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Silverstein ML, Momeni A. Long-Term Outcomes following Hybrid Breast Reconstruction. Plast Reconstr Surg 2024; 154:217e-223e. [PMID: 37566525 DOI: 10.1097/prs.0000000000010987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/13/2023]
Abstract
BACKGROUND Hybrid breast reconstruction combines free tissue transfer with implant placement. Various mesh products have been successfully used to secure the implant position in these reconstructions. In this study, the authors investigate the impact of mesh type on long-term outcomes following hybrid breast reconstruction. METHODS A retrospective analysis of all patients with at least 24 months of follow-up after immediate bilateral prepectoral hybrid breast reconstruction was performed. Univariate and multivariable regression analyses were used to evaluate long-term outcomes and compare breasts reconstructed with polyglactin mesh versus acellular dermal matrix (ADM). RESULTS Thirty-nine patients (78 breasts) who underwent hybrid breast reconstruction with an average follow-up period of 50.4 months (range, 27 to 73 months) were included in the study. Postoperative complications included hematoma ( n = 2 [2.6%]), mastectomy skin necrosis ( n = 12 [15.4%]), and fat necrosis ( n = 6 [7.7%]). There were no instances of implant infection, implant exposure, or flap failure. Polyglactin mesh and ADM were used in 24 breasts and 54 breasts, respectively. Implant malposition and capsular contracture occurred more frequently in the polyglactin cohort leading to 10 (41.7%) instances of reoperation for implant replacement compared with only 1 (1.9%) in the ADM cohort ( P < 0.001). On multivariable regression analysis, polyglactin mesh was associated with a 36-fold greater probability of requiring implant replacement compared with ADM ( P = 0.006). CONCLUSION ADM (versus polyglactin mesh) is associated with lower rates of capsular contracture and implant malposition in the context of hybrid breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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Affiliation(s)
- Max L Silverstein
- From the Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine
| | - Arash Momeni
- From the Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine
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Chiang SN, Keane AM, Ribaudo JG, Tao Y, Margenthaler JA, Tenenbaum MM, Myckatyn TM. Direct-to-Implant vs Tissue Expander Placement in Immediate Breast Reconstruction: A Prospective Cohort Study. Aesthet Surg J 2024; 44:839-849. [PMID: 38452172 DOI: 10.1093/asj/sjae054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2024] [Revised: 02/28/2024] [Accepted: 03/05/2024] [Indexed: 03/09/2024] Open
Abstract
BACKGROUND Direct-to-implant (DTI) breast reconstruction after mastectomy has gained increasing popularity. While concerns over ischemic complications related to tension on the mastectomy flap persist, newer techniques and technologies have enhanced safety of this technique. OBJECTIVES To compare clinical and patient-reported outcomes of DTI and 2-stage tissue expander (TE) reconstruction. METHODS A prospective cohort design was utilized to compare the incidence of reconstructive failure among patients undergoing DTI and TE reconstruction by unadjusted bivariate and adjusted multivariable logistic regression analyses. Secondary clinical outcomes of interest included specific complications requiring intervention (infection, seroma, hematoma, mastectomy flap necrosis, incisional dehiscence, device exposure) and time to final drain removal. Patient-reported outcomes on BREAST-Q were also compared. RESULTS A total of 134 patients (257 breasts) underwent DTI reconstruction and 222 patients (405 breasts) received TEs. DTI patients were significantly younger with lower BMIs; less diabetes, hypertension, and smoking; and smaller breast sizes; they also underwent more nipple-sparing mastectomies with prepectoral reconstructions. Rates of any complication (18% DTI vs 24% TE, P = .047), reconstructive failure (5.1% vs 12%, P = .004), and seroma (3.9% vs 11%, P < .001) were significantly lower in the DTI cohort on unadjusted analyses; however, there were no significant differences on adjusted regressions. Patient-reported satisfaction with breasts, psychosocial well-being, and sexual well-being were more substantively improved with DTI reconstruction. CONCLUSIONS Prepectoral DTI reconstruction is a viable option for postmastectomy reconstruction in carefully selected patients, with no significant increase in reconstructive failure or other complications. LEVEL OF EVIDENCE: 2
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Park JB, Jang BS, Chang JH, Kim JH, Choi CH, Hong KY, Jin US, Chang H, Myung Y, Jeong JH, Heo CY, Kim IA, Shin KH. The impact of the new ESTRO-ACROP target volume delineation guidelines for postmastectomy radiotherapy after implant-based breast reconstruction on breast complications. Front Oncol 2024; 14:1373434. [PMID: 38846971 PMCID: PMC11153655 DOI: 10.3389/fonc.2024.1373434] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Accepted: 04/29/2024] [Indexed: 06/09/2024] Open
Abstract
The European Society for Radiotherapy and Oncology-Advisory Committee in Radiation Oncology Practice (ESTRO-ACROP) updated a new target volume delineation guideline for postmastectomy radiotherapy (PMRT) after implant-based reconstruction. This study aimed to evaluate the impact on breast complications with the new guideline compared to the conventional guidelines. In total, 308 patients who underwent PMRT after tissue expander or permanent implant insertion from 2016 to 2021 were included; 184 received PMRT by the new ESTRO-ACROP target delineation (ESTRO-T), and 124 by conventional target delineation (CONV-T). The endpoints were major breast complications (infection, necrosis, dehiscence, capsular contracture, animation deformity, and rupture) requiring re-operation or re-hospitalization and any grade ≥2 breast complications. With a median follow-up of 36.4 months, the cumulative incidence rates of major breast complications at 1, 2, and 3 years were 6.6%, 10.3%, and 12.6% in the ESTRO-T group, and 9.7%, 15.4%, and 16.3% in the CONV-T group; it did not show a significant difference between the groups (p = 0.56). In multivariable analyses, target delineation is not associated with the major complications (sHR = 0.87; p = 0.77). There was no significant difference in any breast complications (3-year incidence, 18.9% vs. 23.3%, respectively; p = 0.56). Symptomatic RT-induced pneumonitis was developed in six (3.2%) and three (2.4%) patients, respectively. One local recurrence occurred in the ESTRO-T group, which was within the ESTRO-target volume. The new ESTRO-ACROP target volume guideline did not demonstrate significant differences in major or any breast complications, although it showed a tendency of reduced complication risks. As the dosimetric benefits of normal organs and comparable oncologic outcomes have been reported, further analyses with long-term follow-up are necessary to evaluate whether it could be connected to better clinical outcomes.
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Affiliation(s)
- Jung Bin Park
- Department of Radiation Oncology, Seoul National University Hospital, Seoul, Republic of Korea
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Bum-Sup Jang
- Department of Radiation Oncology, Seoul National University Hospital, Seoul, Republic of Korea
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Ji Hyun Chang
- Department of Radiation Oncology, Seoul National University Hospital, Seoul, Republic of Korea
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jin Ho Kim
- Department of Radiation Oncology, Seoul National University Hospital, Seoul, Republic of Korea
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Chang Heon Choi
- Department of Radiation Oncology, Seoul National University Hospital, Seoul, Republic of Korea
| | - Ki Young Hong
- Department of Plastic and Reconstructive Surgery, Seoul National University Hospital, Seoul, Republic of Korea
| | - Ung Sik Jin
- Department of Plastic and Reconstructive Surgery, Seoul National University Hospital, Seoul, Republic of Korea
| | - Hak Chang
- Department of Plastic and Reconstructive Surgery, Seoul National University Hospital, Seoul, Republic of Korea
| | - Yujin Myung
- Department of Plastic and Reconstructive Surgery, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Jae Hoon Jeong
- Department of Plastic and Reconstructive Surgery, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Chan Yeong Heo
- Department of Plastic and Reconstructive Surgery, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - In Ah Kim
- Department of Radiation Oncology, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Kyung Hwan Shin
- Department of Radiation Oncology, Seoul National University Hospital, Seoul, Republic of Korea
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, Republic of Korea
- Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
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Ren Y, Yu Y, Xu K, Li Z, Wang X. Meta-Analysis of Immediate Implant-Based Breast Reconstruction Versus Autologous Breast Reconstruction in the Setting of PMRT. Aesthetic Plast Surg 2024; 48:1940-1948. [PMID: 37380747 DOI: 10.1007/s00266-023-03430-y] [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: 01/05/2023] [Accepted: 05/08/2023] [Indexed: 06/30/2023]
Abstract
BACKGROUND It is still a controversial debate that which type of immediate breast reconstruction should be operated on breast cancer patients in the setting of postmastectomy radiotherapy. This meta-analysis compared incidence of complications requiring reoperation (CRR), reconstruction failure (RF) and patient-reported outcome between immediate autologous breast reconstruction (ABR) and immediate implant-based breast reconstruction (IBBR), tissue expander/implant reconstruction mostly, in the setting of postmastectomy radiotherapy. METHODS Systematic and thorough research was conducted to search for studies published before August 1, 2022, by using three online databases. Studies that covered complications or reconstruction failure between two cohorts were included. To evaluate the possible bias in the included studies, the Newcastle-Ottawa Scale was applied. RESULTS Eight studies presenting 1261 patients were enrolled. The relative risk associated with reconstructive failure favored IBBR (RR = 8.61; 95% CI, 2.84-26.08; P = 0.0001). While the risk for complications requiring reoperation was not significantly different between two groups, either include reconstruction failure (RR = 1.45 95% CI, 0.82-2.55; P = 0.20) or not (RR = 0.63 95% CI, 0.28-1.43; P = 0.27). However, because statistical definitions and methodologies vary, the synthesized result should be taken critically. CONCLUSION Patients with IBBR have more possibility experiencing RF compared that with ABR, while the chance for CRR is not that different between two groups. For the purpose of clinical practice refinement, more high-quality studies are needed. LEVEL OF EVIDENCE III This journal requires that authors assign a level of evidence to each article. For a full description of these evidence-based medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
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Affiliation(s)
- Yanxin Ren
- Hebei Medical University, Shijiazhuang, 050018, Hebei Province, People's Republic of China
- Department of Medical Cosmetology, Surgery, Hebei Province General Hospital, 348, West He-Ping Road, Shijiazhuang, 050051, Hebei Province, People's Republic of China
| | - Yan Yu
- Department of Medical Cosmetology, Surgery, Hebei Province General Hospital, 348, West He-Ping Road, Shijiazhuang, 050051, Hebei Province, People's Republic of China
| | - Kexin Xu
- Hebei Medical University, Shijiazhuang, 050018, Hebei Province, People's Republic of China
- Department of Medical Cosmetology, Surgery, Hebei Province General Hospital, 348, West He-Ping Road, Shijiazhuang, 050051, Hebei Province, People's Republic of China
| | - Zhoujian Li
- Department of Medical Cosmetology, Surgery, Hebei Province General Hospital, 348, West He-Ping Road, Shijiazhuang, 050051, Hebei Province, People's Republic of China
- Hebei North University, Shijiazhuang, 075000, Hebei Province, People's Republic of China
| | - Xiao Wang
- Department of Medical Cosmetology, Surgery, Hebei Province General Hospital, 348, West He-Ping Road, Shijiazhuang, 050051, Hebei Province, People's Republic of China.
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Chen YF, Chawla S, Mousa-Doust D, Nichol A, Ng R, Isaac KV. Machine Learning to Predict the Need for Postmastectomy Radiotherapy after Immediate Breast Reconstruction. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e5599. [PMID: 38322813 PMCID: PMC10846766 DOI: 10.1097/gox.0000000000005599] [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: 10/02/2023] [Accepted: 12/15/2023] [Indexed: 02/08/2024]
Abstract
Background Post mastectomy radiotherapy (PMRT) is an independent predictor of reconstructive complications. PMRT may alter the timing and type of reconstruction recommended. This study aimed to create a machine learning model to predict the probability of requiring PMRT after immediate breast reconstruction (IBR). Methods In this retrospective study, breast cancer patients who underwent IBR from January 2017 to December 2020 were reviewed and data were collected on 81 preoperative characteristics. Primary outcome was recommendation for PMRT. Four algorithms were compared to maximize performance and clinical utility: logistic regression, elastic net (EN), logistic lasso, and random forest (RF). The cohort was split into a development dataset (75% of cohort for training-validation) and 25% used for the test set. Model performance was evaluated using area under the receiver operating characteristic curve (AUC), precision-recall curves, and calibration plots. Results In a total of 800 patients, 325 (40.6%) patients were recommended to undergo PMRT. With the training-validation dataset (n = 600), model performance was logistic regression 0.73 AUC [95% confidence interval (CI) 0.65-0.80]; RF 0.77 AUC (95% CI, 0.74-0.81); EN 0.77 AUC (95% CI, 0.73-0.81); logistic lasso 0.76 AUC (95% CI, 0.72-0.80). Without significantly sacrificing performance, 81 predictive factors were reduced to 12 for prediction with the EN method. With the test dataset (n = 200), performance of the EN prediction model was confirmed [0.794 AUC (95% CI, 0.730-0.858)]. Conclusion A parsimonious accurate machine learning model for predicting PMRT after IBR was developed, tested, and translated into a clinically applicable online calculator for providers and patients.
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Affiliation(s)
- Yi-Fu Chen
- From the Department of Computer Science, Faculty of Science, University of British Columbia, Vancouver, British Columbia, Canada
| | - Sahil Chawla
- Department of Surgery, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Dorsa Mousa-Doust
- Department of Surgery, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Alan Nichol
- Department of Radiation Oncology, BC Cancer, Vancouver, British Columbia, Canada
| | - Raymond Ng
- From the Department of Computer Science, Faculty of Science, University of British Columbia, Vancouver, British Columbia, Canada
| | - Kathryn V Isaac
- Department of Surgery, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- From the Department of Computer Science, Faculty of Science, University of British Columbia, Vancouver, British Columbia, Canada
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Tallroth L, Mobargha N, Velander P, Becker M, Klasson S. Expander prosthesis and DIEP flaps in delayed breast reconstruction: Sensibility, patient-reported outcome, and complications in a five-year randomised follow-up study. J Plast Surg Hand Surg 2023; 58:101-109. [PMID: 37747180 DOI: 10.2340/jphs.v58.13477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Accepted: 08/17/2023] [Indexed: 09/26/2023]
Abstract
Breast reconstruction is a given choice for many women following mastectomy. There are a multitude of methods available today, and thus, comparative studies are essential to match patients with suitable methods. The aim of this study was to compare 5-year outcomes following delayed breast reconstruction with expander prosthesis (EP) and with deep inferior epigastric perforator (DIEP) flaps. Seventy-three patients, previously randomised to either a permanent EP or a DIEP flap breast reconstruction, were invited for a 5-year follow-up. Assessments included symmetry measurements, breast sensibility with Semmes-Weinstein monofilaments and patient-reported outcome (PRO) with the BREAST-Q. Complications within the first 5 postoperative years were recorded. Additionally, BREAST-Q questionnaires were collected from non-randomised patients with an EP breast reconstruction. Between 2019 and 2022, 65 patients completed the follow-ups. Symmetry and PRO were significantly higher in the DIEP flap group. However, EP-reconstructed breasts were significantly more sensate and demonstrated areas with protective sensibility, unlike the DIEP flap breasts. The overall complication rates were comparable between the two groups (p = 0.27). Regression analysis identified body mass index as a risk factor for reoperation in general anaesthesia and for wound infection. No significant differences were found in a comparison of the randomised and the non-randomised EP groups' BREAST-Q results. This randomised 5-year follow-up study found PRO to be favourable following a DIEP flap reconstruction and sensibility to be better in EP reconstructions. The complication rates were comparable; however, longer follow-ups are warranted to cover the complete lifespans of the two breast reconstruction methods.
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Affiliation(s)
- Linda Tallroth
- Department of Clinical Sciences in Malmö, Lund University.
| | - Nathalie Mobargha
- Department of Reconstructive Plastic Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Patrik Velander
- Department of Clinical Sciences in Malmö, Lund University, Sweden; Department of Plastic and Reconstructive Surgery, Skåne University Hospital, Malmö, Sweden
| | - Magnus Becker
- Department of Clinical Sciences in Malmö, Lund University, Sweden; Department of Plastic and Reconstructive Surgery, Skåne University Hospital, Malmö, Sweden
| | - Stina Klasson
- Department of Clinical Sciences in Malmö, Lund University, Sweden; Department of Plastic and Reconstructive Surgery, Skåne University Hospital, Malmö, Sweden
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Shauly O, Olson B, Marxen T, Menon A, Losken A, Patel KM. Direct-to-implant versus autologous tissue transfer: A meta-analysis of patient-reported outcomes after immediate breast reconstruction. J Plast Reconstr Aesthet Surg 2023; 84:93-106. [PMID: 37329749 DOI: 10.1016/j.bjps.2023.05.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 05/12/2023] [Accepted: 05/15/2023] [Indexed: 06/19/2023]
Abstract
BACKGROUND The effect of immediate implant and autologous breast reconstruction on complication rates has been studied extensively; however, the patient-reported outcomes for these procedures during immediate, one-stage reconstruction has yet to be comprehensively investigated. OBJECTIVE This study compared the patient-reported outcomes for immediate implant reconstruction with those associated with immediate autologous reconstruction to determine the advantages and disadvantages for each modality from the patient's perspective. METHODS A literature search of PubMed between 2010 and 2021 was performed, and 21 studies containing patient-reported outcomes were selected for the analysis. A meta-analysis of patient-reported outcome scores was performed separately for immediate breast reconstruction using autologous tissue transfer and synthetic implants. RESULTS Nineteen manuscripts were included, representing data on a total of 1342 patients across all studies. The pooled mean of patients' satisfaction with their breasts was 70.7 (95% CI, 69.4-72.0) after immediate autologous reconstruction and 68.5 (95% CI, 67.1-69.9) after immediate implant reconstruction, showing a statistically significant difference in outcomes (p < 0.05). The pooled mean of patients' sexual well-being was 59.3 (95% CI, 57.8-60.8) after immediate autologous reconstruction and 62.8 (95% CI, 60.7-64.8) after immediate implant reconstruction (p < 0.01). The pooled mean of patients' satisfaction with their outcome was 78.8 (95% CI, 76.2-81.3) after immediate autologous reconstruction and 82.3 (95% CI, 80.4-84.1) after immediate implant reconstruction (p < 0.05). The results of each meta-analysis were summarized on forest plots depicting the distribution of patient-reported outcome scores from each study. CONCLUSIONS Immediate reconstruction with implants may have a similar or greater capacity to achieve patient satisfaction and improve patients' QoL compared to those associated with immediate reconstruction with autologous tissue transfer when both procedures are available.
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Affiliation(s)
- Orr Shauly
- Emory University School of Medicine, Division of Plastic and Reconstructive Surgery, GA, United States
| | - Blade Olson
- University of Southern California, Keck School of Medicine, Division of Plastic and Reconstructive Surgery, CA, United States
| | - Troy Marxen
- Emory University School of Medicine, Division of Plastic and Reconstructive Surgery, GA, United States.
| | - Ambika Menon
- Emory University School of Medicine, Division of Plastic and Reconstructive Surgery, GA, United States
| | - Albert Losken
- Emory University School of Medicine, Division of Plastic and Reconstructive Surgery, GA, United States
| | - Ketan M Patel
- University of Southern California, Keck School of Medicine, Division of Plastic and Reconstructive Surgery, CA, United States
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8
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Chen Y, Qin N, Wang ML, Black GG, Vaeth A, Asadourian P, Chinta M, Bernstein JL, Otterburn DM. An Evaluation of Native Breast Dimension and Tissue Expander Inflation Rate on the Risk of Capsular Contracture Development in Postmastectomy Reconstruction. Ann Plast Surg 2023; 90:S462-S465. [PMID: 37115940 DOI: 10.1097/sap.0000000000003514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/30/2023]
Abstract
INTRODUCTION Capsular contracture is a common complication after 2-stage breast reconstruction. The relationships between native breast size, the rate of tissue expander expansion, and capsule formation have not been elucidated. This study aims to evaluate how these factors contribute to capsular contracture and establish cutoff values for increased risk. METHODS A data set consisting of 229 patients who underwent 2-stage breast reconstruction between 2012 and 2021 was included in the study. The rate of expansion is estimated as the final expanded volume subtracted by the initial filling volume of the tissue expander over time elapsed. The native breast size was estimated using various preoperative breast measurements and the weight of mastectomy specimen (grams). Further stratified analysis evaluated patients separately based on postoperative radiation status. RESULTS Greater nipple-inframammary fold distance and faster tissue expander enlargement rate conferred decreased odds of developing capsular contracture ( P < 0.05). On stratified analysis, faster tissue expansion rate was not significant in the nonradiated cohort but remained a significant negative predictor in the radiation group (odds ratio, 0.996; P < 0.05). Cut-point analysis showed an expansion rate of <240 mL/mo and a nipple-inframammary fold value of <10.5 cm as conferring a greater risk of capsular contracture. CONCLUSION Smaller inframammary fold distance may be associated with a higher risk of capsular contracture. Slower expansion rates correlate with increased odds of contracture in patients undergoing adjuvant radiation. Breast geometry should be considered when risk stratifying various reconstruction approaches (implant vs autologous). In addition, longer delays between implant exchange and initial tissue expansion should be avoided if clinically feasible.
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Affiliation(s)
- Yunchan Chen
- From the Division of Plastic & Reconstructive Surgery, Weill Cornell Medicine, New York, NY
| | - Nancy Qin
- From the Division of Plastic & Reconstructive Surgery, Weill Cornell Medicine, New York, NY
| | - Marcos Lu Wang
- From the Division of Plastic & Reconstructive Surgery, Weill Cornell Medicine, New York, NY
| | - Grant G Black
- From the Division of Plastic & Reconstructive Surgery, Weill Cornell Medicine, New York, NY
| | - Anna Vaeth
- From the Division of Plastic & Reconstructive Surgery, Weill Cornell Medicine, New York, NY
| | - Paul Asadourian
- Division of Plastic & Reconstructive Surgery, Columbia University Irving Medical Center, New York, NY
| | - Malini Chinta
- From the Division of Plastic & Reconstructive Surgery, Weill Cornell Medicine, New York, NY
| | - Jaime L Bernstein
- From the Division of Plastic & Reconstructive Surgery, Weill Cornell Medicine, New York, NY
| | - David M Otterburn
- From the Division of Plastic & Reconstructive Surgery, Weill Cornell Medicine, New York, NY
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Atiyeh B, Emsieh S. Letter-to-the-Editor: Two-Stage Expander-Based (EB) or Single-Stage Direct-to-Implant (DTI) Breast Reconstruction-An Ongoing Debate. Aesthetic Plast Surg 2023; 47:154-158. [PMID: 36171405 DOI: 10.1007/s00266-022-03113-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 09/08/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Bishara Atiyeh
- American University of Beirut Medical Center, Beirut, Lebanon.
| | - Saif Emsieh
- American University of Beirut Medical Center, Beirut, Lebanon
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10
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Tramm T, Kaidar-Person O. Optimising post-operative radiation therapy after oncoplastic and reconstructive procedures. Breast 2023; 69:366-374. [PMID: 37023565 PMCID: PMC10119683 DOI: 10.1016/j.breast.2023.03.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 02/16/2023] [Accepted: 03/25/2023] [Indexed: 03/30/2023] Open
Abstract
Surgical techniques for breast cancer have been refined over the past decades to deliver an aesthetic outcome as close as possible to the contralateral intact breast. Current surgery further allows excellent aesthetic outcome even in case of mastectomy, by performing skin sparing or nipple sparing mastectomy in combination with breast reconstruction. In this review we discuss how to optimise post-operative radiation therapy after oncoplastic and breast reconstructive procedures, including dose, fractionation, volumes, surgical margins, and boost application.
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11
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Breast Reconstruction Trends in the Setting of Postmastectomy Radiation Therapy: Analysis of Practices among Plastic Surgeons in the United States. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e4800. [PMID: 36817273 PMCID: PMC9937102 DOI: 10.1097/gox.0000000000004800] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 12/07/2022] [Indexed: 02/19/2023]
Abstract
Radiation is an integral part of breast cancer therapy. The ideal type and timing of breast reconstruction with relation to radiation delivery are not well established. The study aimed to identify reconstructive practices among American plastic surgeons in the setting of pre- and postmastectomy radiation. Methods A cross-sectional survey of members of the American Society of Plastic Surgery was performed. Practice/demographic information and breast reconstruction protocols were queried. Univariate descriptive statistics were calculated, and outcomes were compared across cohorts with χ2 and Fischer exact tests. Results Overall, 477 plastic surgeons averaging 16.3 years in practice were surveyed. With respect to types of reconstruction, all options were well represented, although nearly 60% preferred autologous reconstruction with prior radiation and 55% preferred tissue expansion followed by implant/autologous reconstruction in the setting of unknown postoperative radiation. There was little consensus on the optimal timing of reconstruction in the setting of possible postoperative radiation. Most respondents wait 4-6 or 7-12 months between the end of radiation and stage 2 implant-based or autologous reconstruction. Common concerns regarding the effect of radiation on reconstructive outcomes included mastectomy flap necrosis, wound dehiscence, capsular contracture, tissue fibrosis, and donor vessel complications. Conclusions Despite considerable research, there is little consensus on the ideal type and timing of reconstruction in the setting of pre- and postoperative radiation. Understanding how the current body of knowledge is translated into clinical practice by different populations of surgeons allows us to forge a path forward toward more robust, evidence-based guidelines for patient care.
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12
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Jayatilaka A, Lokhandwala A, Manouchehri K, Brackstone M, Lock M. Are Radiation Target Volumes for Postmastectomy Radiation Therapy Too Large? Initial Report of the Complication Avoidance of Reconstruction Implant Radiation Therapy (CARIT) Study. Curr Oncol 2023; 30:2271-2276. [PMID: 36826136 PMCID: PMC9954939 DOI: 10.3390/curroncol30020175] [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: 01/29/2023] [Revised: 02/10/2023] [Accepted: 02/11/2023] [Indexed: 02/16/2023] Open
Abstract
Following mastectomy for breast cancer, women may choose implant-based reconstruction for many reasons, such as cosmesis, self-identity, and the ability to wear particular items of clothing. However, postmastectomy radiation therapy (PMRT) can compromise these cosmetic goals, including as much as a 40% loss of implant rate. To minimize the risk of radiation toxicity, it is important to consider how clinical target volumes (CTVs) can be optimized in PMRT to preserve the implant and reduce complications. Typically, guidelines from organizations such as the Radiation Oncology Group are used, which include regions previously encompassed by tangential fields. This includes all structures below the pectoralis muscle, such as the chest wall, where the risk of recurrence is negligible; this technique often requires incidental inclusion of portions of the lung and heart plus circumferential radiation of the implant. We present the preliminary single institution case series of a technique of complication avoidance of reconstruction implant radiation therapy, called CARIT, where the chest wall, and a large proportion of the implant, is not irradiated. In a retrospective review of 30 cases in which CARIT has been attempted, it was found that 24% of patients treated required a second surgery due to Baker grade III/IV capsular contracture. Using the Modified Harvard Harris Cosmetic Scale, 66.5% of patients had cosmetic outcomes rated as "good" or "excellent". CARIT could offer a technique to reduce complications in postmastectomy implant-based reconstruction patients, with our next steps focusing on improving dosimetry, and formally comparing the cosmesis and tumor control aspects with commonly used techniques.
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Affiliation(s)
- Aruni Jayatilaka
- Schulich School of Medicine and Dentistry, Western University, London, ON N6A 3K7, Canada
| | - Ashira Lokhandwala
- Schulich School of Medicine and Dentistry, Western University, London, ON N6A 3K7, Canada
| | - Kimya Manouchehri
- Schulich School of Medicine and Dentistry, Western University, London, ON N6A 3K7, Canada
| | - Muriel Brackstone
- Department of Oncology, London Regional Cancer Program, London, ON N6A 5W9, Canada
- Division of General Surgery, London Health Sciences Centre, London, ON N6A 5W9, Canada
| | - Michael Lock
- Department of Oncology, London Regional Cancer Program, London, ON N6A 5W9, Canada
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Stefura T, Rusinek J, Wątor J, Zagórski A, Zając M, Libondi G, Wysocki WM, Koziej M. Implant vs. autologous tissue-based breast reconstruction: A systematic review and meta-analysis of the studies comparing surgical approaches in 55,455 patients. J Plast Reconstr Aesthet Surg 2023; 77:346-358. [PMID: 36621238 DOI: 10.1016/j.bjps.2022.11.044] [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: 04/13/2022] [Revised: 10/13/2022] [Accepted: 11/17/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND The choice of reconstruction type is of utmost importance in treating breast cancer. There are two major reconstructive pathways in this group of patients: autologous breast reconstruction (ABR) and implant-based breast reconstruction (IBR). The aim of this systematic review and meta-analysis was to assess and compare IBR vs. ABR. METHODS A review of studies reporting the differences between the procedures was performed. The MEDLINE/PubMed, ScienceDirect, EMBASE, BIOSIS, SciELO, Scopus, and Web of Science databases were thoroughly searched in September 2021. The data concerning group characteristics, BREAST-Q scores, complication rates, length of stay (LOS), and costs were extracted. The Cochrane risk-of-bias tool was used for randomized studies, while Newcastle-Ottawa Quality Assessment for Cohort Studies was used for other types of research. RESULTS Our meta-analysis included 32 studies (n = 55,455). We observed significantly better outcomes following ABR when it comes to esthetic satisfaction (mean difference [MD] -8.51; 95% confidence interval [CI] -10.70, -6.33; p<0.001) and satisfaction with the entire reconstructive treatment (MD -6.56; 95% CI -9.97, -3.14; p<0.001). Both methods appeared to be comparable in terms of safety, while the complication rates varied insignificantly between the groups (odds ratio [OR] 1.06; 95% CI 0.71, 1.59; p = 0.76). ABR seems to be correlated with significantly higher costs (standard mean difference [SMD] -0.69; 95% CI -1.21, -0.17; p = 0.010). CONCLUSIONS The results obtained from this evidence-based study will improve the understanding of the different clinical pathways that patients can be assigned to. The study emphasized the advantages and disadvantages of both methods.
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Affiliation(s)
| | - Jakub Rusinek
- Jagiellonian University Medical College, Cracow, Poland
| | - Julia Wątor
- Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland
| | | | - Maciej Zając
- Jagiellonian University Medical College, Cracow, Poland
| | - Guido Libondi
- Department of General, Oncological and Vascular Surgery, 5th Military Clinical Hospital in Cracow, Poland
| | - Wojciech M Wysocki
- Department of General, Oncological and Vascular Surgery, 5th Military Clinical Hospital in Cracow, Poland; Chair of Surgery, Faculty of Medicine and Health Sciences, Andrzej Frycz Modrzewski Cracow University, Cracow, Poland
| | - Mateusz Koziej
- Department of Anatomy, Jagiellonian University Medical College, Cracow, Poland.
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14
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Emanuele Lisa AV, Salgarello M, Huscher A, Corsi F, Piovani D, Rubbino F, Andreoletti S, Papa G, Klinger F, Tinterri C, Testori A, Scorsetti M, Veronesi P, Leonardi MC, Rietjens M, Cortinovis U, Summo V, Rampino Cordaro E, Parodi PC, Persichetti P, Barone M, De Santis G, Murolo M, Riccio M, Aquinati A, Cavaliere F, Vaia N, Pagura G, Dalla Venezia E, Bassetto F, Vindigni V, Ciuffreda L, Bocchiotti MA, Sciarillo A, Renzi N, Meneghini G, Kraljic T, Loreti A, Fortunato L, Pino V, Vinci V, Klinger M. The Effect of Adjuvant Radiotherapy on One- and Two-Stage Prosthetic Breast Reconstruction and on Autologous Reconstruction: A Multicenter Italian Study among 18 Senonetwork Breast Centres. Breast J 2023; 2023:6688466. [PMID: 37205012 PMCID: PMC10188256 DOI: 10.1155/2023/6688466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Revised: 04/07/2023] [Accepted: 04/15/2023] [Indexed: 05/21/2023]
Abstract
Purpose In modern breast cancer treatment, a growing role has been observed for breast reconstruction together with an increase in clinical indications for postmastectomy radiotherapy (PMRT). Choosing the optimum type of reconstructive technique is a clinical challenge. We therefore conducted a national multicenter study to analyze the impact of PMRT on breast reconstruction. Methods We conducted a retrospective case-control multicenter study on women undergoing breast reconstruction. Data were collected from 18 Italian Breast Centres and stored in a cumulative database which included the following: autologous reconstruction, direct-to-implant (DTI), and tissue expander/immediate (TE/I). For all patients, we described complications and surgical endpoints to complications such as reconstruction failure, explant, change in type of reconstruction, and reintervention. Results From 2001 to April 2020, 3116 patients were evaluated. The risk for any complication was significantly increased in patients receiving PMRT (aOR, 1.73; 95% CI, 1.33-2.24; p < 0.001). PMRT was associated with a significant increase in the risk of capsular contracture in the DTI and TE/I groups (aOR, 2.24; 95% CI, 1.57-3.20; p < 0.001). Comparing type of procedures, the risk of failure (aOR, 1.82; 95% CI, 1.06-3.12, p=0.030), explant (aOR, 3.34; 95% CI, 3.85-7.83, p < 0.001), and severe complications (aOR, 2.54; 95% CI, 1.88-3.43, p < 0.001) were significantly higher in the group undergoing DTI reconstruction as compared to TE/I reconstruction. Conclusion Our study confirms that autologous reconstruction is the procedure least impacted by PMRT, while DTI appears to be the most impacted by PMRT, when compared with TE/I which shows a lower rate of explant and reconstruction failure. The trial is registered with NCT04783818, and the date of registration is 1 March, 2021, retrospectively registered.
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Affiliation(s)
- Andrea Vittorio Emanuele Lisa
- Reconstructive and Aesthetic Plastic Surgery School, Department of Medical Biotechnology and Translational Medicine BIOMETRA-Plastic Surgery Unit, University of Milan, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Marzia Salgarello
- Department of Plastic Surgery, Director of the Residency Program of Plastic Surgery, IRCCS Policlinico Gemelli, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Alessandra Huscher
- Department of Radiotherapy, Fondazione Poliambulanza “Guido Berlucchi” Hospital, Brescia, Italy
| | - Fabio Corsi
- Breast Unit, Department of Surgery, IRCCS Istituti Clinici Maugeri, Pavia, Italy
- Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy
| | - Daniele Piovani
- Department of Biomedical Sciences, IRCCS Humanitas University, Pieve Emanuele, Milan, Italy
- IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Federica Rubbino
- Laboratory of Molecular Gastroenterology, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Stefania Andreoletti
- Reconstructive and Aesthetic Plastic Surgery School, Department of Medical Biotechnology and Translational Medicine BIOMETRA-Plastic Surgery Unit, University of Milan, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Giovanni Papa
- Department of Plastic Surgery, UCO, University of Trieste, Trieste, Italy
| | | | - Corrado Tinterri
- Breast Unit, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Alberto Testori
- Breast Unit, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Marta Scorsetti
- Radiotherapy and Radiosurgery Department, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Paolo Veronesi
- Division of Senology, Department of Oncology and Oncohematology, IEO, IRCCS European Institute of Oncology, University of Milan, Milan, Italy
| | | | - Mario Rietjens
- Division of Plastic and Reconstructive Surgery, IEO, IRCCS European Institute of Oncology, Milan, Italy
| | - Umberto Cortinovis
- Department of Plastic Reconstructive Surgery, IRCCS National Cancer Institute, Milan, Italy
| | - Valeria Summo
- Department of Plastic Surgery, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC), Santa Maria della Misericordia Hospital, Udine, Italy
| | - Emanuele Rampino Cordaro
- Department of Plastic Surgery, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC), Santa Maria della Misericordia Hospital, Udine, Italy
| | | | | | - Mauro Barone
- Department of Plastic Surgery, Policlinico di Modena, University of Modena and Reggio, Modena, Italy
| | - Giorgio De Santis
- Department of Plastic Surgery, Policlinico di Modena, University of Modena and Reggio, Modena, Italy
| | - Matteo Murolo
- Department of Reconstructive Surgery and Hand Surgery, Azienda Ospedaliero Universitaria-Ospedali Riuniti, Ancona, Italy
| | - Michele Riccio
- Department of Reconstructive Surgery and Hand Surgery, Azienda Ospedaliero Universitaria-Ospedali Riuniti, Ancona, Italy
| | - Angelica Aquinati
- Department of Breast Surgery and Integrated Senology Centre, Belcolle Hospital, Viterbo, Italy
| | - Francesco Cavaliere
- Department of Breast Surgery and Integrated Senology Centre, Belcolle Hospital, Viterbo, Italy
| | - Nicola Vaia
- Department of Breast Surgery, AULSS 3 Veneziana, Venice, Italy
| | - Giulia Pagura
- Department of Breast Surgery, AULSS 3 Veneziana, Venice, Italy
| | - Erica Dalla Venezia
- Unit of Plastic Surgery, Department of Neurosciences, University of Padova, Padova, Italy
| | - Franco Bassetto
- Unit of Plastic Surgery, Department of Neurosciences, University of Padova, Padova, Italy
| | - Vincenzo Vindigni
- Department of Breast Surgery and Breast Unit, Casa Sollievo della Sofferenza Hospital, San Giovanni Rotondo, Foggia, Italy
| | - Luigi Ciuffreda
- Department of Breast Surgery and Breast Unit, Casa Sollievo della Sofferenza Hospital, San Giovanni Rotondo, Foggia, Italy
| | | | - Alberto Sciarillo
- Department of Plastic Surgery, ASUGI Cattinara Hospital, Trieste, Italy
| | - Nadia Renzi
- Department of Plastic Surgery, ASUGI Cattinara Hospital, Trieste, Italy
| | - Graziano Meneghini
- Functional Department Transmural Breast Surgery, AULSS 8 Berica, Vicenza, Italy
| | - Tajna Kraljic
- Department of Breast Surgery, AULSS 8 Berica, Vicenza, Italy
| | - Andrea Loreti
- Department of Plastic Surgery, San Giovanni Addolorata Hospital, Rome, Italy
| | - Lucio Fortunato
- Department of Breast Surgery and Breast Unit, San Giovanni Addolorata Hospital, Rome, Italy
| | - Valentina Pino
- Istituto di Clinica Chirurgica, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Valeriano Vinci
- Department of Biomedical Sciences, IRCCS Humanitas University, Pieve Emanuele, Milan, Italy
- IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Marco Klinger
- Reconstructive and Aesthetic Plastic Surgery School, Department of Medical Biotechnology and Translational Medicine BIOMETRA-Plastic Surgery Unit, University of Milan, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
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15
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Kim JM, Song WJ, Kang SG. Comparison of Patients Satisfaction with Direct to Implant versus Latissimus Dorsi Flap with Implant Breast Reconstruction Using Breast-Q. Arch Plast Surg 2022; 49:710-715. [PMCID: PMC9747284 DOI: 10.1055/s-0042-1744420] [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: 06/28/2021] [Accepted: 11/07/2022] [Indexed: 12/15/2022] Open
Abstract
Background
The latissimus musculocutaneous flap (LD flap) is a useful option for breast reconstruction following mastectomy. It has the advantage of obtaining sufficient tissue padding and natural shape by using autologous tissue. However, with the emergence of the skin-sparing mastectomy technique and artificial dermis matrix, direct-to-implant (DTI) breast reconstruction has become the first choice of surgery. The purpose of this study was to compare the satisfaction levels of patients who underwent DTI and LD flap with implant using patient-reported Breast-Q results.
Methods
A retrospective study was performed reviewing the records of 49 women who underwent immediate breast reconstruction with DTI or LD flap with implant and responded to the BREAST-Q questionnaire after the operation. The patient-reported breast-Q results were analyzed and correlated to the demographic information and intraoperative information.
Results
A total of 26 patients who underwent reconstruction with LD flap with implant and 23 patients with DTI were identified and responded to the questionnaire after an average of 32.3 and 10.4 months postoperation, respectively. According to the patient response to the breast-q values, satisfaction with breast was 60.0 and 57.0 points, psychosocial well-being 61.0 and 60.0 points, and sexual well-being 41.0 and 43.0 points in the two groups. Overall, there was no significant difference in the breast-Q score between the two groups.
Conclusion
Patients who underwent DTI breast reconstruction seemed equally satisfied with the appearance and outcome of their breast reconstruction compared with LD flap with implant. Therefore, it appears that DTI is adequately replacing LD with implant.
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Affiliation(s)
- Ji Min Kim
- Department of Plastic and Reconstructive Surgery, Soonchunhyang University Hospital, Seoul, Korea
| | - Woo Jin Song
- Department of Plastic and Reconstructive Surgery, Soonchunhyang University Hospital, Seoul, Korea
| | - Sang Gue Kang
- Department of Plastic and Reconstructive Surgery, Soonchunhyang University Hospital, Seoul, Korea,Address for correspondence Sang Gue Kang, MD, PhD Department of Plastic and Reconstructive Surgery, Soonchunhyang University Hospital59, Daesagwan-ro, Yongsan-gu, Seoul 04401Korea
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16
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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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Sub-Muscular Direct-to-Implant Immediate Breast Reconstruction in Previously Irradiated Patients Avoiding the Use of ADM: A Preliminary Study. J Clin Med 2022; 11:jcm11195856. [PMID: 36233723 PMCID: PMC9573151 DOI: 10.3390/jcm11195856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Revised: 09/27/2022] [Accepted: 09/28/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND The aim of this paper is to present a preliminary experience of sub-muscular primary direct-to-implant (DTI) breast reconstruction without acellular dermal matrix (ADM), after salvage mastectomy for local recurrence following prior irradiation. METHODS A retrospective investigation was performed on a prospectively maintained database of breast reconstruction cases at our institution between January 2015 and December 2020. We considered only immediate DTI breast reconstructions without ADM following radiotherapy and salvage mastectomy for local recurrence, with at least a 12-month follow-up. RESULTS The study considered 18 female patients with an average of 68 years. According to the BREAST-Q questionnaire, all patients reported high levels of "satisfaction with outcome" with good "psychosocial wellness" and "physical impact" related to the reconstruction. The aesthetic evaluation showed a significant difference between the VAS score gave by the patient (mean 6.9) and the surgeon (mean 5.4). No implant exposure occurred in this series. In terms of complications, four patients (22%) suffered from wound dehiscence and were managed conservatively. Three patients (17%) required primary closure in day surgery following superficial mastectomy flap necrosis. Late capsular contracture was seen in seven patients (four Baker stage II and three Baker stage III, totally 39%); however, no patient was willing to undergo implant exchange. CONCLUSIONS DTI breast reconstruction following prior irradiation can be considered as an option in patients who are not good candidates for autologous breast reconstruction. Our general outcomes compared favorably with literature data regarding the use of staged procedures, with acceptable complication rates and levels of patient satisfaction.
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Oda G, Nakagawa T, Mori H, Onishi I, Fujioka T, Mori M, Kubota K, Hanazawa R, Hirakawa A, Ishikawa T, Okamoto K, Uetakesszsz H. Factors predicting upstaging from clinical N0 to pN2a/N3a in breast cancer patients. World J Clin Oncol 2022; 13:748-757. [PMID: 36212601 PMCID: PMC9537504 DOI: 10.5306/wjco.v13.i9.748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 07/25/2022] [Accepted: 09/06/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND With sentinel node metastasis in breast cancer (BC) patients, axillary lymph node (ALN) dissection is often omitted from cases with breast-conserving surgery. Omission of lymph node dissection reduces the invasiveness of surgery to the patient, but it also obscures the number of metastases to non-sentinel nodes. The possibility of finding ≥ 4 lymph nodes (pN2a/pN3a) preoperatively is important given the ramifications for postoperative treatment.
AIM To search for clinicopathological factors that predicts upstaging from N0 to pN2a/pN3a.
METHODS Patients who were sentinel lymph node (SLN)-positive and underwent ALN dissection between September 2007 and August 2018 were selected by retrospective chart review. All patients had BC diagnosed preoperatively as N0 with axillary evaluation by fluorodeoxyglucose (FDG) positron emission tomography/computed tomography and ultrasound (US) examination. When suspicious FDG accumulation was found in ALN, the presence of metastasis was reevaluated by second US. We examined predictors of upstaging from N0 to pN2a/pN3a.
RESULTS Among 135 patients, we identified 1-3 ALNs (pN1) in 113 patients and ³4 ALNs (pN2a/pN3a) in 22 patients. Multivariate analysis identified the total number of SLN metastasis, the maximal diameter of metastasis in the SLN (SLNDmax), and FDG accumulation of ALN as predictors of upstaging to pN2a/pN3a.
CONCLUSION We identified factors involved in upstaging from N0 to pN2a/pN3a. The SLNDmax and number of SLN metastasis are predictors of ≥ 4 ALNs (pN2a/pN3a) and predictors of metastasis to non-sentinel nodes, which have been reported in the past. Attention should be given to axillary accumulations of FDG, even when faint.
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Affiliation(s)
- Goshi Oda
- Department of Breast Surgery, Tokyo Medical and Dental University, Tokyo 1138519, Japan
| | - Tsuyoshi Nakagawa
- Department of Breast Surgery, Tokyo Medical and Dental University, Tokyo 1138519, Japan
| | - Hiroki Mori
- Department of Plastic and Reconstructive Surgery, Tokyo Medical and Dental University, Tokyo 1138519, Japan
| | - Iichiro Onishi
- Department of Pathology, Tokyo Medical and Dental University, Tokyo 1138519, Japan
| | - Tomoyuki Fujioka
- Department of Radiology, Tokyo Medical and Dental University, Tokyo 1138519, Japan
| | - Mio Mori
- Department of Radiology, Tokyo Medical and Dental University, Tokyo 1138519, Japan
| | - Kazunori Kubota
- Department of Radiology, Tokyo Medical and Dental University, Tokyo 1138519, Japan
| | - Ryoichi Hanazawa
- Department of Clinical Biostatistics, Tokyo Medical and Dental University, Tokyo 1138519, Japan
| | - Akihiro Hirakawa
- Department of Clinical Biostatistics, Tokyo Medical and Dental University, Tokyo 1138519, Japan
| | - Toshiaki Ishikawa
- Department of Specialized Surgeries, Tokyo Medical and Dental University, Tokyo 1138519, Japan
| | - Kentaro Okamoto
- Department of Specialized Surgeries, Tokyo Medical and Dental University, Tokyo 1138519, Japan
| | - Hiroyuki Uetakesszsz
- Department of Specialized Surgeries, Tokyo Medical and Dental University, Tokyo 1138519, Japan
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Marxen T, Shauly O, Losken A. The Safety of Same-day Discharge after Immediate Alloplastic Breast Reconstruction: A Systematic Review. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2022; 10:e4448. [PMID: 35924002 PMCID: PMC9298472 DOI: 10.1097/gox.0000000000004448] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Accepted: 06/02/2022] [Indexed: 11/25/2022]
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20
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Wolter A, Fertsch S, Lisboa BW, Andree C. [Breast Reconstruction Strategies in Case of Planned Radiotherapy]. HANDCHIR MIKROCHIR P 2022; 54:279-296. [PMID: 35728602 DOI: 10.1055/a-1826-2992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION The ideal technical and chronological approach of breast reconstruction in case of planned radiotherapy after mastectomy (post-mastectomy radiotherapy, PMRT) continues to be controversially discussed. METHODS The authors analysed the MEDLINE Database PubMed for relevant studies concerning PMRT and breast reconstruction. The main theses from these publications were extracted and summarised. RESULTS An implant-based approach is the least invasive technique for immediate breast-mound formation in a PMRT setting. Reconstruction in a PMRT setting with a two-stage expander-implant technique or expander-implant-autologous procedure can provide good to excellent cosmetic outcomes. In contrast to the implant-based approach, autologous reconstruction methods provide an improved quality of life as well as haptic and sensory advantages and are usually associated with lower complication rates. PMRT after autologous reconstruction can have a negative impact on the autologous tissue. A delayed autologous approach can be advantageous and should be generally favoured in high-risk patients. CONCLUSION Factors influencing a meticulous planning of breast reconstruction including PMRT are surgical, aesthetic and patient characteristics, quality of life, preference and expectation. Ideally, PMRT is completed before autologous reconstruction to avoid radiation-associated side-effects on the final reconstructive result. If PMRT is likely, but potentially not necessary, an immediate-delayed procedure may be of advantage.
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Affiliation(s)
- Andreas Wolter
- Plastische und Ästhetische Chirurgie, Sana Krankenhaus Gerresheim, Düsseldorf, Germany.,Fakultät für Gesundheit, Universität Witten/Herdecke, Witten, Germany
| | - Sonia Fertsch
- Plastische und Ästhetische Chirurgie, Sana Krankenhaus Gerresheim, Düsseldorf, Germany.,Fakultät für Gesundheit, Universität Witten/Herdecke, Witten, Germany
| | | | - Christoph Andree
- Plastische und Ästhetische Chirurgie, Sana Krankenhaus Gerresheim, Düsseldorf, Germany
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21
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Abstract
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Recent decades have
seen substantial interest in the development
and application of biocompatible shape memory polymers (SMPs), a class
of “smart materials” that can respond to external stimuli.
Although many studies have used SMP platforms triggered by thermal
or photothermal events to study cell mechanobiology, SMPs triggered
by cell activity have not yet been demonstrated. In a previous work,
we developed an SMP that can respond directly to enzymatic activity.
Here, our goal was to build on that work by demonstrating enzymatic
triggering of an SMP in response to the presence of enzyme-secreting
human cells. To achieve this phenomenon, poly(ε-caprolactone)
(PCL) and Pellethane were dual electrospun to form a fiber mat, where
PCL acted as a shape-fixing component that is labile to lipase, an
enzyme secreted by multiple cell types including HepG2 (human hepatic
cancer) cells, and Pellethane acted as a shape memory component that
is enzymatically stable. Cell-responsive shape memory performance
and cytocompatibility were quantitatively and qualitatively analyzed
by thermal analysis (thermal gravimetric analysis and differential
scanning calorimetry), surface morphology analysis (scanning electron
microscopy), and by incubation with HepG2 cells in the presence or
absence of heparin (an anticoagulant drug present in the human liver
that increases the secretion of hepatic lipase). The results characterize
the shape-memory functionality of the material and demonstrate successful
cell-responsive shape recovery with greater than 90% cell viability.
Collectively, the results provide the first demonstration of a cytocompatible
SMP responding to a trigger that is cellular in origin.
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Affiliation(s)
- Junjiang Chen
- BioInspired Syracuse: Institute for Material and Living Systems, Syracuse University, Syracuse, New York 13244, United States.,Department of Biomedical and Chemical Engineering, Syracuse University, Syracuse, New York 13244, United States
| | - Lauren E Hamilton
- BioInspired Syracuse: Institute for Material and Living Systems, Syracuse University, Syracuse, New York 13244, United States.,Department of Biomedical and Chemical Engineering, Syracuse University, Syracuse, New York 13244, United States
| | - Patrick T Mather
- Department of Chemical Engineering, Penn State University, University Park, Pennsylvania 16802, United States
| | - James H Henderson
- BioInspired Syracuse: Institute for Material and Living Systems, Syracuse University, Syracuse, New York 13244, United States.,Department of Biomedical and Chemical Engineering, Syracuse University, Syracuse, New York 13244, United States
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22
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Du F, Liu R, Zhang H, Xiao Y, Long X. Post-mastectomy adjuvant radiotherapy for direct-to-implant and two-stage implant-based breast reconstruction: A meta-analysis. J Plast Reconstr Aesthet Surg 2022; 75:3030-3040. [DOI: 10.1016/j.bjps.2022.06.063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Revised: 05/14/2022] [Accepted: 06/10/2022] [Indexed: 10/17/2022]
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23
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Kooijman MML, Hage JJ, Scholten AN, Vrancken Peeters MJTFD, Woerdeman LAE. Short-Term Surgical Complications of Skin-Sparing Mastectomy and Direct-to-Implant Immediate Breast Reconstruction in Women Concurrently Treated with Adjuvant Radiotherapy for Breast Cancer. Arch Plast Surg 2022; 49:332-338. [PMID: 35832162 PMCID: PMC9142242 DOI: 10.1055/s-0042-1748648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background
Postmastectomy radiotherapy (PMRT) is allegedly associated with a higher risk of complications of combined nipple-sparing or skin-sparing mastectomy and subpectoral direct-to-implant immediate breast reconstruction ([N]SSM/SDTI-IBR). For this reason, this combination is usually advised against or, even, refused in women who need to undergo PMRT. Because this advice has never been justified, we assessed the short-term complications that may potentially be associated with PMRT after [N]SSM/SDTI-IBR.
Methods
We compared the complications requiring reintervention and implant loss occurring after 273 [N]SSM/SDTI-IBR that were exposed to PMRT within the first 16 postoperative weeks (interventional group) to those occurring in 739 similarly operated breasts that were not (control group). Additionally, we compared the fraction of complications requiring reintervention occurring after the onset of radiotherapy in the interventional group to that occurring after a comparable postoperative period in the control group.
Results
The fraction of breasts requiring unscheduled surgical reinterventions for complications and the loss of implants did not differ significantly between both groups but significantly more reinterventions were needed among the controls (
p
= 0.00). The fraction of events after the onset of radiotherapy in the interventional group was higher than the fraction of events after 6.2 weeks in the control group, but not significantly so.
Conclusion
We found no prove for the alleged increase of short-term complications of adjuvant radiotherapy. Therefore, we advise that these should not be considered valid arguments to advice against [N]SSM/SDTI-IBR.
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Affiliation(s)
- Merel M. L. Kooijman
- Department of Plastic and Reconstructive Surgery, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - J. Joris Hage
- Department of Plastic and Reconstructive Surgery, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Astrid N. Scholten
- Department of Radiotherapy, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Marie-Jeanne T. F. D. Vrancken Peeters
- Department of Surgical Oncology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
- Department of Surgery, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Leonie A. E. Woerdeman
- Department of Plastic and Reconstructive Surgery, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
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24
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Broyles JM, Balk EM, Adam GP, Cao W, Bhuma MR, Mehta S, Dominici LS, Pusic AL, Saldanha IJ. Implant-based versus Autologous Reconstruction after Mastectomy for Breast Cancer: A Systematic Review and Meta-analysis. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2022; 10:e4180. [PMID: 35291333 PMCID: PMC8916208 DOI: 10.1097/gox.0000000000004180] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 01/13/2022] [Indexed: 01/29/2023]
Abstract
For women undergoing breast reconstruction after mastectomy, the comparative benefits and harms of implant-based reconstruction (IBR) and autologous reconstruction (AR) are not well known. We performed a systematic review with meta-analysis of IBR versus AR after mastectomy for breast cancer. Methods We searched Medline, Embase, Cochrane CENTRAL, CINAHL, and ClinicalTrials.gov for studies from inception to March 23, 2021. We assessed the risk of bias of individual studies and strength of evidence (SoE) of our findings using standard methods. Results We screened 15,936 citations and included 40 studies (two randomized controlled trials and 38 adjusted nonrandomized comparative studies). Compared with patients who undergo IBR, those who undergo AR experience clinically significant better sexual well-being [summary adjusted mean difference (adjMD) 5.8, 95% CI 3.4-8.2; three studies] and satisfaction with breasts (summary adjMD 8.1, 95% CI 6.1-10.1; three studies) (moderate SoE for both outcomes). AR was associated with a greater risk of venous thromboembolism (moderate SoE), but IBR was associated with a greater risk of reconstructive failure (moderate SoE) and seroma (low SoE) in long-term follow-up (1.5-4 years). Other outcomes were comparable between groups, or the evidence was insufficient to merit conclusions. Conclusions Most evidence regarding IBR versus AR is of low or moderate SoE. AR is probably associated with better sexual well-being and satisfaction with breasts and lower risks of seroma and long-term reconstructive failure but a higher risk of thromboembolic events. New high-quality research is needed to address the important research gaps.
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Affiliation(s)
- Justin M. Broyles
- From the Department of Surgery, Division of Plastic and Reconstructive Surgery, Harvard Medical School, Boston, Mass
| | - Ethan M. Balk
- Center for Evidence Synthesis in Health, Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, R.I
| | - Gaelen P. Adam
- Center for Evidence Synthesis in Health, Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, R.I
| | - Wangnan Cao
- Center for Evidence Synthesis in Health, Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, R.I
| | - Monika Reddy Bhuma
- Center for Evidence Synthesis in Health, Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, R.I
| | - Shivani Mehta
- Center for Evidence Synthesis in Health, Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, R.I
| | - Laura S. Dominici
- Department of Surgery, Division of Breast Surgery, Harvard Medical School, Boston, Mass
| | - Andrea L. Pusic
- From the Department of Surgery, Division of Plastic and Reconstructive Surgery, Harvard Medical School, Boston, Mass
| | - Ian J. Saldanha
- Center for Evidence Synthesis in Health, Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, R.I
- Department of Epidemiology, Brown University School of Public Health, Providence, R.I
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25
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Ticha P, Mestak O, Wu M, Sukop A. Early postoperative complications of breast reconstruction by history of radiotherapy and reconstruction approach. EUROPEAN JOURNAL OF PLASTIC SURGERY 2022. [DOI: 10.1007/s00238-021-01918-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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26
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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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27
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Theunissen CIJM, Brohet RM, Hu Y, van Uchelen JH, Mensen JHC, van Rijssen AL. ≠Risk of breast implant removal after one- versus two-stage breast reconstructive surgery. J Plast Reconstr Aesthet Surg 2021; 75:1610-1616. [PMID: 34975002 DOI: 10.1016/j.bjps.2021.11.112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 10/11/2021] [Accepted: 11/21/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND To date, both one- and two-stage techniques are used in immediate 'implant-based breast reconstruction' (IBBR) after mastectomy. Because it is still unknown what technique offers the best clinical outcomes, a multicenter retrospective study was conducted to compare both breast reconstruction techniques. METHODS All patients, who underwent a mastectomy followed by immediate one- or two-stage IBBR during 2010 - 2016 were included. Our primary outcome measure was explantation of the 'tissue expander' (TE) and/ or implants within 60 days after breast reconstruction. Secondary outcomes were overall complication rate and secondary corrections. FINDINGS Among a total of 383 women, TE/ implant explantation rate was higher in one-stage (19.9%) than in two-stage (11.3%) treated patients (p = 0.082). Overall complication rate (35.7% and 19.9% respectively, p = 0.008) and secondary corrections (29.8% and 20.3% respectively, p = 0.156) were also higher in one-stage compared to two-stage IBBR respectively. However, explantation (OR = 1.55; 95%CI = 0.67-3.58, p = 0.301) and complication (OR = 1.85; 95%CI = 0.92-3.37, p = 0.084) rates were comparable in one- and two-stage IBBR in our stratified multivariate logistic regression analyses, when controlling for history of smoking, nipple-sparing mastectomy, neoadjuvant radiation therapy, and removed breast tissue weight. A remarkable outcome in this study is that women treated with prophylactic surgery were more likely to have an explantation of the TE/ implant after a one-stage IBBR (OR = 4.49; 95%CI = 1.10-18.3, p = 0.037) than two-stage IBBR. In contrast, no association between type of IBBR and risk of TE/implants removal was found among women with a therapeutic mastectomy (OR = 0.82; 95%CI = 0.24-2.79, p = = 0.74). CONCLUSION One- and two-stage IBBR showed a comparable explantation and complication rate in our retrospective study. In one-stage IBBR more secondary corrections were detected. In addition, women who have to decide on a prophylactic mastectomy should be aware of a significantly higher risk of explantation of their implant after one-stage IBBR.
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Affiliation(s)
- C I J M Theunissen
- Department of Plastic and Reconstructive Surgery, Zwolle, Isala, the Netherlands; Department of Plastic and Reconstructive Surgery, Breda, Amphia, the Netherlands.
| | - R M Brohet
- Department of Epidemiology and Statistics, Zwolle, Isala, the Netherlands
| | - Y Hu
- Department of Plastic and Reconstructive Surgery, Zwolle, Isala, the Netherlands
| | - J H van Uchelen
- Department of Plastic and Reconstructive Surgery, Velp, Xpert Clinics, the Netherlands
| | - J H C Mensen
- Department of Plastic and Reconstructive Surgery, Zwolle, Isala, the Netherlands
| | - A L van Rijssen
- Department of Plastic and Reconstructive Surgery, Zwolle, Isala, the Netherlands
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28
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The Impact of Adjuvant Radiotherapy on Immediate Implant-based Breast Reconstruction Surgical and Satisfaction Outcomes: A Systematic Review and Meta-analysis. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3910. [PMID: 34765389 PMCID: PMC8575424 DOI: 10.1097/gox.0000000000003910] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 09/10/2021] [Indexed: 12/31/2022]
Abstract
Adjuvant radiotherapy could be a necessary step in the oncological treatment for breast cancer. However, radiotherapy may have negative effects on implant-based immediate breast reconstruction. The aim of this study was to determine the impact of adjuvant radiation therapy on surgical results and patient-reported satisfaction outcomes in women undergoing immediate implant-based breast reconstruction. Methods A systematic search in PubMed was conducted on September 2019 and updated on April 2021. The risk of bias of the included studies was assessed using the Newcastle-Ottawa Quality Assessment Form for Observational Studies. RevMan 5 was used for statistical analysis. We obtained relative risks to determine the complication incidence and mean differences for 2-year BREAST-Q scores. Results Fourteen studies were included. A total of 11,958 implant-based immediate reconstructions were performed, 2311 received postmastectomy radiation therapy, and 9647 were considered as control group. Surgical complications, reoperation rates, and reconstruction failure were significantly higher among irradiated breasts. Significantly lower BREAST-Q scores were reported by irradiated women receiving radiotherapy. Conclusions This systematic review and meta-analysis combines reconstruction complication rates with aesthetic and patient-reported satisfaction outcomes. Adjuvant radiotherapy is consistently associated with greater complication rates and poorer aesthetic and satisfaction outcomes. The magnitude of association is significantly lower when the reconstruction is based on autologous tissues.
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29
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Stuart SR, Munhoz AM, Chaves CLG, Montag E, Cordeiro TCS, Fuzisaki TT, Marta GN, Carvalho HA. Complications after breast reconstruction with alloplastic material in breast cancer patients submitted or not to post mastectomy radiotherapy. Rep Pract Oncol Radiother 2021; 26:730-739. [PMID: 34760307 DOI: 10.5603/rpor.a2021.0087] [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: 05/19/2021] [Accepted: 08/02/2021] [Indexed: 11/25/2022] Open
Abstract
Background and purpose Breast reconstruction following mastectomy is a relevant element of breast cancer treatment. The purpose of this study was to evaluate the influence of radiotherapy (RT) on local complications in patients with breast cancer that had undergone breast reconstruction with alloplastic material. Materials and methods Retrospective study of breast cancer patients submitted to mastectomy and breast reconstruction from 2009 to 2013. Clinical and treatment variables were correlated with early and late complications. Results 251 patients were included; mean age was 49.7 (25 to 78) years. Reconstruction was immediate in 94% of the patients, with 88% performed with a temporary tissue expander. Postoperative radiotherapy (RT) was delivered to 167 patients (66.5%). Early complications were present in 26.3% of the patients. Irradiated patients presented 5.4% incidence of late complications versus 2.4% for non-irradiated patients (p = 0.327). Diabetes (OR = 3.41 95% CI: 1.23-9.45, p = 0.018) and high body mass index (BMI) (OR = 2.65; 95% CI: 1.60-4.37, p < 0.0001) were the main risk factors. The overall incidence of late complications was 4.4%, with predominance of severe capsular contracture (8/11). Arterial hypertension (OR = 4.78; 95% CI: 1.97-11.63, p = 0.001), BMI (OR = 0.170; 95% CI: 0.048-0.607, p = 0.006) and implant placement (OR = 3.55; 95% CI: 1.26-9.99, p = 0.016) were related to late complications. Conclusions The overall rate of complications was low in this population. Radiotherapy delivery translated into a higher but not statistically significant risk of late complications when compared with the non-irradiated patients. Already well-known clinical risk factors for complications after breast reconstruction were identified.
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Affiliation(s)
- Silvia Radwanski Stuart
- Department of Radiology and Oncology - Radiotherapy, Instituto do Câncer do Estado de São Paulo (ICESP), Brasil.,Instituto de Radiologia (INRAD) - Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brasil
| | - Alexandre Mendonça Munhoz
- Instituto de Radiologia (INRAD) - Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brasil
| | - Cristiane L G Chaves
- Department of Radiology and Oncology - Radiotherapy, Instituto do Câncer do Estado de São Paulo (ICESP), Brasil
| | - Eduardo Montag
- Instituto de Radiologia (INRAD) - Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brasil
| | - Thalita C S Cordeiro
- Department of Radiology and Oncology - Radiotherapy, Instituto do Câncer do Estado de São Paulo (ICESP), Brasil
| | - Tatiana Taba Fuzisaki
- Department of Radiology and Oncology - Radiotherapy, Instituto do Câncer do Estado de São Paulo (ICESP), Brasil
| | - Gustavo N Marta
- Department of Radiology and Oncology - Radiotherapy, Instituto do Câncer do Estado de São Paulo (ICESP), Brasil
| | - Heloisa A Carvalho
- Department of Radiology and Oncology - Radiotherapy, Instituto do Câncer do Estado de São Paulo (ICESP), Brasil.,Instituto de Radiologia (INRAD) - Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brasil
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30
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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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31
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Mutter RW, Choi JI, Jimenez RB, Kirova YM, Fagundes M, Haffty BG, Amos RA, Bradley JA, Chen PY, Ding X, Carr AM, Taylor LM, Pankuch M, Vega RBM, Ho AY, Nyström PW, McGee LA, Urbanic JJ, Cahlon O, Maduro JH, MacDonald SM. Proton Therapy for Breast Cancer: A Consensus Statement From the Particle Therapy Cooperative Group Breast Cancer Subcommittee. Int J Radiat Oncol Biol Phys 2021; 111:337-359. [PMID: 34048815 PMCID: PMC8416711 DOI: 10.1016/j.ijrobp.2021.05.110] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 05/12/2021] [Accepted: 05/17/2021] [Indexed: 12/23/2022]
Abstract
Radiation therapy plays an important role in the multidisciplinary management of breast cancer. Recent years have seen improvements in breast cancer survival and a greater appreciation of potential long-term morbidity associated with the dose and volume of irradiated organs. Proton therapy reduces the dose to nontarget structures while optimizing target coverage. However, there remain additional financial costs associated with proton therapy, despite reductions over time, and studies have yet to demonstrate that protons improve upon the treatment outcomes achieved with photon radiation therapy. There remains considerable heterogeneity in proton patient selection and techniques, and the rapid technological advances in the field have the potential to affect evidence evaluation, given the long latency period for breast cancer radiation therapy recurrence and late effects. In this consensus statement, we assess the data available to the radiation oncology community of proton therapy for breast cancer, provide expert consensus recommendations on indications and technique, and highlight ongoing trials' cost-effectiveness analyses and key areas for future research.
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Affiliation(s)
- Robert W Mutter
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota.
| | - J Isabelle Choi
- Department of Radiation Oncology, New York Proton Center and Memorial Sloan Kettering Cancer Center, New York, New York
| | - Rachel B Jimenez
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Youlia M Kirova
- Department of Radiation Oncology, Institut Curie, Paris, France
| | - Marcio Fagundes
- Department of Radiation Oncology, Miami Cancer Institute, Miami, Florida
| | - Bruce G Haffty
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
| | - Richard A Amos
- Proton and Advanced Radiotherapy Group, Department of Medical Physics and Biomedical Engineering, University College London, London, United Kingdom
| | - Julie A Bradley
- Department of Radiation Oncology, University of Florida, Jacksonville, Florida
| | - Peter Y Chen
- Department of Radiation Oncology, Beaumont Health, Royal Oak, Michigan
| | - Xuanfeng Ding
- Department of Radiation Oncology, Beaumont Health, Royal Oak, Michigan
| | - Antoinette M Carr
- Department of Radiation Oncology, Beaumont Health, Royal Oak, Michigan
| | - Leslie M Taylor
- Department of Radiation Oncology, Beaumont Health, Royal Oak, Michigan
| | - Mark Pankuch
- Department of Radiation Oncology, Northwestern Medicine Proton Center, Warrenville, Illinois
| | | | - Alice Y Ho
- Department of Radiation Oncology, New York Proton Center and Memorial Sloan Kettering Cancer Center, New York, New York
| | - Petra Witt Nyström
- The Skandion Clinic, Uppsala, Sweden and the Danish Centre for Particle Therapy, Aarhus, Denmark
| | - Lisa A McGee
- Department of Radiation Oncology, Mayo Clinic Hospital, Phoenix, Arizona
| | - James J Urbanic
- Department of Radiation Medicine and Applied Sciences, UC San Diego Health, Encinitas, California
| | - Oren Cahlon
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - John H Maduro
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Shannon M MacDonald
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
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Wang K, Tepper JE. Radiation therapy-associated toxicity: Etiology, management, and prevention. CA Cancer J Clin 2021; 71:437-454. [PMID: 34255347 DOI: 10.3322/caac.21689] [Citation(s) in RCA: 125] [Impact Index Per Article: 41.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 05/25/2021] [Accepted: 05/27/2021] [Indexed: 12/25/2022] Open
Abstract
Radiation therapy (RT) is a curative treatment for many malignancies and provides effective palliation in patients with tumor-related symptoms. However, the biophysical effects of RT are not specific to tumor cells and may produce toxicity due to exposure of surrounding organs and tissues. In this article, the authors review the clinical context, pathophysiology, risk factors, presentation, and management of RT side effects in each human organ system. Ionizing radiation works by producing DNA damage leading to tumor death, but effects on normal tissue may result in acute and/or late toxicity. The manifestation of toxicity depends on both cellular characteristics and affected organs' anatomy and physiology. There is usually a direct relationship between the radiation dose and volume to normal tissues and the risk of toxicity, which has led to guidelines and recommended dose limits for most tissues. Side effects are multifactorial, with contributions from baseline patient characteristics and other oncologic treatments. Technological advances in recent decades have decreased RT toxicity by dramatically improving the ability to deliver RT that maximizes tumor dose and minimizes organ dose. Thus the study of RT-associated toxicity is a complex, core component of radiation oncology training that continues to evolve alongside advances in cancer management. Because RT is used in up to one-half of all patients with cancer, an understanding of its acute and late effects in different organ systems is clinically pertinent to both oncologists and nononcologists.
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Affiliation(s)
- Kyle Wang
- Department of Radiation Oncology, University of Cincinnati, Cincinnati, Ohio
| | - Joel E Tepper
- Department of Radiation Oncology, University of North Carolina, Chapel Hill, North Carolina
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Rojas DP, Leonardi MC, Frassoni S, Morra A, Gerardi MA, La Rocca E, Cattani F, Luraschi R, Fodor C, Zaffaroni M, Rietjens M, De Lorenzi F, Veronesi P, Galimberti VE, Intra M, Bagnardi V, Orecchia R, Dicuonzo S, Jereczek-Fossa BA. Implant risk failure in patients undergoing postmastectomy 3-week hypofractionated radiotherapy after immediate reconstruction. Radiother Oncol 2021; 163:105-113. [PMID: 34419507 DOI: 10.1016/j.radonc.2021.08.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 08/05/2021] [Accepted: 08/12/2021] [Indexed: 01/29/2023]
Abstract
AIM To evaluate reconstruction failure (RF) rate in patients receiving implant-based immediate breast reconstruction (IBR) and hypofractionated (HF) postmastectomy radiation therapy (PMRT). MATERIALS AND METHODS Stage II-III breast cancer patients, treated with HF-PMRT using intensity modulated radiotherapy were stratified in two groups according to IBR: single-stage direct-to-implant (DTI-group) and two-stage expander and implant (TE/I-group). Irradiated patients were matched with non-irradiated ones who underwent the same IBR during the same period. Prescription dose was 40.05 Gy/15 fractions to chest wall and infra/supraclavicular nodal region. Primary endpoint was RF defined as the need of major revisional surgery (MaRS) for implant removal or conversion to autologous reconstruction. Secondary endpoint was the rate of minor revisional surgeries (MiRS) including implant repositioning or substitution with another implant. RESULTS One hundred and seven irradiated patients (62 in TE/I-group, 45 in DTI-group) were matched with 107 non-irradiated subjects. Median follow-up was 4.2 years (0.1-6.1) In the TE/I setting, MaRS was performed in 8/62 irradiated patients (12.9%) of the irradiated TE/I group compared to 1/62 (1.6%) non-irradiated subjects (p = 0.015). In the DTI setting, MaRs occurred in 3/45 irradiated patients (6.7%) compared to 1/45 non-irradiated ones (2.2%) (p = 0.35). Overall MaRS rate was 10.3% in the irradiated group. MiRS was performed in 35.6% and 31.1% of the irradiated and non-irradiated DTI-groups (p = 0.65), respectively, and in 12.9% and 8.1% of the irradiated and non-irradiated TE/I groups (p = 0.38), respectively. CONCLUSIONS Compared to the non-irradiated counterparts, the TE/I group showed higher rate of RF, while no statistically significant difference was observed for the DTI group. The use of hypofractionation and IMRT to implant-based IBR did not seem to increase the risk of RF which appeared to be in line with the literature.
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Affiliation(s)
| | | | - Samuele Frassoni
- Department of Statistics and Quantitative Methods, University of Milan-Bicocca, Italy
| | - Anna Morra
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | | | - Eliana La Rocca
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, Milan, Italy; Department of Oncology and Hemato-oncology, University of Milan, Italy
| | - Federica Cattani
- Unit of Medical Physics, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Rosa Luraschi
- Unit of Medical Physics, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Cristiana Fodor
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Mattia Zaffaroni
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Mario Rietjens
- Division of Plastic and Reconstructive Surgery, European Institute of Oncology IRCCS, Milan, Italy
| | - Francesca De Lorenzi
- Division of Plastic and Reconstructive Surgery, European Institute of Oncology IRCCS, Milan, Italy
| | - Paolo Veronesi
- Division of Breast Surgery, IEO, European Institute of Oncology IRCCS, Milan, Italy; Department of Oncology and Hemato-oncology, University of Milan, Italy
| | | | - Mattia Intra
- Division of Breast Surgery, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Vincenzo Bagnardi
- Department of Statistics and Quantitative Methods, University of Milan-Bicocca, Italy
| | - Roberto Orecchia
- Scientific Direction, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Samantha Dicuonzo
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Barbara Alicja Jereczek-Fossa
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, Milan, Italy; Department of Oncology and Hemato-oncology, University of Milan, Italy
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Nepon H, Safran T, Reece EM, Murphy AM, Vorstenbosch J, Davison PG. Radiation-Induced Tissue Damage: Clinical Consequences and Current Treatment Options. Semin Plast Surg 2021; 35:181-188. [PMID: 34526866 PMCID: PMC8432995 DOI: 10.1055/s-0041-1731464] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Radiation therapy is a valuable tool in the treatment of numerous malignancies but, in certain cases, can also causes significant acute and chronic damage to noncancerous neighboring tissues. This review focuses on the pathophysiology of radiation-induced damage and the clinical implications it has for plastic surgeons across breast reconstruction, osteoradionecrosis, radiation-induced skin cancers, and wound healing. The current understanding of treatment modalities presented here include hyperbaric oxygen therapy, autologous fat grafting and stem cells, and pharmaceutical agents.
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Affiliation(s)
- Hillary Nepon
- Division of Experimental Surgery, McGill University, Montreal, Quebec, Canada
| | - Tyler Safran
- Division of Plastic Surgery, McGill University, Montreal, Quebec, Canada
| | - Edward M. Reece
- Michael E. DeBakey Department of Surgery, Division of Plastic Surgery, Baylor College of Medicine, Houston, Texas
| | - Amanda M. Murphy
- Division of Plastic Surgery, McGill University, Montreal, Quebec, Canada
| | | | - Peter G. Davison
- Division of Plastic Surgery, McGill University, Montreal, Quebec, Canada
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Hermiz SJR, Lauzon S, Brown G, Herrera FA. Use of a 5-Item Modified Frailty Index for Risk Stratification in Patients Undergoing Breast Reconstruction. Ann Plast Surg 2021; 86:S615-S621. [PMID: 33625028 DOI: 10.1097/sap.0000000000002765] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Frailty can be quantified using an index score to effectively predict surgical outcomes and complications. The modified frailty index (mFI) score includes 5 patient-specific medical history comorbidities including diabetes mellitus, congestive heart failure, hypertension, chronic obstructive pulmonary disease/pneumonia, and nonindependent functional status. The purpose of our study was to apply the 5-item mFI score to predict and minimize complications in patients undergoing breast reconstruction. METHODS The National Surgical Quality Improvement Program was queried for all patients undergoing primary breast reconstruction from 2016 to 2018. Patients were divided based on timing of reconstruction and type of reconstruction: immediate or delayed, and implant based or autologous based. A validated modified fragility score was applied to all patients. Patients were stratified by mFI scores of 0 (no comorbidities), 1 (1 comorbidity), and 2+ (2 or more comorbidities). Patient demographics and 30-day complications rates were recorded. RESULTS A total of 22,700 patients were identified. There were 10,673 patients who underwent immediate breast reconstruction, and 12,027 patients who underwent delayed breast reconstruction. A total of 14,159 patients underwent implant-based, and 8541 underwent autologous-based reconstruction. A total of 16,627 patients had an mFI score of 0, 4923 had a mFI score of 1, and 1150 had a mFI score of 2+. Compared with patients with an mFI score of 0, patients with an mFI score of 2 or greater were more likely to develop a postoperative complication (7.2 vs 12.3; P < 0.0001). Patients undergoing immediate reconstruction were more likely to develop a postoperative complications for every mFI category. The most common complications were wound and hematologic related. CONCLUSION Patients with higher mFI scores are likely to have an increase in postoperative complications after breast reconstruction. Increasing body mass index increases postoperative complications independent of frailty index scores. Patients with increasing frailty index scores undergoing immediate breast reconstruction have a significantly higher risk of postoperative complications compared with delayed reconstruction.Patients with increasing frailty index scores undergoing autologous breast reconstruction have a significantly higher risk of postoperative complications compared with implant-based reconstruction. High frailty index scores are associated with a higher risk of postoperative complications, reoperation rates, and readmission rates. Patients with higher mFI scores may benefit from a delayed implant-based reconstruction.
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Affiliation(s)
| | | | - Geoffrey Brown
- College of Medicine, Medical University of South Carolina, Charleston, SC
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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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Kaidar-Person O, Hermann N, Poortmans P, Offersen BV, Boersma LJ, de Ruysscher D, Tramm T, Kühn T, Engberg Damsgaard T, Gentilini O, Maarse W, Sklair-Levi M, Mátrai Z. A multidisciplinary approach for autologous breast reconstruction: A narrative (re)view for better management. Radiother Oncol 2021; 157:263-271. [PMID: 33582192 DOI: 10.1016/j.radonc.2021.01.036] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 01/27/2021] [Accepted: 01/28/2021] [Indexed: 01/16/2023]
Abstract
Breast reconstruction and oncoplastic surgery have become an important part of breast cancer care. The use of autologous breast reconstruction (ABR) has evolved significantly with advances in microsurgery, aiming to reduce donor site complications and improve cosmesis. For years, immediate-ABR was considered a contraindication if postmastectomy irradiation (PMRT) was planned. As a result of de-escalation of axillary surgery the indication of PMRT are increasing along-side with observations that PMRT in the setting of ABR is not contraindicated. Surgical techniques may result in different amount and areas of breast residual glandular tissue and patient selection is important to reduce potential residual disease. Meticulus radiation planning is important to potentially reduce complications without compromising oncologic outcomes. Surgical techniques change constantly in aim to improve aesthetic results but should most importantly maintain priority to the oncological indications. By multidisciplinary team work with a comprehensive understanding of each discipline, we can preserve the accomplishments of breast surgery in the setting of PMRT, without compromising disease control.
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Affiliation(s)
- Orit Kaidar-Person
- Breast Cancer Radiation Therapy Unit, at Sheba Medical Center, Ramat Gan, Israel; GROW-School for Oncology and Developmental Biology (Maastro), Maastricht University, The Netherlands; Sackler School of Medicine, Tel-Aviv University, Israel.
| | - Naama Hermann
- Sackler School of Medicine, Tel-Aviv University, Israel; General Surgery B and The Meirav Breast Center, Sheba Medical Center
| | - Philip Poortmans
- Iridium Kankernetwerk, 2610 Wilrijk-Antwerp, Belgium; University of Antwerp, Faculty of Medicine and Health Sciences, 2610 Wilrijk-Antwerp, Belgium
| | - Birgitte V Offersen
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Denmark
| | - Liesbeth J Boersma
- Department of Radiation Oncology (Maastro), GROW School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Dirk de Ruysscher
- Department of Radiation Oncology (Maastro), GROW School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Trine Tramm
- Department of Pathology, Aarhus University Hospital, Denmark
| | - Thorsten Kühn
- Department of Gynaecology and Obstetrics, Interdisciplinary Breast Center, Klinikum Esslingen, Germany
| | - Tine Engberg Damsgaard
- Department of Plastic Surgery and Burns Treatment, Copenhagen University Hospital and University of Copenhagen, Denmark
| | - Oreste Gentilini
- Breast Surgery Unit, San Raffaele University and Research Hospital, Milano, Italy
| | - Wies Maarse
- Departmentof Plastic and Reconstructive Surgery, University Medical Centre Utrecht, the Netherlands
| | - Miri Sklair-Levi
- Sackler School of Medicine, Tel-Aviv University, Israel; Radiology Department, Mercaz Mierav Breast Clinic, Sheba Tel Hashomer, Ramat Gan, Israel
| | - Zoltán Mátrai
- Department of Breast and Sarcoma Surgery, National Institute of Oncology, Budapest, Hungary, Budapest, Hungary
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Kaidar-Person O, Offersen BV, Boersma LJ, de Ruysscher D, Tramm T, Kühn T, Gentilini O, Mátrai Z, Poortmans P. A multidisciplinary view of mastectomy and breast reconstruction: Understanding the challenges. Breast 2021; 56:42-52. [PMID: 33610903 PMCID: PMC7905468 DOI: 10.1016/j.breast.2021.02.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 01/25/2021] [Accepted: 02/05/2021] [Indexed: 12/18/2022] Open
Abstract
The current review paper was written in collaboration with breast cancer surgeons from the European Breast Cancer Research Association of Surgical Trialists (EUBREAST), a breast pathologist from the Danish Breast Cancer Group (DBCG), and representatives from the European SocieTy for Radiotherapy & Oncology (ESTRO) breast cancer course. Herein we summarize the different mastectomies and reconstruction procedures and define high-risk anatomical areas for breast cancer recurrences, to further specify the challenges in the surgical procedure, histopathological evaluation, and target volumes in case of postmastectomy irradiation, as recommended by the ESTRO guidelines according to the surgical procedure. The paper has original figures and illustrations for all disciplines for in-depth understanding of the differences between the procedures. Mastectomy techniques and reconstruction evolved to improve cosmetic outcomes. Different techniques maybe associated with different amount of residual breast tissue. More data is needed to estimate who are the patients at risk for residual disease or recurrence. Multidisciplinary work needed to individualise treatment for optimal oncological outcomes while maintaining the significant improvements in achieving better cosmesis for these patients.
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Affiliation(s)
- Orit Kaidar-Person
- Breast Cancer Radiation Therapy Unit, At Sheba Medical Center, Ramat Gan, Israel; Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel; GROW-School for Oncology and Developmental Biology (Maastro), Maastricht University, Maastricht, the Netherlands.
| | - Birgitte V Offersen
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Denmark
| | - Liesbeth J Boersma
- GROW-School for Oncology and Developmental Biology (Maastro), Maastricht University, Maastricht, the Netherlands; Department of Radiation Oncology (Maastro), Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Dirk de Ruysscher
- GROW-School for Oncology and Developmental Biology (Maastro), Maastricht University, Maastricht, the Netherlands; Department of Radiation Oncology (Maastro), Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Trine Tramm
- Department of Pathology, Aarhus University Hospital, Denmark
| | - Thorsten Kühn
- Department of Gynaecology and Obstetrics, Interdisciplinary Breast Center, Klinikum Esslingen, Germany
| | - Oreste Gentilini
- Breast Surgery Unit, San Raffaele University Hospital, Milan, Italy
| | - Zoltán Mátrai
- Department of Breast and Sarcoma Surgery, National Institute of Oncology, Budapest, 1122, Budapest, Ráth György U 7, Hungary
| | - Philip Poortmans
- Iridium Kankernetwerk, 2610, Wilrijk-Antwerp, Belgium; University of Antwerp, Faculty of Medicine and Health Sciences, 2610, Wilrijk-Antwerp, Belgium
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Hershenhouse KS, Bick K, Shauly O, Kondra K, Ye J, Gould DJ, Patel KM. "Systematic review and meta-analysis of immediate versus delayed autologous breast reconstruction in the setting of post-mastectomy adjuvant radiation therapy". J Plast Reconstr Aesthet Surg 2020; 74:931-944. [PMID: 33423976 DOI: 10.1016/j.bjps.2020.11.027] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Revised: 11/03/2020] [Accepted: 11/22/2020] [Indexed: 01/29/2023]
Abstract
BACKGROUND Immediate post-mastectomy autologous breast reconstruction in breast cancer patients requiring post-mastectomy radiation therapy (PMRT) minimizes the number of operations that patients must undergo and alleviates the psychological impact of living without a breast. However, the safety and impact of radiation on the reconstructed breast remains to be established. This study aimed to compare immediate versus delayed autologous reconstruction in the setting of PMRT to determine the optimal sequencing of reconstruction and adjuvant radiation. METHODS A systematic review of the literature identified 292 studies meeting criteria for full-text review, 44 of which underwent meta-analysis. This represented data on 1,927 immediate reconstruction (IR) patients and 1,546 delayed reconstruction (DR) patients (3,473 total patients). Early complications included flap loss, fat necrosis, thrombosis, seroma, hematoma, infection, and skin dehiscence. Late complications included fibrosis or contracture, severe asymmetry, hyperpigmentation, and decreased flap volume. RESULTS Immediate breast reconstruction did not demonstrate significantly increased complication rates. Reported mean complication rates in IR versus DR groups, respectively, were fat necrosis 14.91% and 8.12% (p = 0.076), flap loss 0.99% and 1.80% (p = 0.295), hematoma 1.91% and 1.14% (p = 0.247), infection 11.66% and 4.68% (p = 0.155), and thrombosis 1.51% and 3.36% (p = 0.150). Seroma rates were significantly lower in the immediate cohort at 2.69% versus 10.57% in the delayed cohort (p = 0.042). CONCLUSION Complication rates are comparable between immediate and delayed breast reconstruction in the setting of PMRT. Given the patient benefits incurred by an IR algorithm, immediate autologous breast reconstruction should be considered as a viable treatment option in patients requiring PMRT.
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Affiliation(s)
| | - Katherine Bick
- Keck School of Medicine of USC, Los Angeles, California, USA
| | - Orr Shauly
- Keck School of Medicine of USC, Los Angeles, California, USA
| | - Katelyn Kondra
- Department of Surgery, Keck Hospital of USC, Los Angeles, California, USA
| | - Jason Ye
- Radiation Oncology, Keck School of Medicine of USC, Los Angeles, California, USA
| | | | - Ketan M Patel
- Department of Plastic and Reconstructive Surgery, Keck Hospital of USC, Los Angeles, California, USA.
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Complications May Outweigh the Benefits. Int J Radiat Oncol Biol Phys 2020; 108:1131-1132. [PMID: 33220222 DOI: 10.1016/j.ijrobp.2020.01.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Accepted: 01/21/2020] [Indexed: 11/23/2022]
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41
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Schwartz JCD. Early Expander-to-Implant Exchange after Postmastectomy Reconstruction Reduces Rates of Subsequent Major Infectious Complications. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e3275. [PMID: 33425590 PMCID: PMC7787320 DOI: 10.1097/gox.0000000000003275] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 10/02/2020] [Indexed: 04/11/2023]
Abstract
Major infectious complications after implant-based postmastectomy reconstruction commonly occur late (>30 days postoperative). We set out to determine if early expander-to-implant exchange (3-6 weeks after tissue expander placement) reduced rates of subsequent major infectious complications. METHODS We retrospectively examined patients after mastectomy and tissue expander reconstruction followed by early expander-to-implant exchange versus exchange at least 6 months after initial tissue expander placement (the control group). Multivariate logistic regression analysis was performed to determine whether the timing of implant exchange independently predicted major infectious complications occurring more than 30 days after initial tissue expander placement after adjusting for differences in patient variables between groups. RESULTS In total, 252 consecutive patients (430 breasts) between August 2014 and October 2019 were included. While the rates of major early infectious complications after mastectomy and tissue expander placement were similar between the groups, the control group had more subsequent major infectious complications during the reconstructive process [9.8% (n = 22) versus 1.9% (n = 4), P < 0.001]. CONCLUSIONS Early implant exchange results in a reduced subsequent rate of major infectious complications. This protocol reduces the window of time for late infectious complications to develop by proceeding with exchange within 6 weeks of tissue expander placement instead of the standard 6 months, which is common practice. We hypothesize that early exchange allows for washout of the mastectomy cavity, eliminating indolent bacterial contamination that could have subsequently manifested as a late infection. This protocol also obviates the need to operate on patients that undergo post-mastectomy radiotherapy, which also reduces reconstructive failure rates.
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Affiliation(s)
- Jean-Claude D. Schwartz
- From the Northside Gwinnett Surgical Associates, Northside Hospital Gwinnett, Lawrenceville, Ga
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Alipour S. Re: Naoum et al., Optimal breast reconstruction type for patients treated with neoadjuvant chemotherapy, mastectomy followed by radiation therapy. Breast Cancer Res Treat 2020; 185:885-886. [PMID: 33113090 DOI: 10.1007/s10549-020-05993-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 10/20/2020] [Indexed: 10/23/2022]
Affiliation(s)
- Sadaf Alipour
- Breast Disease Research Center, Tehran University of Medical Sciences, Tehran, Iran.
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Di Bartolo A, Melchels FPW. Prolonged recovery of 3D printed, photo-cured polylactide shape memory polymer networks. APL Bioeng 2020; 4:036105. [PMID: 32844139 PMCID: PMC7442493 DOI: 10.1063/5.0008910] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 08/07/2020] [Indexed: 01/29/2023] Open
Abstract
Shape memory polymers are materials that are able to retain a deformed state until an external stimulus, most typically heat, triggers recovery to the original geometry. Whereas typically, shape memory polymers are required to recover fast (seconds to minutes), many applications, particularly in the medical field, would benefit from a slow recovery (days to weeks). In this work, we exploit the broad glass transition range of photo-cured poly(D,L-lactide) dimethacrylate networks to obtain recovery times of up to 2 weeks, at 11 °C below the peak glass transition temperature of 58 °C. Recovery times decreased considerably for higher recovery temperatures, down to ∼10 min at 55 °C. A large spread in glass transition values (53.3-61.0 °C) was observed between samples, indicating poor reproducibility in sample preparation and, hence, in predicting shape recovery kinetics for individual samples. Furthermore, a staged recovery was observed with different parts of the samples recovering at different times. The ability to prepare complex structures using digital light processing stereolithography 3D printing from these polymers was confirmed. To the best of our knowledge, this work provides the first experimental evidence of prolonged recovery of shape memory polymers.
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Affiliation(s)
- Alberto Di Bartolo
- Institute of Biological Chemistry, Biophysics and Bioengineering, School of Engineering and Physical Sciences, Heriot-Watt University, EH14 4AS Edinburgh, United Kingdom
| | - Ferry P. W. Melchels
- Institute of Biological Chemistry, Biophysics and Bioengineering, School of Engineering and Physical Sciences, Heriot-Watt University, EH14 4AS Edinburgh, United Kingdom
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Naoum GE, Roberts S, Brunelle CL, Shui AM, Salama L, Daniell K, Gillespie T, Bucci L, Smith BL, Ho AY, Taghian AG. Quantifying the Impact of Axillary Surgery and Nodal Irradiation on Breast Cancer-Related Lymphedema and Local Tumor Control: Long-Term Results From a Prospective Screening Trial. J Clin Oncol 2020; 38:3430-3438. [PMID: 32730184 DOI: 10.1200/jco.20.00459] [Citation(s) in RCA: 59] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
PURPOSE To independently evaluate the impact of axillary surgery type and regional lymph node radiation (RLNR) on breast cancer-related lymphedema (BCRL) rates in patients with breast cancer. PATIENTS AND METHODS From 2005 to 2018, 1,815 patients with invasive breast cancer were enrolled in a lymphedema screening trial. Patients were divided into the following 4 groups according to axillary surgery approach: sentinel lymph node biopsy (SLNB) alone, SLNB+RLNR, axillary lymph node dissection (ALND) alone, and ALND+RLNR. A perometer was used to objectively assess limb volume. All patients received baseline preoperative and follow-up measurements after treatment. Lymphedema was defined as a ≥ 10% relative increase in arm volume arising > 3 months postoperatively. The primary end point was the BCRL rate across the groups. Secondary end points were 5-year locoregional control and disease-free-survival. RESULTS The cohort included 1,340 patients with SLNB alone, 121 with SLNB+RLNR, 91 with ALND alone, and 263 with ALND+RLNR. The overall median follow-up time after diagnosis was 52.7 months for the entire cohort. The 5-year cumulative incidence rates of BCRL were 30.1%, 24.9%, 10.7%, and 8.0% for ALND+RLNR, ALND alone, SLNB+RLNR, and SLNB alone, respectively. Multivariable Cox models adjusted for age, body mass index, surgery, and reconstruction type showed that the ALND-alone group had a significantly higher BCRL risk (hazard ratio [HR], 2.66; P = .02) compared with the SLNB+RLNR group. There was no significant difference in BCRL risk between the ALND+RLNR and ALND-alone groups (HR, 1.20; P = .49) and between the SLNB-alone and SLNB+RLNR groups (HR, 1.33; P = .44). The 5-year locoregional control rates were similar for the ALND+RLNR, ALND-alone, SLNB+RLNR, and SLNB-alone groups (2.8%, 3.8%, 0%, and 2.3%, respectively). CONCLUSION Although RLNR adds to the risk of lymphedema, the main risk factor is the type of axillary surgery used.
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Affiliation(s)
- George E Naoum
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA.,Lymphedema Research Program, Massachusetts General Hospital, Boston, MA
| | - Sacha Roberts
- Lymphedema Research Program, Massachusetts General Hospital, Boston, MA
| | - Cheryl L Brunelle
- Lymphedema Research Program, Massachusetts General Hospital, Boston, MA
| | - Amy M Shui
- Lymphedema Research Program, Massachusetts General Hospital, Boston, MA.,Biostatistics Center, Massachusetts General Hospital, Boston, MA
| | - Laura Salama
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA.,Charles E. Schmidt College of Medicine, Boca Raton, FL
| | - Kayla Daniell
- Lymphedema Research Program, Massachusetts General Hospital, Boston, MA
| | - Tessa Gillespie
- Lymphedema Research Program, Massachusetts General Hospital, Boston, MA
| | - Loryn Bucci
- Lymphedema Research Program, Massachusetts General Hospital, Boston, MA
| | - Barbara L Smith
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Alice Y Ho
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Alphonse G Taghian
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA.,Lymphedema Research Program, Massachusetts General Hospital, Boston, MA
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Venkatesh A, Khajuria A. Direct-to-Implant Breast Reconstruction in Patients Undergoing Post-Mastectomy Radiotherapy. Ann Surg Oncol 2020; 27:919-920. [PMID: 32705515 DOI: 10.1245/s10434-020-08907-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Accepted: 06/29/2020] [Indexed: 11/18/2022]
Affiliation(s)
- Ashwin Venkatesh
- School of Clinical Medicine, University of Cambridge, Cambridge, UK.
| | - Ankur Khajuria
- Kellogg College, University of Oxford, 60-62 Banbury Rd, Park Town, Oxford, OX2 6PN, UK.,Department of Surgery and Cancer, Imperial College London, London, UK.,Department of Plastic Surgery, St Thomas' Hospital, London, UK
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Optimal breast reconstruction type for patients treated with neoadjuvant chemotherapy, mastectomy followed by radiation therapy. Breast Cancer Res Treat 2020; 183:127-136. [PMID: 32607638 DOI: 10.1007/s10549-020-05747-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 06/13/2020] [Indexed: 12/31/2022]
Abstract
PURPOSE To explore the optimal type of breast reconstruction and the time interval to postmastectomy radiotherapy (PMRT) associated with lower complications in breast cancer patients receiving neoadjuvant chemotherapy. METHODS We reviewed the medical records of 300 patients who received neoadjuvant chemotherapy, mastectomy with breast reconstruction and PMRT at our institution from 2000 to 2017. Reconstruction types included autologous flaps (AR), single-stage-direct-to-implant and two-stages expander/implant (TE/I). The primary endpoint was the rate of reconstruction complications including infection, skin and fat necrosis. Subgroup analysis compared rates of capsular contracture, implant rupture, implant exposure and overall implant failure in single-stage-direct-to-implant to TE/I. The secondary endpoint was identifying the time interval between surgery with immediate implant-based reconstruction and PMRT associated with lower probability of implant failure. Logistic regression models, Kaplan-Meier estimates and Polynomial regression were used to assess endpoints. RESULTS The median follow-up was 43.5 months. 29.3%, 28.3% and 42.4% of the cohort had AR, TE/I and single-stage-direct-to-implant D, respectively. The 5-year cumulative incidence rate of complications was 14.0%, 29.7% and 19.4% for AR, TE/I and single-stage-direct-to-implant, respectively (Log rank p = 0.02). Multivariate analysis showed significant association between TE/I and higher risk of infection (OR 8.1, p = 0.009) compared to AR, while single-stage-direct-to-implant and AR were comparable (OR 3.2, p = 0.2). On subgroup analysis, TE/I was significantly associated with higher rates of implant failure. The mean wait time to deliver PMRT after immediate reconstruction with no adjuvant chemotherapy was 8.4 and 10.7 weeks in single-stage-direct-to-implant and TE/I, respectively (p < 0.005). Delivering PMRT after 8 weeks of surgery yielded 10% probability of reconstruction failure in single-stage-direct-to-implant versus 40% in TE/I. CONCLUSION In comparison to two stages reconstruction, single-stage-direct-to-implant following neoadjuvant chemotherapy has lower complications and offers timely delivery of PMRT.
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In Regard to Naoum et al. Int J Radiat Oncol Biol Phys 2020; 107:223. [PMID: 32277918 DOI: 10.1016/j.ijrobp.2020.01.041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Accepted: 01/23/2020] [Indexed: 01/29/2023]
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Naoum GE, Taghian AG. In Reply to Kim et al. Int J Radiat Oncol Biol Phys 2020; 107:224. [PMID: 32277920 DOI: 10.1016/j.ijrobp.2020.01.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 01/23/2020] [Indexed: 11/18/2022]
Affiliation(s)
- George E Naoum
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Alphonse G Taghian
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
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