the Biostatistics Center, Massachusetts General Hospital, Harvard Medical School; and Department of Clinical Oncology, Alexandria University
| | - Waleed Arafat
- From the Departments of Radiation Oncology, Plastic Surgery, and Surgery and the Biostatistics Center, Massachusetts General Hospital, Harvard Medical School; and Department of Clinical Oncology, Alexandria University
| | - Jonathan Winograd
- From the Departments of Radiation Oncology, Plastic Surgery, and Surgery and the Biostatistics Center, Massachusetts General Hospital, Harvard Medical School; and Department of Clinical Oncology, Alexandria University
| | - Amy Colwell
- From the Departments of Radiation Oncology, Plastic Surgery, and Surgery and the Biostatistics Center, Massachusetts General Hospital, Harvard Medical School; and Department of Clinical Oncology, Alexandria University
| | - Barbara L Smith
- From the Departments of Radiation Oncology, Plastic Surgery, and Surgery and the Biostatistics Center, Massachusetts General Hospital, Harvard Medical School; and Department of Clinical Oncology, Alexandria University
| | - Alphonse G Taghian
- From the Departments of Radiation Oncology, Plastic Surgery, and Surgery and the Biostatistics Center, Massachusetts General Hospital, Harvard Medical School; and Department of Clinical Oncology, Alexandria University
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Choi JI, Khan AJ, Powell SN, McCormick B, Lozano AJ, Del Rosario G, Mamary J, Liu H, Fox P, Gillespie E, Braunstein LZ, Mah D, Cahlon O. Proton reirradiation for recurrent or new primary breast cancer in the setting of prior breast irradiation. Radiother Oncol 2021; 165:142-151. [PMID: 34688807 DOI: 10.1016/j.radonc.2021.10.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 10/07/2021] [Accepted: 10/11/2021] [Indexed: 12/25/2022]
Abstract
BACKGROUND AND PURPOSE Late local recurrences and second primary breast cancers are increasingly common. Proton beam therapy (PBT) reirradiation (reRT) may allow safer delivery of a second definitive radiotherapy (RT) course. We analyzed outcomes of patients with recurrent or new primary breast cancer who underwent reRT. MATERIALS AND METHODS In an IRB-approved retrospective study, patient/tumor characteristics, treatment parameters, outcomes, and toxicities were collected for all consecutive patients with recurrent or new primary non-metastatic breast cancer previously treated with breast or chest wall RT who underwent PBT reRT. RESULTS Forty-six patients received reRT using uniform (70%) or pencil beam (30%) scanning PBT. Median first RT, reRT, and cumulative doses were 60 Gy (range 45-66 Gy), 50.4 Gy(RBE) (40-66.6 Gy(RBE)), and 110 Gy(RBE) (96.6-169.4 Gy(RBE)), respectively. Median follow-up was 21 months. There were no local or regional recurrences; 17% developed distant recurrence. Two-year DMFS and OS were 92.0% and 93.6%, respectively. Nine of 13 (69.2%) patients who underwent implant or flap reconstruction developed capsular contracture, 3 (23.1%) requiring surgical intervention. One (7.7%) patient developed grade 3 breast pain requiring mastectomy after breast conserving surgery. No acute or late grade 4-5 toxicities were seen. Increased body mass index (BMI) was protective of grade ≥ 2 acute toxicity (OR = 0.84, 95%CI = 0.70-1.00). CONCLUSION In the largest series to date of PBT reRT for breast cancer recurrence or new primary after prior definitive breast or chest wall RT, excellent locoregional control and few high-grade toxicities were encountered. PBT reRT may provide a relatively safe and highly effective salvage option. Additional patients and follow-up are needed to correlate composite normal tissue doses with toxicities and assess long-term outcomes.
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Affiliation(s)
- J Isabelle Choi
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, USA; New York Proton Center, New York, USA.
| | - Atif J Khan
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Simon N Powell
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Beryl McCormick
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, USA
| | | | | | | | - Haoyang Liu
- ProCure Proton Therapy Center, Somerset, USA
| | - Pamela Fox
- ProCure Proton Therapy Center, Somerset, USA
| | - Erin Gillespie
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Lior Z Braunstein
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Dennis Mah
- ProCure Proton Therapy Center, Somerset, USA
| | - Oren Cahlon
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, USA; New York Proton Center, New York, USA
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Meattini I, Becherini C, Bernini M, Bonzano E, Criscitiello C, De Rose F, De Santis MC, Fontana A, Franco P, Gentilini OD, Livi L, Meduri B, Parisi S, Pasinetti N, Prisco A, Rocco N. Breast reconstruction and radiation therapy: An Italian expert Delphi consensus statements and critical review. Cancer Treat Rev 2021; 99:102236. [PMID: 34126314 DOI: 10.1016/j.ctrv.2021.102236] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Revised: 05/21/2021] [Accepted: 05/24/2021] [Indexed: 02/06/2023]
Abstract
Breast conserving surgery (BCS) plus radiation therapy (RT) or mastectomy have shown comparable oncological outcomes in early-stage breast cancer and are considered standard of care treatments. Postmastectomy radiation therapy (PMRT) targeted to both the chest wall and regional lymph nodes is recommended in high-risk patients. Oncoplastic breast conserving surgery (OBCS) represents a significant recent improvement in breast surgery. Nevertheless, it represents a challenge for radiation oncologists as it triggers different decision-making strategies related to treatment volume definition and target delineation. Hence, the choice of the best combination and timing when offering RT to breast cancer patients who underwent or are planned to undergo reconstruction procedures should be carefully evaluated and based on individual considerations. We present an Italian expert Delphi Consensus statements and critical review, led by a core group of all the professional profiles involved in the management of breast cancer patients undergoing reconstructive procedures and RT. The report was structured as to consider the main recommendations on breast reconstruction and RT and analyse the current open issues deserving investigation and consensus. We used a three key-phases and a Delphi process. The final expert panel of 40 colleagues selected key topics as identified by the core group of the project. A final consensus on 26 key statements on RT and breast reconstruction after three rounds of the Delphi voting process and harmonisation was reached. An accompanying critical review of available literature was summarized. A clear communication and cooperation between surgeon and radiation oncologist is of paramount relevance both in the setting of breast reconstruction following mastectomy when PMRT is planned and when extensive glandular rearrangements as OBCS is performed. A shared-decision making, relying on outcome-based and patient-centred considerations, is essential, while waiting for higher level-of-evidence data.
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Affiliation(s)
- Icro Meattini
- Department of Experimental and Clinical Biomedical Sciences "M. Serio", University of Florence, Florence, Italy; Radiation Oncology Unit - Oncology Department, Azienda Ospedaliero Universitaria Careggi, Florence, Italy; Italian Association of Radiotherapy and Clinical Oncology (AIRO) Breast Cancer Group, Italy; Clinical Oncology Breast Cancer Group (COBCG), Italy.
| | - Carlotta Becherini
- Department of Experimental and Clinical Biomedical Sciences "M. Serio", University of Florence, Florence, Italy; Radiation Oncology Unit - Oncology Department, Azienda Ospedaliero Universitaria Careggi, Florence, Italy; Italian Association of Radiotherapy and Clinical Oncology (AIRO) Breast Cancer Group, Italy
| | - Marco Bernini
- Breast Surgery Unit - Oncology Department, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Elisabetta Bonzano
- Department of Radiation Oncology, IRCCS San Matteo Polyclinic Foundation & PhD School in Experimental Medicine, University of Pavia, Pavia, Italy; Italian Association of Radiotherapy and Clinical Oncology (AIRO) Breast Cancer Group, Italy; Clinical Oncology Breast Cancer Group (COBCG), Italy
| | - Carmen Criscitiello
- Department of Oncology and Haematology (DIPO), University of Milan & Division of Early Drug Development for Innovative Therapy, European Institute of Oncology, IRCCS, Milan, Italy
| | - Fiorenza De Rose
- Division of Radiation Oncology, Santa Chiara Hospital, Trento, Italy; Italian Association of Radiotherapy and Clinical Oncology (AIRO) Breast Cancer Group, Italy; Clinical Oncology Breast Cancer Group (COBCG), Italy
| | - Maria Carmen De Santis
- Radiation Oncology Unit 1, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy; Italian Association of Radiotherapy and Clinical Oncology (AIRO) Breast Cancer Group, Italy; Clinical Oncology Breast Cancer Group (COBCG), Italy
| | - Antonella Fontana
- Radiation Oncology Unit, Ospedale Santa Maria Goretti, Latina, Italy; Italian Association of Radiotherapy and Clinical Oncology (AIRO) Breast Cancer Group, Italy
| | - Pierfrancesco Franco
- Department of Translational Medicine, University of Eastern Piedmont & Radiation Oncology Unit, AOU "Maggiore della Carità", Novara, Italy; Italian Association of Radiotherapy and Clinical Oncology (AIRO) Breast Cancer Group, Italy; Clinical Oncology Breast Cancer Group (COBCG), Italy
| | | | - Lorenzo Livi
- Department of Experimental and Clinical Biomedical Sciences "M. Serio", University of Florence, Florence, Italy; Radiation Oncology Unit - Oncology Department, Azienda Ospedaliero Universitaria Careggi, Florence, Italy; Italian Association of Radiotherapy and Clinical Oncology (AIRO) Breast Cancer Group, Italy
| | - Bruno Meduri
- Radiation Oncology Unit, University Hospital of Modena, Modena, Italy; Italian Association of Radiotherapy and Clinical Oncology (AIRO) Breast Cancer Group, Italy; Clinical Oncology Breast Cancer Group (COBCG), Italy
| | - Silvana Parisi
- Radiation Oncology Unit, Department of Biomedical, Dental Science and Morphological and Functional Images, University of Messina, Messina, Italy; Italian Association of Radiotherapy and Clinical Oncology (AIRO) Breast Cancer Group, Italy
| | - Nadia Pasinetti
- Radiation Oncology Service, ASST Valcamonica, Esine, Italy; Italian Association of Radiotherapy and Clinical Oncology (AIRO) Breast Cancer Group, Italy; Clinical Oncology Breast Cancer Group (COBCG), Italy
| | - Agnese Prisco
- Department of Radiation Oncology, University Hospital of Udine, ASUFC, Udine, Italy; Italian Association of Radiotherapy and Clinical Oncology (AIRO) Breast Cancer Group, Italy
| | - Nicola Rocco
- Group for Reconstructive and Therapeutic Advancements (G.RE.T.A.), Milan, Naples, Catania, Italy
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Zeidan YH, Poortmans P. Don't Miss the Devil in the Details. Int J Radiat Oncol Biol Phys 2020; 108:1133. [PMID: 33220225 DOI: 10.1016/j.ijrobp.2020.05.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 05/14/2020] [Indexed: 11/24/2022]
Affiliation(s)
- Youssef H Zeidan
- Department of Radiation Oncology, American University of Beirut, Beirut, Lebanon
| | - Philip Poortmans
- Iridium Kankernetwerk, Wilrijk-Antwerp, Belgium; University of Antwerp, Faculty of Medicine and Health Sciences, Wilrijk-Antwerp, Belgium
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Crawford K, Endara M. Lipotransfer Strategies and Techniques to Achieve Successful Breast Reconstruction in the Radiated Breast. MEDICINA (KAUNAS, LITHUANIA) 2020; 56:E516. [PMID: 33019768 PMCID: PMC7599742 DOI: 10.3390/medicina56100516] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 09/21/2020] [Accepted: 09/22/2020] [Indexed: 12/24/2022]
Abstract
Radiation therapy is frequently a critical component of breast cancer care but carries with it side effects that are particularly damaging to reconstructive efforts. Autologous lipotransfer has the ability to improve radiated skin throughout the body due to the pluripotent stem cells and multiple growth factors transferred therein. The oncologic safety of lipotransfer to the breasts is demonstrated in the literature and is frequently considered an adjunctive procedure for improving the aesthetic outcomes of breast reconstruction. Using lipotransfer as an integral rather than adjunctive step in the reconstructive process for breast cancer patients requiring radiation results in improved complication rates equivalent to those of nonradiated breasts, expanding options in these otherwise complicated cases. Herein, we provide a detailed review of the cellular toxicity conferred by radiotherapy and describe at length our approach to autologous lipotransfer in radiated breasts.
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Affiliation(s)
- Kristina Crawford
- Resident Physician, Vanderbilt University Medical Center, Nashville, TN 37232, USA;
| | - Matthew Endara
- Plastic Surgeon, Maury Regional Medical Group, Columbia, TN 38401, USA
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Lee KT, Bae J, Jeon BJ, Pyon JK, Mun GH, Bang SI. Adjuvant Chemotherapy in Two-Stage Tissue Expander/Implant Breast Reconstruction: Does it Affect Final Outcomes? Ann Surg Oncol 2020; 28:2191-2198. [PMID: 32974692 DOI: 10.1245/s10434-020-09177-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Accepted: 09/03/2020] [Indexed: 01/04/2023]
Abstract
BACKGROUND In immediate two-stage implant-based breast reconstruction, adjuvant chemotherapy, when indicated, is usually conducted between the stages, which might influence the outcomes of the second-stage operation. OBJECTIVE The purpose of this study was to evaluate the potential influence of adjuvant chemotherapy on the final outcomes of two-stage implant-based reconstructions. METHODS Patients who underwent immediate tissue expander/implant breast reconstruction between 2010 and 2016, with completion of both stages, were reviewed. Cases were categorized into two groups-adjuvant chemotherapy and no adjuvant chemotherapy. The rates of adverse outcomes were compared between the groups. RESULTS A total of 602 cases in 568 patients were analyzed, with a mean follow-up period of 58.5 months, including 236 patients receiving adjuvant chemotherapy and 366 patients not receiving adjuvant chemotherapy. The two groups had similar baseline characteristics, except for a significantly higher rate of adjuvant radiotherapy in the former group. The adjuvant chemotherapy group showed significantly higher rates of overall complications (odds ratio [OR] 2.127, 95% confidence interval [CI] 1.231-3.676), including infections (OR 4.239, 95% CI 1.059-16.970), severe capsular contractures (OR 2.107, 95% CI 1.067-4.159), and reconstruction failures (OR 12.754, 95% CI 1.587-102.481) compared with the control group, after adjusting for other variables, including adjuvant radiotherapy. In the analysis regarding the influence of chemotherapy regimens, the use of sequential anthracycline/cyclophosphamide and taxane, and concurrent 5-fluorouracil, doxorubicin and cyclophosphamide, were associated with increased risks for adverse outcomes compared with the no chemotherapy group, while the use of other regimens, including anthracycline/cyclophosphamide alone, was not. CONCLUSIONS Adjuvant chemotherapy might influence the final outcomes of two-stage implant-based reconstruction.
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Affiliation(s)
- Kyeong-Tae Lee
- Department of Plastic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Gangnam-gu, Seoul, Korea
| | - Juyoung Bae
- Department of Plastic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Gangnam-gu, Seoul, Korea
| | - Byung Joon Jeon
- Department of Plastic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Gangnam-gu, Seoul, Korea
| | - Jai Kyong Pyon
- Department of Plastic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Gangnam-gu, Seoul, Korea
| | - Goo-Hyun Mun
- Department of Plastic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Gangnam-gu, Seoul, Korea
| | - Sa Ik Bang
- Department of Plastic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Gangnam-gu, Seoul, Korea.
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Chen JJ, von Eyben R, Gutkin PM, Hawley E, Dirbas FM, Lee GK, Horst KC. Development of a Classification Tree to Predict Implant-Based Reconstruction Failure with or without Postmastectomy Radiation Therapy for Breast Cancer. Ann Surg Oncol 2020; 28:1669-1679. [PMID: 32875465 DOI: 10.1245/s10434-020-09068-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 08/10/2020] [Indexed: 11/18/2022]
Abstract
PURPOSE The aim of this study was to determine the complications, incidence, and predictors of implant-based reconstruction failure (RF) among patients treated with mastectomy for breast cancer. METHODS We retrospectively reviewed 108 patients who underwent mastectomy, tissue expander, and implant-based breast reconstruction with or without radiation therapy (RT) at our institution (2000-2014). Descriptive statistics determined complication incidences, with major complications defined as any complications requiring surgical intervention or inpatient management. Chi square and Fisher's exact tests determined differences in RF incidences, defined as implant loss. Logistic regression analyses identified predictors of RF. RESULTS Median follow-up was 42.5 months. Sixty patients (55.6%) experienced major complications. Overall, 27 patients (25%) experienced RF. Incidences of RF were significantly increased in patients who had any major complication (43.3% vs. 2.1%; p < 0.0001), especially infection (61.3% vs. 10.4%; p < 0.0001), delayed wound healing (83.3% vs. 21.7%; p = 0.004), and implant exposure (80.0% vs. 19.4%; p = 0.0002). Receiving RT, but not timing of RT, significantly predicted RF [odds ratio (OR) 4.00, 95% confidence interval (CI) 1.11-14.47; p = 0.03]. On multivariable analysis, infection (OR 7.69, 95% CI 2.12-27.89; p = 0.002) and delayed wound healing (OR 17.86, 95% CI 1.59-200.48; p = 0.02) independently predicted for RF. Our newly developed classification tree, which includes stepwise assessment of major infection, delayed wound healing, implant exposure, age ≥ 50 years, and total number of lymph nodes removed ≥ 10, accurately predicted 74% of RF events and 75% of non-RF events. CONCLUSIONS Infection or delayed wound healing requiring surgical intervention or hospitalization and receipt of RT, but not radiation timing, were significant predictors of RF. Our classification tree demonstrated > 70% accuracy for stepwise prediction of RF.
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Affiliation(s)
| | - Rie von Eyben
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA, USA
| | - Paulina M Gutkin
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA, USA
| | - Erin Hawley
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA, USA
| | - Frederick M Dirbas
- Department of General Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Gordon K Lee
- Department of Plastic and Reconstructive Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Kathleen C Horst
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA, USA.
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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: 22] [Impact Index Per Article: 5.5] [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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22
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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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Yoon AP, Qi J, Kim HM, Hamill JB, Jagsi R, Pusic AL, Wilkins EG, Kozlow JH. Patient-Reported Outcomes after Irradiation of Tissue Expander versus Permanent Implant in Breast Reconstruction: A Multicenter Prospective Study. Plast Reconstr Surg 2020; 145:917e-926e. [PMID: 32332528 PMCID: PMC7184969 DOI: 10.1097/prs.0000000000006724] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Whether to irradiate the tissue expander before implant exchange or to defer irradiation until after exchange in immediate, two-stage expander/implant reconstruction remains uncertain. The authors evaluated the effects of irradiation timing on complication rates and patient-reported outcomes in patients undergoing immediate expander/implant reconstruction. METHODS Immediate expander/implant reconstruction patients undergoing postmastectomy radiation therapy at 11 Mastectomy Reconstruction Outcomes Consortium sites with demographic, clinical, and complication data were analyzed. Patient-reported outcomes were assessed with BREAST-Q, Patient-Reported Outcomes Measurement Information System, and European Organisation for Research and Treatment of Cancer Breast Cancer-Specific Quality-of-Life Questionnaire surveys preoperatively and 2 years postoperatively. Survey scores and complication rates were analyzed using bivariate comparison and multivariable regressions. RESULTS Of 317 patients who met inclusion criteria, 237 underwent postmastectomy radiation therapy before expander/implant exchange (before-exchange cohort), and 80 did so after exchange (after-exchange cohort). Timing of radiation had no significant effect on risks of overall complications (OR, 1.25; p = 0.46), major complications (OR, 1.18; p = 0.62), or reconstructive failure (OR, 0.72; p = 0.49). Similarly, radiation timing had no significant effect on 2-year patient-reported outcomes measured by the BREAST-Q or the European Organisation for Research and Treatment of Cancer survey. Outcomes measured by the Patient-Reported Outcomes Measurement Information System showed less anxiety, fatigue, and depression in the after-exchange group. Compared with preoperative assessments, 2-year patient-reported outcomes significantly declined in both cohorts for Satisfaction with Breasts, Physical Well-Being, and Sexual Well-Being, but improved for anxiety and depression. CONCLUSIONS Radiation timing (before or after exchange) had no significant effect on complication risks or on most patient-reported outcomes in immediate expander/implant reconstruction. Although lower levels of anxiety, depression, and fatigue were observed in the after-exchange group, these differences may not be clinically significant. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, II.
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Affiliation(s)
- Alfred P. Yoon
- Section of Plastic and Reconstructive Surgery, University of Michigan, Ann Arbor, MI
| | - Ji Qi
- Section of Plastic and Reconstructive Surgery, University of Michigan, Ann Arbor, MI
| | - Hyungjin M. Kim
- Center for Statistical Consultation and Research, University of Michigan, Ann Arbor, MI
| | - Jennifer B. Hamill
- Section of Plastic and Reconstructive Surgery, University of Michigan, Ann Arbor, MI
| | - Reshma Jagsi
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI
| | | | - Edwin G. Wilkins
- Section of Plastic and Reconstructive Surgery, University of Michigan, Ann Arbor, MI
| | - Jeffrey H. Kozlow
- Section of Plastic and Reconstructive Surgery, University of Michigan, Ann Arbor, MI
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Long-Term Results and Reconstruction Failure in Patients Receiving Postmastectomy Radiation Therapy with a Temporary Expander or Permanent Implant in Place. Plast Reconstr Surg 2020; 145:317-327. [DOI: 10.1097/prs.0000000000006441] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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25
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Successful Immediate Staged Breast Reconstruction with Intermediary Autologous Lipotransfer in Irradiated Patients. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 7:e2398. [PMID: 31942379 PMCID: PMC6908383 DOI: 10.1097/gox.0000000000002398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 06/24/2019] [Indexed: 11/26/2022]
Abstract
As indications for radiotherapy in mastectomized patients grow, the need for greater reconstructive options is critical. Preliminary research suggests an ameliorating impact of lipotransfer on irradiated patients with expander-to-implant reconstruction. Herein, we present our technique using lipotransfer during the expansion stage to facilitate implant placement.
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26
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Abstract
One of the most influential factors in the success of breast reconstruction is whether or not radiation therapy has or will be performed. While traditional teaching is that all breasts treated with radiation therapy must be reconstructed with an autologous component, many reconstructive surgeons perform implant-based breast reconstruction without an autologous component and have success doing so. The purpose of this article is to explore the risks, benefits, and nuances of performing implant-based breast reconstruction in the setting of radiation therapy. The authors performed a review of the literature of all topics relevant to performing implant-based reconstruction with radiation therapy.
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Affiliation(s)
- Alexander F Mericli
- Department of Plastic Surgery, Division of Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Safa E Sharabi
- Department of Plastic Surgery, Division of Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas
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27
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Ono MCC, Groth AK, da Silva ABD, da Silva Freitas R, Kawasaki CS, de Paula DR, Nissel MAZ. Inframammary fold subcutaneous cushion assessment using MRI (magnetic resonance imaging). Gland Surg 2019; 8:378-384. [PMID: 31538062 DOI: 10.21037/gs.2019.06.09] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background The inframammary fold (IMF) is one of the most important elements in the determination of the aesthetic of the female breast. During mastectomies, it is important to preserve the subcutaneous portion nearby the IMF, attempting that, this preservation will greatly facilitate reconstruction allowing more satisfying aesthetic results. The aim of the present study is to evaluate the thickness of the subcutaneous IMF cushion using magnetic resonance imaging (MRI) acquisition images. Methods We have gauged the right breast IMF subcutaneous cushion from patients (all the cases without previous surgery in this topography) who were submitted to MRI in a diagnosis radiology center, between January and February of 2017. MRI images were analyzed in T1 fat saturated sequences. The assessment of the fold cushion was realized in the projection of axial measurements in sagittal plane. Results Among the 50 evaluated patients, the median measure of breast base was 9.91 cm. The median measure of the subcutaneous IMF cushion assessment in the sagittal projection of the breast base meridian was 2.40 cm (varying from 1.34 to 4.05 cm, with percentile 5% of 1.51 cm and percentile 95% of 3.55 cm). Conclusions Other studies indicate the negligible amount of breast tissue and the low incidence of neoplasia in this topography, the preservation of the IMF seems feasible. The measurements of the IMF thickness, evaluated by MRI in this study, provide reference values for maintaining a desirable inframammary crease.
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Affiliation(s)
- Maria Cecilia Closs Ono
- Department of Plastic Surgery, University Federal of Paraná, Curitiba, Brazil.,Service of Plastic Surgery, Hospital Erasto Gaertner, Curitiba, Brazil
| | - Anne Karoline Groth
- Service of Plastic Surgery, Hospital Erasto Gaertner, Curitiba, Brazil.,Positivo University, Curitiba, Brazil
| | - Alfredo Benjamin Duarte da Silva
- Department of Plastic Surgery, University Federal of Paraná, Curitiba, Brazil.,Service of Plastic Surgery, Hospital Erasto Gaertner, Curitiba, Brazil
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28
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Young WA, Degnim AC, Hoskin TL, Jakub JW, Nguyen MD, Tran NV, Harless CA, Manrique OJ, Boughey JC, Hieken TJ. Outcomes of > 1300 Nipple-Sparing Mastectomies with Immediate Reconstruction: The Impact of Expanding Indications on Complications. Ann Surg Oncol 2019; 26:3115-3123. [DOI: 10.1245/s10434-019-07560-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Indexed: 11/18/2022]
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29
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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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30
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Smith NL, Jethwa KR, Viehman JK, Harmsen WS, Gonuguntla K, Elswick SM, Grauberger JN, Amundson AC, Whitaker TJ, Remmes NB, Harless CA, Boughey JC, Nguyen MDT, Park SS, Corbin KS, Mutter RW. Post-mastectomy intensity modulated proton therapy after immediate breast reconstruction: Initial report of reconstruction outcomes and predictors of complications. Radiother Oncol 2019; 140:76-83. [PMID: 31185327 DOI: 10.1016/j.radonc.2019.05.022] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Revised: 05/16/2019] [Accepted: 05/20/2019] [Indexed: 01/02/2023]
Abstract
PURPOSE To report reconstructive outcomes of patients treated with post-mastectomy intensity modulated proton therapy (IMPT) following immediate breast reconstruction (IBR). MATERIALS AND METHODS Consecutive women with breast cancer who underwent implant-based IBR and post-mastectomy IMPT were included. Clinical characteristics, dosimetry, and acute toxicity were collected prospectively and reconstruction complications retrospectively. RESULTS Fifty-one women were treated between 2015 and 2017. Forty-two had bilateral reconstruction with unilateral IMPT. The non-irradiated contralateral breasts served as controls. Conventional fractionation (median 50 Gy/25 fractions) was administered in 37 (73%) and hypofractionation (median 40.5 Gy/15 fractions) in 14 (27%) patients. Median mean heart, ipsilateral lung V20Gy, and CTV-IMN V95% were 0.6 Gy, 13.9%, and 97.4%. Maximal acute dermatitis grade was 1 in 32 (63%), 2 in 17 (33%), and 3 in 2 (4%) patients. Surgical site infection (hazard ratio [HR] 13.19, 95% confidence interval [CI] 1.67-104.03, p = 0.0012), and unplanned surgical intervention (HR 9.86, 95% CI 1.24-78.67, p = 0.0068) were more common in irradiated breasts. Eight of 51 irradiated breasts and 2 of 42 non-irradiated breasts had reconstruction failure (HR 3.59, 95% CI 0.78-16.41, p = 0.084). Among irradiated breasts, hypofractionation was significantly associated with reconstruction failure (HR 4.99, 95% CI 1.24-20.05, p = 0.024), as was older patient age (HR 1.14, 95% CI 1.05-1.24, p = 0.002). CONCLUSIONS IMPT following IBR spared underlying organs and had low rates of acute toxicity. Reconstruction complications are more common in irradiated breasts, and reconstructive outcomes appear comparable with photon literature. Hypofractionation was associated with higher reconstruction failure rates. Further investigation of optimal dose-fractionation after IBR is needed.
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Affiliation(s)
- Na L Smith
- Department of Radiation Oncology, Mayo Clinic, Rochester, USA
| | | | - Jason K Viehman
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, USA
| | - William S Harmsen
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, USA
| | | | | | | | - Adam C Amundson
- Department of Radiation Oncology, Mayo Clinic, Rochester, USA
| | | | | | | | | | | | - Sean S Park
- Department of Radiation Oncology, Mayo Clinic, Rochester, USA
| | | | - Robert W Mutter
- Department of Radiation Oncology, Mayo Clinic, Rochester, USA.
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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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Quality of life in breast cancer patients and surgical results of immediate tissue expander/implant-based breast reconstruction after mastectomy. Arch Gynecol Obstet 2019; 300:409-420. [PMID: 31144025 DOI: 10.1007/s00404-019-05201-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2019] [Accepted: 05/22/2019] [Indexed: 01/13/2023]
Abstract
OBJECTIVES The purpose of this study was to analyze the effects of prior radiotherapy (RT) as well as postmastectomy radiotherapy (PMRT) on patient-reported quality of life (QoL) and on surgical/aesthetic outcomes in patients with expander-/implant-based delayed immediate reconstruction (EIBR) compared to patients that underwent EIBR without any RT. MATERIAL AND METHODS QoL was assessed by BREAST-Q, the surgical/aesthetic outcome by a structured examination and a picture analysis (BCCT.CORE software) and subsequently compared between the three cohorts. RESULTS Of 161 eligible patients, 97 followed the invitation (no RT n = 54, 9 of them with bilateral EIBR; PMRT n = 26; history of RT n = 15). The surgical/aesthetic results were better in the RT-naive cohort than in the PMRT cohort, but satisfaction with outcome and psychosocial well-being were better in the PMRT cohort. The RT-naive cohort showed (significantly) higher scores in satisfaction with breast, satisfaction with implant and sexual well-being compared to the history of RT cohort, although satisfaction with outcome was comparable. The PMRT cohort reached significantly more points in almost all categories and better BCCT.CORE and examination results than the history of RT cohort. Of all patients, 92.7%, 84.6% and 78.6% (RT naive, PMRT, history of RT) would agree to undergo EIBR again. CONCLUSION EIBR results in acceptable QoL and surgical results. In patients with a prior RT, QoL is significantly lower and surgical results are significantly worse. However, high acceptance rates suggest EIBR being a justifiable option even for this group. Prospective studies and long-term follow-up are required for definitive conclusions.
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HALFMOON TomoTherapy (Helical ALtered Fractionation for iMplant partial OmissiON): implant-sparing post-mastectomy radiotherapy reshaping the clinical target volume in the reconstructed breast. J Cancer Res Clin Oncol 2019; 145:1887-1896. [PMID: 31144158 DOI: 10.1007/s00432-019-02938-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 05/16/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE To report the dosimetric feasibility of the radiation technique HALFMOON (Helical ALtered Fractionation for iMplant partial OmissiON) for post-mastectomy radiation therapy (PMRT) in intermediate-high-risk breast cancer patients with implant-based immediate breast reconstruction, where the clinical target volume (CTV) does not include the whole implant (implant-sparing approach). METHODS In the HALFMOON technique, the CTV consisted of skin, subcutaneous tissues, and pectoralis major muscle, excluding the implant, chest wall muscles, and rib plane. The HALFMOON plans were compared with conventionally contoured CTV plans, in which the whole implant, chest wall muscles, and ribs plane were included in the CTV, in a ratio 1:3. All patients underwent hypofractionated treatment of 40.05 Gy/15 fractions, using helical Tomotherapy®. RESULTS Eighteen patients undergoing HALFMOON technique were compared to 54 subjects treated with conventionally contoured CTV plans. No difference was found in the planning target volume coverage between the two groups. Conversely, a statistically relevant dose reduction in HALFMOON patients was observed for ipsilateral lung (D15%, p < 0.0001; D20%, p < 0.0001; D35%, p = 0.003), contralateral lung (D20%, p = 0.048), contralateral breast (D15%, p = 0.031; D20%, p = 0.047), and stomach (Dmean, p = 0.011). Regarding the implant, V90% and D50% decreased by 46% and 8%, respectively, in the HALFMOON plans (p < 0.0001). CONCLUSION The HALFMOON approach is technically feasible and resulted in high-dose conformity of the target with a significant reduction of radiation dose delivered to implant and other organs. A clinical study is needed to assess the impact on reconstruction cosmetic outcome and local control.
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Naoum GE, Salama L, Ho A, Horick NK, Oladeru O, Abouegylah M, Daniell K, MacDonald S, Arafat WO, Smith BL, Colwell AS, Taghian AG. The Impact of Chest Wall Boost on Reconstruction Complications and Local Control in Patients Treated for Breast Cancer. Int J Radiat Oncol Biol Phys 2019; 105:155-164. [PMID: 31055108 DOI: 10.1016/j.ijrobp.2019.04.027] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 04/17/2019] [Accepted: 04/22/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE Giving an additional radiation dose to the incision or chest wall has been a practice, but it has never been studied in a randomized setting, and it might lead to inferior cosmetic outcomes. This study aims to evaluate whether delivery of a chest wall boost (CWB) to the mastectomy scar or chest wall is independently associated with reconstruction complications and to assess its disease control efficacy in the setting of breast reconstruction. METHODS AND MATERIALS We conducted a retrospective chart review of 746 patients with breast cancer who underwent mastectomy, breast reconstruction, and PMRT; all underwent treatment at our institution during 1997 to 2016. Various reconstruction techniques were used among this cohort including autologous reconstruction, single-stage direct-to-implant reconstruction, and 2-stage tissue expander implant. Cohorts were divided by administration of CWB. The primary objective was comparing the rate of reconstruction complications including skin necrosis, fat necrosis and infection between groups. Subgroup analysis for patients with implant-based reconstruction was performed to evaluate the effect of CWB on implant-related complications such as capsular contracture, implant exposure, and implant failure. The secondary objective was comparison of the cumulative incidence of local failure between groups overall and within clinically high-risk subgroups. RESULTS The median follow-up was 5.2 years. Most clinicopathologic features were well balanced between the 379 (51%) patients who received CWB and the 367 (49%) who did not. On multivariate analysis, CWB was significantly associated with infection, skin necrosis, and implant exposure. For implant reconstruction patients, CWB independently increased risks of implant failure. CWB administration was not associated with local tumor control benefits, even in high-risk subgroups. CONCLUSIONS Our findings suggest that omission of chest wall boost in postmastectomy radiation improves breast reconstruction outcomes without compromising local tumor control.
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Affiliation(s)
- George E Naoum
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Masters of Medical Sciences in Clinical Investigation program, Harvard Medical School, Boston, Massachusetts
| | - Laura Salama
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Charles E. Schmidt College of Medicine, Boston, Massachusetts
| | - Alice Ho
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Nora K Horick
- Biostatistics Center, Massachusetts General Hospital, Boston, Massachusetts
| | - Oluwadamilola Oladeru
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Mohamed Abouegylah
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Department of Clinical Oncology, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Kayla Daniell
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Shannon MacDonald
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Waleed O Arafat
- Department of Clinical Oncology, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Barbara L Smith
- Department of Surgical Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Amy S Colwell
- Department of Plastic Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Alphonse G Taghian
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
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De Rose F, Fogliata A, Franceschini D, Cozzi S, Iftode C, Stravato A, Tomatis S, Masci G, Torrisi R, Testori A, Tinterri C, Lisa AVE, Maione L, Vinci V, Klinger M, Santoro A, Scorsetti M. Postmastectomy radiation therapy using VMAT technique for breast cancer patients with expander reconstruction. Med Oncol 2019; 36:48. [PMID: 31028487 DOI: 10.1007/s12032-019-1275-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Accepted: 04/19/2019] [Indexed: 11/28/2022]
Abstract
Postmastectomy radiotherapy (PMRT) following immediate breast reconstruction is increasingly adopted in the management of breast cancer patients. We retrospectively evaluate the complication rates of PMRT using VMAT technique to immediate tissue expander-based reconstructions and the possible impact of tissue expander volume on radiotherapy planning. We reviewed the data of patients who underwent immediate expander breast reconstruction and received PMRT with VMAT (50 Gy in 25 fractions) on the reconstructed breast and axillary levels III-IV. Neoadjuvant or adjuvant systemic therapy was administered in most of the patients. Autologous fat grafting was routinely performed at the time of second-stage reconstruction. Between 2015 and 2017, PMRT was delivered to 46 consecutive patients (median age 50 years) with expander reconstruction. Median follow-up was 27 months (range 10-41). Two patients (4.3%) had a reconstruction failure, as expander rupture and infection, following the first- and the second-stage reconstruction, respectively. In most cases expanders were completely inflated before PMRT (65.2%). Median expander volume before PMRT was 425 cm3 (range 150-700 cm3). The amount of expander inflation did not significantly affect dosimetry, except for skin dose, with a surface receiving more than 30 Gy of 36.6 ± 0.9 cm2 and 47.0 ± 2.5 cm2 for a volume expander below or above the median, respectively. However, this variable was not predictor for complications. Disease progression was recorded in 15.2% of patients. PMRT using VMAT technique for breast cancer patients with expander reconstruction is associated with a very low complication rate. The expander volume before PMRT does not significantly compromise radiotherapy dose distribution.
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Affiliation(s)
- Fiorenza De Rose
- Radiotherapy and Radiosurgery Department, Humanitas Research Hospital, Milan, Rozzano, Italy
| | - Antonella Fogliata
- Radiotherapy and Radiosurgery Department, Humanitas Research Hospital, Milan, Rozzano, Italy.
| | - Davide Franceschini
- Radiotherapy and Radiosurgery Department, Humanitas Research Hospital, Milan, Rozzano, Italy
| | - Salvatore Cozzi
- Radiotherapy and Radiosurgery Department, Humanitas Research Hospital, Milan, Rozzano, Italy
| | - Cristina Iftode
- Radiotherapy and Radiosurgery Department, Humanitas Research Hospital, Milan, Rozzano, Italy
| | - Antonella Stravato
- Radiotherapy and Radiosurgery Department, Humanitas Research Hospital, Milan, Rozzano, Italy
| | - Stefano Tomatis
- Radiotherapy and Radiosurgery Department, Humanitas Research Hospital, Milan, Rozzano, Italy
| | - Giovanna Masci
- Medical Oncology Department, Humanitas Research Hospital, Milan, Rozzano, Italy
| | - Rosalba Torrisi
- Medical Oncology Department, Humanitas Research Hospital, Milan, Rozzano, Italy
| | - Alberto Testori
- Breast Surgery Department, Humanitas Research Hospital, Milan, Rozzano, Italy
| | - Corrado Tinterri
- Breast Surgery Department, Humanitas Research Hospital, Milan, Rozzano, Italy
| | - Andrea V E Lisa
- Plastic Surgery Department, Humanitas Research Hospital, Milan, Rozzano, Italy
| | - Luca Maione
- Plastic Surgery Department, Humanitas Research Hospital, Milan, Rozzano, Italy
| | - Valeriano Vinci
- Plastic Surgery Department, Humanitas Research Hospital, Milan, Rozzano, Italy
| | - Marco Klinger
- Plastic Surgery Department, Humanitas Research Hospital, Milan, Rozzano, Italy
| | - Armando Santoro
- Medical Oncology Department, Humanitas Research Hospital, Milan, Rozzano, Italy.,Department of Biomedical Sciences, Humanitas University, Milan, Rozzano, Italy
| | - Marta Scorsetti
- Radiotherapy and Radiosurgery Department, Humanitas Research Hospital, Milan, Rozzano, Italy.,Department of Biomedical Sciences, Humanitas University, Milan, Rozzano, Italy
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Bing Z, Feng L, Wu CS, Du JT, Liu YF, Liu SX. Acellular dermal matrix contributes to epithelialization in patients with chronic sinusitis. J Biomater Appl 2019; 33:1053-1059. [PMID: 30651053 DOI: 10.1177/0885328218822636] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Nasal endoscopic surgery is widely used for nasal diseases, including sinusitis and tumors. However, scar hyperplasia, nasal irritation, scab, and nasal obstruction delay nasal mucosal recovery, with prolonged cleaning exacerbating the patient's financial burden. Here, we presented a novel approach for the treatment of nasal mucosal defects, termed acellular dermal matrix. METHODS A total of 31 patients with bilateral chronic sinusitis (maxillary sinusitis and ethmoid sinusitis) underwent nasal surgery and nasal mucosal repair in September-October 2016. We divided the nasal cavities of each patient into control and acellular dermal matrix groups, randomly selected one side for nasal mucosal repair by surgery. A suitable acellular dermal matrix size was selected according to the defect in each patient. After pruning, the acellular dermal matrix was placed on the wound surface and filled with gelatin sponge. All patients were followed up for 14 weeks to compare nasal mucosal epithelialization between the control and acellular dermal matrix groups. Results:No obvious complications and adverse reactions were observed after nasal surgery. Lund-Kennedy scores in the acellular dermal matrix group were significantly decreased compared with the control group at 8 (0 (0, 1) vs. 2 (2, 4); P<0.05) weeks. Epithelialization time of eight weeks in the acellular dermal matrix groups was significantly decreased than the control group of 14 weeks. CONCLUSION Acellular dermal matrix provides a growth framework for the healthy mucosa on the wounded surface and reduces postoperative epithelialization time.
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Affiliation(s)
- Zhong Bing
- Sichuan University, West China Hospital, Department of Otolaryngology Head and Neck Surgery, Chengdu, Sichuan, China
| | - Liu Feng
- Sichuan University, West China Hospital, Department of Otolaryngology Head and Neck Surgery, Chengdu, Sichuan, China
| | - Chun-Shu Wu
- Sichuan University, West China Hospital, Department of Otolaryngology Head and Neck Surgery, Chengdu, Sichuan, China
| | - Jin-Tao Du
- Sichuan University, West China Hospital, Department of Otolaryngology Head and Neck Surgery, Chengdu, Sichuan, China
| | - Ya-Feng Liu
- Sichuan University, West China Hospital, Department of Otolaryngology Head and Neck Surgery, Chengdu, Sichuan, China
| | - Shi-Xi Liu
- Sichuan University, West China Hospital, Department of Otolaryngology Head and Neck Surgery, Chengdu, Sichuan, China
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Riggio E, Toffoli E, Tartaglione C, Marano G, Biganzoli E. Local safety of immediate reconstruction during primary treatment of breast cancer. Direct-to-implant versus expander-based surgery. J Plast Reconstr Aesthet Surg 2018; 72:232-242. [PMID: 30497914 DOI: 10.1016/j.bjps.2018.10.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2018] [Revised: 10/14/2018] [Accepted: 10/28/2018] [Indexed: 10/27/2022]
Abstract
INTRODUCTION After mastectomy, immediate breast reconstruction is paramount. With the growing number of nipple-sparing mastectomies, the chances of successful one-stage reconstruction with implants are also increasing. Local safety is one of the main issues. This study investigated the factors that could lead to major or minor complications after expander-based versus direct-to-implant (DTI) reconstruction. METHODS The studied factors were age, body mass index (BMI), hypertension, smoking, diabetes, type of mastectomy (nipple-sparing/total), implant size, neoadjuvant/adjuvant chemotherapy, and radiotherapy. The study sample included 294 immediate reconstructions over 3 years. The primary outcome was the incidence of complications, major or minor depending on the necessity of revision surgery. For the DTI pocket, we applied a variant of the conventional submuscular technique. RESULTS In DTI reconstructions (median follow-up 26 months), the complication rate was 17.2% (4.3% major and 12.8% minor) with no significant association with clinical variables. In expander-based reconstructions (median follow-up 19 months), the complication rate was 18.3% (12.5% major and 5.8% minor). Univariate analysis showed a significant association between overall complications and radiotherapy (P = 0.01) as well as between major complications and expander size (P < 0.005), BMI (P < 0.005), and radiotherapy (P < 0.01); radiotherapy and BMI retained significance in multivariate analysis. Neoadjuvant/adjuvant chemotherapy did not affect the complication rate. CONCLUSIONS There was evidence of an association between major complications and clinical variables in the expander-based cohort. Larger expander size was a predictor of failure, especially combined with radiation. Direct-to-implant reconstruction proved to be safe. We describe a reliable method of reconstruction and a safe range of implant sizes even beyond 500 g.
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Affiliation(s)
- Egidio Riggio
- Unit of Plastic and Reconstructive Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, 20133 Milan, Italy.
| | - Elisa Toffoli
- Unit of Plastic and Reconstructive Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, 20133 Milan, Italy
| | - Caterina Tartaglione
- Unit of Plastic and Reconstructive Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, 20133 Milan, Italy
| | - Giuseppe Marano
- Laboratory of Medical Statistics, Biometry and Bioinformatics G.A. Maccacaro, Department of Clinical Science and Community Health, University of Milan, 20133 Milan, Italy
| | - Elia Biganzoli
- Laboratory of Medical Statistics, Biometry and Bioinformatics G.A. Maccacaro, Department of Clinical Science and Community Health, University of Milan, 20133 Milan, Italy; Unit of Medical Statistics, Biometry and Bioinformatics, Fondazione IRCCS Istituto Nazionale dei Tumori, 20133 Milan, Italy
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Complications After Total Skin-Sparing Mastectomy and Expander-Implant Reconstruction: Effects of Radiation Therapy on the Stages of Reconstruction. Ann Plast Surg 2018; 80:10-13. [PMID: 28671888 DOI: 10.1097/sap.0000000000001186] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Many patients undergoing total-skin sparing mastectomy (TSSM) and 2-staged expander-implant (TE-I) reconstruction require postmastectomy radiation therapy (PMRT). Additionally, many patients undergoing TSSM for recurrent cancer have a history of lumpectomy and radiation therapy (XRT). Few studies have looked at the impact of XRT on the stages of TE-I reconstruction. METHODS Patients undergoing TSSM and immediate TE-I reconstruction between 2006 and 2013 were identified from a prospectively maintained database. Rates of TE-I loss and severe infection requiring intravenous antibiotics were compared in patients with prior XRT (85 cases) and PMRT (133 cases). Complications were divided by stage of reconstruction: first stage (TSSM and TE placement) and second stage (TE-I exchange). RESULTS Mean follow-up time was 2.5 years. Patients with prior XRT had more complications after the first stage of reconstruction than the second (TE-I loss: 15% vs 5%, P = 0.03; infection: 20% vs 8%, P = 0.04). Patients receiving PMRT had low complication rates after the first stage, when they had not yet received radiation (TE-I loss: 2%; infection: 5%). However, complication rates after TE-I exchange (TE-I loss, 18%; infection, 31%) were significantly higher, and nearly 4-fold higher than patients with prior XRT. CONCLUSIONS Patients with prior XRT are at high risk for complications after the first stage of TE-I reconstruction after TSSM; however, the risk of complications at the second stage is comparable to patients without radiation exposure and significantly lower than patients receiving PMRT. Patients receiving radiation therapy should be given appropriate preoperative counseling regarding their risks.
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Recent Advances and Future Directions in Postmastectomy Breast Reconstruction. Clin Breast Cancer 2018; 18:e571-e585. [DOI: 10.1016/j.clbc.2018.02.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Revised: 02/08/2018] [Accepted: 02/10/2018] [Indexed: 11/20/2022]
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Carbine NE, Lostumbo L, Wallace J, Ko H. Risk-reducing mastectomy for the prevention of primary breast cancer. Cochrane Database Syst Rev 2018; 4:CD002748. [PMID: 29620792 PMCID: PMC6494635 DOI: 10.1002/14651858.cd002748.pub4] [Citation(s) in RCA: 81] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Recent progress in understanding the genetic basis of breast cancer and widely publicized reports of celebrities undergoing risk-reducing mastectomy (RRM) have increased interest in RRM as a method of preventing breast cancer. This is an update of a Cochrane Review first published in 2004 and previously updated in 2006 and 2010. OBJECTIVES (i) To determine whether risk-reducing mastectomy reduces death rates from any cause in women who have never had breast cancer and in women who have a history of breast cancer in one breast, and (ii) to examine the effect of risk-reducing mastectomy on other endpoints, including breast cancer incidence, breast cancer mortality, disease-free survival, physical morbidity, and psychosocial outcomes. SEARCH METHODS For this Review update, we searched Cochrane Breast Cancer's Specialized Register, MEDLINE, Embase and the WHO International Clinical Trials Registry Platform (ICTRP) on 9 July 2016. We included studies in English. SELECTION CRITERIA Participants included women at risk for breast cancer in at least one breast. Interventions included all types of mastectomy performed for the purpose of preventing breast cancer. DATA COLLECTION AND ANALYSIS At least two review authors independently abstracted data from each report. We summarized data descriptively; quantitative meta-analysis was not feasible due to heterogeneity of study designs and insufficient reporting. We analyzed data separately for bilateral risk-reducing mastectomy (BRRM) and contralateral risk-reducing mastectomy (CRRM). Four review authors assessed the methodological quality to determine whether or not the methods used sufficiently minimized selection bias, performance bias, detection bias, and attrition bias. MAIN RESULTS All 61 included studies were observational studies with some methodological limitations; randomized trials were absent. The studies presented data on 15,077 women with a wide range of risk factors for breast cancer, who underwent RRM.Twenty-one BRRM studies looking at the incidence of breast cancer or disease-specific mortality, or both, reported reductions after BRRM, particularly for those women with BRCA1/2 mutations. Twenty-six CRRM studies consistently reported reductions in incidence of contralateral breast cancer but were inconsistent about improvements in disease-specific survival. Seven studies attempted to control for multiple differences between intervention groups and showed no overall survival advantage for CRRM. Another study showed significantly improved survival following CRRM, but after adjusting for bilateral risk-reducing salpingo-oophorectomy (BRRSO), the CRRM effect on all-cause mortality was no longer significant.Twenty studies assessed psychosocial measures; most reported high levels of satisfaction with the decision to have RRM but greater variation in satisfaction with cosmetic results. Worry over breast cancer was significantly reduced after BRRM when compared both to baseline worry levels and to the groups who opted for surveillance rather than BRRM, but there was diminished satisfaction with body image and sexual feelings.Seventeen case series reporting on adverse events from RRM with or without reconstruction reported rates of unanticipated reoperations from 4% in those without reconstruction to 64% in participants with reconstruction.In women who have had cancer in one breast, removing the other breast may reduce the incidence of cancer in that other breast, but there is insufficient evidence that this improves survival because of the continuing risk of recurrence or metastases from the original cancer. Additionally, thought should be given to other options to reduce breast cancer risk, such as BRRSO and chemoprevention, when considering RRM. AUTHORS' CONCLUSIONS While published observational studies demonstrated that BRRM was effective in reducing both the incidence of, and death from, breast cancer, more rigorous prospective studies are suggested. BRRM should be considered only among those at high risk of disease, for example, BRCA1/2 carriers. CRRM was shown to reduce the incidence of contralateral breast cancer, but there is insufficient evidence that CRRM improves survival, and studies that control for multiple confounding variables are recommended. It is possible that selection bias in terms of healthier, younger women being recommended for or choosing CRRM produces better overall survival numbers for CRRM. Given the number of women who may be over-treated with BRRM/CRRM, it is critical that women and clinicians understand the true risk for each individual woman before considering surgery. Additionally, thought should be given to other options to reduce breast cancer risk, such as BRRSO and chemoprevention when considering RRM.
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Affiliation(s)
- Nora E Carbine
- Georgetown University Lombardi Cancer CenterTranslational Breast Cancer Research Consortium (TBCRC)WashingtonD.C.USA20007
| | | | | | - Henry Ko
- University of SydneyNHMRC Clinical Trials CentreK25 ‐ Medical Foundation Building92‐94 Parramatta Rd.,CamperdownNSWAustralia2050
- Academic Medicine Research Institute, Duke‐NUS Graduate Medical SchoolCentre for Health Services Research, SingHealthSingaporeSingapore169857
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The Assisi Think Tank Meeting and Survey of post MAstectomy Radiation Therapy after breast reconstruction: The ATTM-SMART report. Eur J Surg Oncol 2018; 44:436-443. [DOI: 10.1016/j.ejso.2018.01.010] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2017] [Revised: 12/11/2017] [Accepted: 01/02/2018] [Indexed: 11/23/2022] Open
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Ho AY, Hu ZI, Mehrara BJ, Wilkins EG. Radiotherapy in the setting of breast reconstruction: types, techniques, and timing. Lancet Oncol 2017; 18:e742-e753. [DOI: 10.1016/s1470-2045(17)30617-4] [Citation(s) in RCA: 107] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Revised: 07/06/2017] [Accepted: 07/17/2017] [Indexed: 11/30/2022]
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Affiliation(s)
- Rod J Rohrich
- Dallas, Texas.,From the Editor-in-Chief, Plastic and Reconstructive Surgery
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Ogita M, Nagura N, Kawamori J, In R, Yoshida A, Yamauchi H, Takei J, Hayashi N, Iwahira Y, Ohde S, Fukushima S, Sekiguchi K. Risk factors for complications among breast cancer patients treated with post-mastectomy radiotherapy and immediate tissue-expander/permanent implant reconstruction: a retrospective cohort study. Breast Cancer 2017; 25:167-175. [DOI: 10.1007/s12282-017-0808-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Accepted: 10/12/2017] [Indexed: 12/13/2022]
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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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Fowble B, Jairam AK, Wang F, Peled A, Alvarado M, Ewing C, Esserman L, Park C, Lazar A. Indications for Postmastectomy Radiation After Neoadjuvant Chemotherapy in ypN0 and ypN1-3 Axillary Node-Positive Women. Clin Breast Cancer 2017; 18:e107-e113. [PMID: 28830795 DOI: 10.1016/j.clbc.2017.07.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Revised: 05/18/2017] [Accepted: 07/24/2017] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Downstaging with neoadjuvant chemotherapy (NAC) might obscure indications for postmastectomy radiation (PMRT). The degree of downstaging that results in local-regional recurrence (LRR) rates low enough to omit PMRT remains controversial. We examined the rate of LRR in women who received NAC who underwent mastectomy without PMRT. PATIENTS AND METHODS Between 2004 and 2013, 81 women with stage I to IIIA breast cancer had NAC and mastectomy; 48 patients (59%) were clinical N0 and 33 patients (41%) were clinical N1; median age was 45 years; 33 patients (41%) had hormone receptor-positive (HR+)HER2-, 21 patients (26%) HR+HER2+, 19 patients (23%) HR- HER2-, and 7 patients (9%) HR-HER2+ disease. We explored how LRR rates varied with age, BRCA status, Grade, receptor status, clinical N status, pathologic response, lymphovascular invasion, and mastectomy margins. Median follow-up was 4.9 years. RESULTS After NAC, 35 patients (43%) had a pathologic complete response (pCR), 33 patients (41%) were ypN0, and 13 patients (16%) were ypN1-3+. There were 8 LRRs (6 chest wall, 1 axillary, 1 supraclavicular node). The 5-year cumulative incidence of LRR was 8% for all patients, 3% for pCR, 16% for ypN0, 10% for ypN1-3+, 6% for HR+HER2-, 25% for HR+HER2+, 0% for HR-HER2-, and 0% for HR-HER2+. LRR was 31% in the ypN0 and 33% in the ypN1-3+ HR+HER2+ women, and 12% in the ypN0 and 0% in the ypN1 to ypN3+ HR+HER2- patients. CONCLUSION This study is unique. All HER2+ patients received trastuzumab and LRR was analyzed according to treatment response, clinicopathologic factors, and receptor status. pCR patients including young women and clinical stage IIIA had low LRR rates. However, ypN0 and ypN1-3+ HR+HER2+ patients had higher rates of LRR compared with other receptor subgroups and on the basis of limited data should be considered for PMRT.
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Affiliation(s)
- Barbara Fowble
- Department of Radiation Oncology, University of California, San Francisco, San Francisco, CA.
| | - Abhishek Keshav Jairam
- Department of Radiation Oncology, University of California, San Francisco, San Francisco, CA
| | - Frederick Wang
- Division of Plastic and Reconstructive Surgery, University of California, San Francisco, San Francisco, CA
| | - Anne Peled
- Division of Plastic and Reconstructive Surgery, University of California, San Francisco, San Francisco, CA
| | - Michael Alvarado
- Department of Surgery, Carol Frank Buck Breast Care Center, University of California, San Francisco, San Francisco, CA
| | - Cheryl Ewing
- Department of Surgery, Carol Frank Buck Breast Care Center, University of California, San Francisco, San Francisco, CA
| | - Laura Esserman
- Department of Surgery, Carol Frank Buck Breast Care Center, University of California, San Francisco, San Francisco, CA
| | - Catherine Park
- Department of Radiation Oncology, University of California, San Francisco, San Francisco, CA
| | - Ann Lazar
- Department of Preventive and Restorative Dental Sciences, Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA
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Post-mastectomy radiation therapy after breast reconstruction: Indications, timing and results. Breast 2017; 34 Suppl 1:S95-S98. [DOI: 10.1016/j.breast.2017.06.037] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Tissue Expanders and Proton Beam Radiotherapy: What You Need to Know. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2017; 5:e1390. [PMID: 28740794 PMCID: PMC5505855 DOI: 10.1097/gox.0000000000001390] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Accepted: 05/05/2017] [Indexed: 11/26/2022]
Abstract
Proton beam radiotherapy (PBR) has gained acceptance for the treatment of breast cancer because of unique beam characteristics that allow superior dose distributions with optimal dose to the target and limited collateral damage to adjacent normal tissue, especially to the heart and lungs. To determine the compatibility of breast tissue expanders (TEs) with PBR, we evaluated the structural and dosimetric properties of 2 ex vivo models: 1 model with internal struts and another model without an internal structure. Although the struts appeared to have minimal impact, we found that the metal TE port alters PBR dynamics, which may increase proton beam range uncertainty. Therefore, submuscular TE placement may be preferable to subcutaneous TE placement to reduce the interaction of the TE and proton beam. This will reduce range uncertainty and allow for more ideal radiation dose distribution.
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Ricci JA, Epstein S, Momoh AO, Lin SJ, Singhal D, Lee BT. A meta-analysis of implant-based breast reconstruction and timing of adjuvant radiation therapy. J Surg Res 2017; 218:108-116. [PMID: 28985836 DOI: 10.1016/j.jss.2017.05.072] [Citation(s) in RCA: 108] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Revised: 04/25/2017] [Accepted: 05/19/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Implant-based breast reconstruction is the most common type of reconstruction after postmastectomy radiation therapy (PMRT). The impact of the timing of PMRT to a tissue expander or permanent implant is not well understood. The purpose of this systematic review was to evaluate outcomes in implant-based reconstruction and the timing of PMRT. METHODS A review of the English literature in the PubMed/MEDLINE database (2000-2016) was performed to identify all articles on implant-based breast reconstruction and PMRT. Cases from each study were grouped by PMRT to a tissue expander or PMRT to a permanent implant. Outcomes of interest included reconstructive failure and capsular contracture as overall rates and associations were pooled. Effect sizes (z values), risk ratios (RRs), and heterogeneity scores (I2) were calculated on meta-analysis. RESULTS There were 20 studies meeting inclusion criteria with 2348 patients identified. Pooled analysis revealed an overall rate of reconstructive failure of 17.6% and Baker grade III/IV capsular contracture of 37.5%. PMRT applied to tissue expanders resulted in higher rates of reconstructive failure compared with PMRT applied to permanent silicone implants (20% versus 13.4%, RR = 2.33, P = 0.0083, 95% confidence interval 1.24-4.35), but lower rates of capsular contracture (24.5% versus 49.4%, RR = 0.53, P = 0.083, 95% confidence interval 0.26-1.09). CONCLUSIONS Regardless of timing, PMRT applied to implant-based breast reconstruction was associated with high risk of reconstructive failure and capsular contracture. Surgeons should consider alternative strategies, such as autologous tissue reconstructions, in patients requiring PMRT.
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Affiliation(s)
- Joseph A Ricci
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Sherise Epstein
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Adeyiza O Momoh
- Section of Plastic Surgery, University of Michigan Medical School, Ann Arbor, Michigan
| | - Samuel J Lin
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Dhruv Singhal
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Bernard T Lee
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.
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Impact of Evolving Radiation Therapy Techniques on Implant-Based Breast Reconstruction. Plast Reconstr Surg 2017; 139:1232e-1239e. [DOI: 10.1097/prs.0000000000003341] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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