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Park SH, Yang YJ, Sung S, Choi Y, Yang EJ. Postoperative complications of hypofractionated and conventional fractionated radiation therapy in patients with implant-based breast reconstruction: A systematic review and meta-analysis. Breast 2024; 77:103782. [PMID: 39111201 PMCID: PMC11362802 DOI: 10.1016/j.breast.2024.103782] [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: 05/29/2024] [Revised: 07/12/2024] [Accepted: 07/23/2024] [Indexed: 09/02/2024] Open
Abstract
INTRODUCTION Post-mastectomy radiation therapy is an important component of adjuvant therapy for high-risk patients. However, radiation to reconstructed breasts can cause various complications. Recently, hypofractionated (HF) protocols have been adopted in several countries. Here, we aimed to assess the impact of HF protocols on implant-reconstructed breasts through a meta-analysis and systematic review of the currently available literature. METHODS Records published until August 2023 were systematically searched in PubMed, Cochrane Library, and EMBASE databases. Keywords included hypofractionation radiotherapy, mastectomy, and breast reconstruction. Studies that utilized HF and conventional fractionation (CF) after prosthetic reconstruction were selected. Due to the rarity of events in outcomes, Mantel-Haenszel's odds ratios were calculated using a fixed-effect model to compare the complication rates between HF and CF groups. For analysis with high heterogeneity, a random effect model was used. RESULTS Seven articles with 924 implant reconstructions, in which 506 (54.8 %) underwent HF were included. HF patients received 43.8 Gy on average, while CF patients received 51.2 Gy. Mean follow-up ranged from 10.6 to 35 months. Seven studies were included in the meta-analysis. HF groups had a significantly lower risk of capsular contracture (OR 0.25, 95 % CI 0.11-0.55), major revision surgery (OR 0.19, 95 % CI 0.05-0.80), and wound dehiscence (OR 0.24, 95 % CI 0.07-0.78) compared to CF groups. The risks of other complications were not statistically significant. CONCLUSION This study indicates that HF protocols are associated with fewer complications than CF protocols in implant-reconstructed patients. These findings suggest that the application of HF PMRT in implant-reconstructed patients with breast cancer is plausible.
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Affiliation(s)
- Seong-Hyuk Park
- Department of Plastic & Reconstructive Surgery, Institute of Innovative Digital Healthcare, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yun-Jung Yang
- Department of Convergence Science, College of Medicine, Catholic Kwandong University International St. Mary's Hospital, Incheon, Republic of Korea
| | - Sihyun Sung
- Department of Research and Development, Seoul Medical Informatics Intelligence Lab Inc, Seoul, Republic of Korea
| | - Yelim Choi
- Department of Research and Development, Seoul Medical Informatics Intelligence Lab Inc, Seoul, Republic of Korea
| | - Eun-Jung Yang
- Department of Plastic & Reconstructive Surgery, Institute of Innovative Digital Healthcare, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea.
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Wong AWJ, Kuo WL, Cheong DCF, Tsai HP, Kao SW, Chen CF, Huang JJ. Six steps for a successful aesthetic free flap reconstruction after minimally invasive mastectomy: a retrospective case-control study. Int J Surg 2024; 110:645-653. [PMID: 38000051 PMCID: PMC10871604 DOI: 10.1097/js9.0000000000000871] [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: 07/22/2023] [Accepted: 10/22/2023] [Indexed: 11/26/2023]
Abstract
OBJECTIVE Breast cancer treatment has evolved to the modern skin-sparing mastectomy and nipple-sparing mastectomy. To better perform these surgeries, minimally invasive techniques using the endoscope, or Da Vinci Robotic Surgery platform have been developed. The deep inferior epigastric perforator (DIEP) flap is the gold standard in breast reconstruction, but it is still not commonly performed after minimally invasive mastectomy due technical difficulty. Here the authors introduced six key steps to a successful aesthetic autologous free flap reconstruction in in minimally invasive mastectomies. METHODS There are six main steps to our technique: placement of mastectomy incision, precise flap design after angiography studies, trial of shaping, transcutaneous medial suture, footprint recreation and postoperative shaping with bra. Between November 2018 and July 2022, a total of 67 immediate breast reconstructions using free perforator flaps were performed in 63 patients after minimally invasive nipple-sparing mastectomy. RESULTS The results from the minimally invasive mastectomy group were compared with a group of conventional mastectomy patients ( n= 41) performed during the same period. There were no significant differences in flap exploration rates. One hundred percent of the flaps survived. In the minimally invasive group, the final scar was placed in the lateral region, where it would be hidden from the anterior view. Only 70.7% of the conventional mastectomy group could achieve a hidden lateral scar ( P <0.001). The aesthetic revision rates were similar between two groups. CONCLUSION With attention to the six steps above, autologous free flap reconstruction can be offered reliably in the setting of minimally invasive mastectomy.
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Affiliation(s)
- Allen Wei-Jiat Wong
- Departments of Plastic and Reconstructive Surgery
- Plastic, Reconstructive & Aesthetic Surgery Service, Sengkang General Hospital, Singapore
| | - Wen-Ling Kuo
- General Surgery
- Center for Tissue Engineering
- College of Medicine, Chang Gung University, Taoyuan
- School of Medicine, National Tsing Hua University, Hsinchu, Taiwan
| | - David Chon-Fok Cheong
- Departments of Plastic and Reconstructive Surgery
- College of Medicine, Chang Gung University, Taoyuan
| | - Hsiu-Pei Tsai
- General Surgery
- College of Medicine, Chang Gung University, Taoyuan
| | - Shu-Wei Kao
- Departments of Plastic and Reconstructive Surgery
| | - Chia-Fang Chen
- Departments of Plastic and Reconstructive Surgery
- College of Medicine, Chang Gung University, Taoyuan
| | - Jung-Ju Huang
- Departments of Plastic and Reconstructive Surgery
- College of Medicine, Chang Gung University, Taoyuan
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Huang N, Liu L, Qin Y, Xie Y. Effect of radiation therapy during surgery on postoperative wound complications after breast reconstruction in patients with breast cancer: A meta-analysis. Int Wound J 2023; 21:e14473. [PMID: 37905575 PMCID: PMC10828528 DOI: 10.1111/iwj.14473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 10/17/2023] [Accepted: 10/17/2023] [Indexed: 11/02/2023] Open
Abstract
Breast remodelling is a major therapeutic choice in radical mastectomy. Breast reconstruction is regarded as a promising option for the treatment of breast cancer. The purpose of this meta-analysis was to investigate the effect of Post mastectomy radiotherapy (PMRT) on postoperative wound complications in breast carcinoma. A comprehensive review of documents was conducted between the date of establishment and the 28th of August 2023. In all of the trials, patients were treated with breast cancer. The researchers chose 11 publications out of 8068 related studies. Two researchers examined these publications to satisfy the inclusion criteria. Among the 516 patients who had received radiation therapy in the course of the operation, 1772 had not received radiation therapy. The impact of radiation therapy and non-radiation therapy in breast cancer patients after breast reconstruction was reported in 8 studies, and the incidence of postoperative wound infection in non-radiation group was significantly lower (OR, 1.95; 95% CI, 1.26-3.02 p = 0.003). In nine studies, There is not considered to have achieved statistical significance between radiation therapy and non-radiation treatment for post-operation wound dehiscence in breast cancer patients who had received chemotherapy (OR, 1.61; 95% CI, 0.70-3.72 p = 0.27). The results of six trials demonstrated that radiation therapy and non-radiation therapy had no statistical significance on post-operation haemorrhage in breast cancer patients (OR, 1.02; 95% CI, 0.42-2.47 p = 0.96). The results of 7 trials demonstrated that radiation therapy and non-radiation therapy had no significant impact on the post-operation of skin necrosis (OR, 1.22; 95% CI, 0.66-2.28 p = 0.53). Two trials demonstrated that those without radiation therapy were less likely than those who received radiation therapy in skin contracture in patients (OR, 7.24; 95% CI, 1.80-29.10 p = 0.005). Regarding the incidence of wound infection and cutaneous contraction was higher in the radiation group.
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Affiliation(s)
- Na Huang
- Department of Radiotherapy, Radiation Oncology Key Laboratory of Sichuan Province, Sichuan Clinical Research Center for Cancer, Sichuan Cancer Hospital & Institute, Sichuan Cancer CenterAffiliated Cancer Hospital of University of Electronic Science and Technology of ChinaChengduChina
| | - Lihao Liu
- Department of Radiotherapy, Radiation Oncology Key Laboratory of Sichuan Province, Sichuan Clinical Research Center for Cancer, Sichuan Cancer Hospital & Institute, Sichuan Cancer CenterAffiliated Cancer Hospital of University of Electronic Science and Technology of ChinaChengduChina
| | - Yuan Qin
- Department of Radiotherapy, Radiation Oncology Key Laboratory of Sichuan Province, Sichuan Clinical Research Center for Cancer, Sichuan Cancer Hospital & Institute, Sichuan Cancer CenterAffiliated Cancer Hospital of University of Electronic Science and Technology of ChinaChengduChina
| | - Yao Xie
- Department of obstetrics and gynaecology, Sichuan Provincial People's Hospital, School of MedicineUniversity of Electronic Science and Technology of ChinaChengduChina
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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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The Impact of Postmastectomy Radiation Therapy on the Outcomes of Prepectoral Implant-Based Breast Reconstruction: A Systematic Review and Meta-Analysis. Aesthetic Plast Surg 2023; 47:81-91. [PMID: 35879475 PMCID: PMC9945051 DOI: 10.1007/s00266-022-03026-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 07/12/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND Breast reconstruction is the mainstay treatment choice for patients subjected to a mastectomy. Prepectoral implant-based breast reconstruction (IBBR) is deemed to be a promising alternative to subpectoral reconstruction. Postmastectomy radiation therapy (PMRT) is necessary for locoregional recurrence control and to improve the disease-free survival rate in locally advanced breast cancer. This systematic review and meta-analysis study was designed to reveal the surgical, aesthetic, and oncological outcomes of prepectoral IBBR after PMRT. METHODS An extensive literature search was performed from inception to March 28, 2022. All clinical studies that included patients who were subjected to prepectoral IBBR and PMRT were included. Studies that included patients who received radiation therapy before prepectoral IBBR were excluded. RESULTS This systematic review included six articles encompassing 1234 reconstructed breasts. Of them, 391 breasts were subjected to PMRT, while 843 breasts were not subjected. Irradiated breasts were more susceptible to develop wound infection (RR 2.49; 95% 1.43, 4.35; P = 0.001) and capsular contracture (RR 5.17; 95% 1.93, 13.80; P = 0.001) than the non-irradiated breasts. Furthermore, irradiated breasts were more vulnerable to losing implants (RR 2.89; 95% 1.30, 6.39; P = 0.009) than the non-irradiated breast. There was no significant difference between both groups regarding the risk of implant extrusion (RR 1.88; 95% 0.20, 17.63; P = 0.58). CONCLUSIONS Patients with prepectorally IBBR and PMRT were more vulnerable to developing poor outcomes. This included a higher risk of breast-related and implant-related adverse events. 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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Comparison of Autologous Breast Reconstruction Complications by Type of Neoadjuvant Chemotherapy Regimen. Plast Reconstr Surg 2021; 148:1186-1196. [PMID: 34644277 DOI: 10.1097/prs.0000000000008505] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Neoadjuvant chemotherapy before mastectomy helps reduce tumor burden and pathologic response in breast cancer. Limited evidence exists regarding how neoadjuvant chemotherapy impacts outcomes following microvascular breast reconstruction. This study examines the effects of neoadjuvant chemotherapy regimens and schedules on microvascular breast reconstruction complication rates and also assesses the effects of neoadjuvant chemotherapy on circulating immune cells related to wound healing. METHODS Patients who underwent neoadjuvant chemotherapy and microvascular breast reconstruction at Yale New Haven Hospital between 2013 and 2018 were identified. Demographic variables, oncologic history, chemotherapy regimens, and complication profiles were collected. Chemotherapy regimens were stratified by inclusion of anthracycline and order of taxane administration. Chi-square, Fisher's exact, and t tests were used for univariate analysis. Multivariate binary logistic regression was used to control for covariates. RESULTS One hundred patients met inclusion criteria. On multivariate analysis, the administration of taxane first in an anthracycline-containing chemotherapy sequence was associated with increased complications (OR, 3.521; p = 0.012), particularly fat necrosis (OR, 2.481; p = 0.040). In the logistic regression model evaluating the effect of the taxane-first regimen on complication rates, the area under the curve was estimated to be 0.760 (p < 0.0001), particularly fat necrosis 0.635 (p < 0.05). The dosage of chemotherapy, number of days between neoadjuvant chemotherapy completion and surgery, and number of circulating immune cells did not significantly differ among patients who experienced complications. CONCLUSIONS Taxane-first, anthracycline-containing neoadjuvant chemotherapy regimens were associated with increased complications, particularly fat necrosis. The increased postreconstruction complication risk must be weighed against the benefits of taxane-first regimens in improving tumor outcome. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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Superficial Thinning of the DIEP Flap: A Safe Option to Achieve an Aesthetic Reconstructed Breast in the Obese Patient. Plast Reconstr Surg 2021; 148:715e-719e. [PMID: 34705771 DOI: 10.1097/prs.0000000000008481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Abdominal flap-based breast reconstruction is challenging in the overweight and obese population not only because of increased donor-site complications, but also because excessive flap thickness makes inset cumbersome, requiring thinning and remodeling that frequently result in aesthetically poor outcomes. METHODS The authors started by studying 10 deep inferior epigastric artery perforator flaps with angiographic computed tomography. Then, they prospectively performed 21 breast reconstructions using a superficial thinning technique reliant on a constant suprafascial vessel as the pedicle for the remaining deep fat and compared the rate of complications with their previous experience using traditional flap thinning techniques. RESULTS All samples studied showed a suprafascial division of the main perforator. Two constant branches were identified, one coursing over the Scarpa fascia and displaying a robust network of linking vessels with the subcutaneous and subdermal plexuses. That anatomical insight was used to develop a flap-thinning technique tested on 21 consecutive high-body mass index patients. A 7-year retrospective analysis (n = 164) showed no significant correlation between body mass index and incidence of complications except for a long-term upper pole step deformity that was associated with increasing body mass index (p = 0.001). No statistically significant difference in complications was found comparing high-body mass index patients from the retrospective group (n = 72) with the superficial thinning group, but a highly suggestive difference (p = 0.061) was found regarding the avoidance of the step deformity using the superficial thinning technique. CONCLUSION The presence of a constant suprafascial perforator branch makes superficial DIEP thinning a safe technique that facilitates inset and improves the reconstructed breast contour of obese patients. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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Radiation Oncology Applications in Plastic and Reconstructive Surgery: A Nonsystematic Review of Concepts and Principles. Plast Reconstr Surg 2021; 147:314e-324e. [PMID: 33565838 DOI: 10.1097/prs.0000000000007582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
SUMMARY Careful consideration of radiotherapy can determine the success of reconstructive therapy. There is a broad spectrum of radiotherapy modalities, both benign and malignant. Delivery mechanisms differ in the physical design, setup, radiation source, administrable dosage, and mode of delivery. This range of options allows radiation oncologists to tailor individualized treatment; however, radiotherapy concepts can be challenging for nonspecialists. The purpose of this article is to review general radiation oncology concepts, including essential equipment and radiobiology, and provide plastic surgeons with a basic conceptual understanding to facilitate effective multidisciplinary collaboration with radiation oncologists.
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9
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Patel AA, Arquette CP, Yesantharao PS, Borrelli MR, Broderick KP, Cheesborough JE, Lee GK, Nazerali RS. Examining the Effects of Postmastectomy Radiation Therapy in Prepectoral Versus Subpectoral Autologous Breast Reconstruction. Ann Plast Surg 2021; 86:S390-S394. [PMID: 33976068 DOI: 10.1097/sap.0000000000002762] [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: 11/27/2022]
Abstract
BACKGROUND Postmastectomy radiation therapy (PMRT) is known to increase the risk of multiple adverse outcomes after breast reconstruction. In the context of delayed-immediate autologous breast reconstruction, PMRT is typically conducted after placement of subpectoral (SP) tissue expanders. With the re-emergence of prepectoral (PP) reconstruction, there are little data assessing the outcomes of PP reconstruction in breasts receiving PMRT. We compared postoperative outcomes of PMRT patients undergoing delayed-immediate, autologous breast reconstruction with placement of tissue expanders in either the PP or SP plane. METHODS A retrospective chart review was conducted on all consecutive patients who underwent delayed-immediate autologous breast reconstruction and received PMRT at either the Stanford University or the Johns Hopkins University Hospitals between January 2009 and December 2018. Demographics, comorbidities, perioperative information, and oncologic data were collected for all patients. Complications were collected and analyzed after stage 1 surgery, between 30 days of stage 1 and up to stage 2 surgery, and after stage 2 surgery. Multivariable regressions were used to determine predictors of 1 or more complications. RESULTS A total of 71 patients (73 breasts) were included. Prepectoral reconstruction comprised of 52.2% of the cohort, and the remaining 47.8% were SP reconstructions. Demographics and comorbidities were similar between groups, except for premastectomy radiation, which was more prevalent in the PP cohort (P = 0.010). Complications were similar between cohorts after stage 1 surgery (P = 0.420), between stages 1 and 2 (P = 0.100), and after stage 2 (P = 0.570). There were higher rates of skin necrosis in the SP cohort between stages 1 and 2 (PP: 2.6%, SP: 20%, P = 0.004). Multivariable analysis revealed body mass index to be the only predictor of complication (P = 0.041). The mean number of revisionary surgeries was higher in the SP cohort (PP: 0.8 vs SP: 1.9, P = 0.002). The mean follow-up was 385.5 days and similar between groups (P = 0.870). CONCLUSIONS Rates of overall complication were similar between PP and SP expander placement. However, in SP reconstructions, skin necrosis was significantly higher between stages 1 and 2. The patients in the SP cohort also underwent a greater number of revisionary surgeries, although overall rates of pursuing any revisionary surgery were similar between groups.
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Affiliation(s)
- Ashraf A Patel
- From the College of Medicine, SUNY Upstate Medical University, Syracuse, NY
| | - Connor P Arquette
- Division of Plastic and Reconstructive Surgery, Stanford University Medical Center, Palo Alto, CA
| | - Pooja S Yesantharao
- Department of Plastic and Reconstructive Surgery, The John Hopkins Hospital, Baltimore, MD
| | - Mimi R Borrelli
- Division of Plastic and Reconstructive Surgery, Stanford University Medical Center, Palo Alto, CA
| | - Kristen P Broderick
- Department of Plastic and Reconstructive Surgery, The John Hopkins Hospital, Baltimore, MD
| | - Jennifer E Cheesborough
- Division of Plastic and Reconstructive Surgery, Stanford University Medical Center, Palo Alto, CA
| | - Gordon K Lee
- Division of Plastic and Reconstructive Surgery, Stanford University Medical Center, Palo Alto, CA
| | - Rahim S Nazerali
- Division of Plastic and Reconstructive Surgery, Stanford University Medical Center, Palo Alto, CA
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10
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Outcomes of Immediate Implant-Based Mastectomy Reconstruction in Women with Previous Breast Radiotherapy. Plast Reconstr Surg 2020; 145:1029e-1036e. [PMID: 32195865 DOI: 10.1097/prs.0000000000006811] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The objective of this study was to determine whether women with a history of radiation therapy before mastectomy experience a risk for postoperative complications and patient-reported outcomes similar to those of women undergoing postmastectomy radiation therapy in the setting of immediate implant reconstruction. METHODS The cohort included patients undergoing immediate implant reconstruction at 11 centers across North America. Women were categorized into three groups: prior breast conservation therapy, postmastectomy radiation therapy, and no radiation therapy. Mixed effect logistic regressions were used to analyze the effects of radiation therapy status on complication rates and patient-reported outcomes. RESULTS ONE THOUSAND FIVE HUNDRED NINETY-FOUR: patients were analyzed, including 84 women with prior breast conservation therapy, 329 women who underwent postmastectomy radiation therapy, and 1181 women with no history of radiation therapy. Compared with postmastectomy radiation therapy, breast conservation was associated with lower rates of all complications and major complications (OR, 0.65; 95 percent CI, 0.37 to 1.14; p = 0.13; and OR, 0.61; 95 percent CI, 0.33 to 1.13; p = 0.12). These differences were not statistically significant. Rates of reconstructive failure between the two cohorts were comparable. Before reconstruction, satisfaction with breasts was lowest for women with prior breast conservation therapy (p < 0.001). At 2 years postoperatively, satisfaction with breasts was lower for women with postmastectomy radiation therapy compared with breast conservation patients (p = 0.007). CONCLUSIONS Higher postoperative complication rates were observed in women exposed to radiation therapy regardless of timing. Although women with prior breast conservation experienced greater satisfaction with their breasts and fewer complications when compared to women undergoing postmastectomy radiation therapy, there was a similar risk for reconstruction failure. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, II.
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11
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12
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Young WA, Degnim AC, Hoskin TL, Jakub JW, Nguyen MD, Tran NV, Harless CA, Manrique OJ, Boughey JC, Hieken TJ. Outcomes of > 1300 Nipple-Sparing Mastectomies with Immediate Reconstruction: The Impact of Expanding Indications on Complications. Ann Surg Oncol 2019; 26:3115-3123. [DOI: 10.1245/s10434-019-07560-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Indexed: 11/18/2022]
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13
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Jensen JA, Bakkar R, Burnison M, Giuliano AE. Lymphovascular Invasion and the Decision for Postmastectomy Radiation Therapy: A Cautionary Case Report. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2019; 7:e2115. [PMID: 30881840 PMCID: PMC6416125 DOI: 10.1097/gox.0000000000002115] [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: 08/01/2018] [Accepted: 12/05/2018] [Indexed: 11/25/2022]
Abstract
Breast reconstruction is frequently adversely affected by postmastectomy radiation therapy. Some radiation therapists recommend postmastectomy radiation therapy based on the finding of lymphovascular invasion in the context of other findings. However, the diagnosis of lymphovascular invasion varies between pathologists and institutions. Sometimes special endothelial cell stains and outside opinions are necessary for the decision for postmastectomy radiation therapy. This case report illustrates the variation in the diagnosis of lymphovascular invasion. Plastic surgeons must remain current on the standard indications for postmastectomy radiation therapy and on the basic findings of lymphovascular invasion.
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Affiliation(s)
- J Arthur Jensen
- Division of Plastic Surgery, Cedars Sinai Medical Center, Los Angeles, Calif
| | - Rania Bakkar
- Division of Pathology, Cedars Sinai Medical Center, Los Angeles, Calif
| | - Michele Burnison
- Division of Radiation Therapy, Cedars Sinai Medical Center, Los Angeles, Calif
| | - Armando E Giuliano
- Division of Surgical Breast Oncology, Cedars Sinai Medical Center, Los Angeles, Calif
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14
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Grabinski VF, Myckatyn TM, Lee CN, Philpott-Streiff SE, Politi MC. Importance of Shared Decision-Making for Vulnerable Populations: Examples from Postmastectomy Breast Reconstruction. Health Equity 2018; 2:234-238. [PMID: 30283872 PMCID: PMC6167005 DOI: 10.1089/heq.2018.0020] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Shared decision-making (SDM) is a process through which patients and providers collaborate to select a treatment option that aligns with patients' preferences and clinical context. SDM can improve patients' decision quality and satisfaction. However, vulnerable populations face barriers to participation in SDM, which exacerbates disparities in decision quality. This perspective article discusses SDM with vulnerable patients, using examples from patients who made decisions about postmastectomy breast reconstruction. We offer several strategies for clinical practice, medical education, and research to ensure that movements to engage patients in SDM do not exclude already marginalized groups.
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Affiliation(s)
- Victoria F Grabinski
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Terence M Myckatyn
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Clara N Lee
- Department of Plastic and Reconstructive Surgery, College of Medicine, The Ohio State University, Columbus, Ohio.,Division of Health Services Management and Policy, College of Public Health, The Ohio State University, Columbus, Ohio
| | - Sydney E Philpott-Streiff
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Mary C Politi
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
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15
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Beugels J, Bod L, van Kuijk SMJ, Qiu SS, Tuinder SMH, Heuts EM, Piatkowski A, van der Hulst RRWJ. Complications following immediate compared to delayed deep inferior epigastric artery perforator flap breast reconstructions. Breast Cancer Res Treat 2018; 169:349-357. [PMID: 29399731 PMCID: PMC5945748 DOI: 10.1007/s10549-018-4695-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Accepted: 01/24/2018] [Indexed: 11/26/2022]
Abstract
Purpose As more breast cancer patients opt for immediate breast reconstruction, the incidence of complications should be evaluated. The aim of this study was to analyze the recipient-site complications and flap re-explorations of immediate compared to delayed deep inferior epigastric artery perforator (DIEP) flap breast reconstructions. Methods For this multicenter retrospective cohort study, the medical records of all patients who underwent DIEP flap breast reconstruction in three hospitals in the Netherlands between January 2010 and June 2017 were reviewed. Patient demographics, risk factors, timing of reconstruction, recipient-site complications, and flap re-explorations were recorded. Results A total of 910 DIEP flap breast reconstructions (n = 397 immediate and n = 513 delayed reconstructions) in 737 patients were included. There were no significant differences in major complications or flap re-explorations between immediate and delayed reconstructions. The total flap failure rate was 1.5 and 2.5% in the immediate and delayed group, respectively. Significantly more hematomas (OR 2.91; 95% CI 1.59–5.30; p = 0.001) and seromas (OR 3.60; 95% CI 1.14–11.4; p = 0.029) occurred in immediate reconstructions, whereas wound problems were more frequently observed in delayed reconstructions (OR 1.99; 95% CI 1.27–3.11; p = 0.003). Correction for potential confounders still showed significant differences for hematoma and seroma, but no longer for wound problems (p = 0.052). Conclusions This study demonstrated similar incidences of major recipient-site complications and flap re-explorations between immediate and delayed DIEP flap breast reconstructions. However, hematoma and seroma occurred significantly more often in immediate reconstructions, while wound problems were more frequently observed in delayed reconstructions. Electronic supplementary material The online version of this article (10.1007/s10549-018-4695-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- J Beugels
- Department of Plastic, Reconstructive and Hand Surgery, Maastricht University Medical Centre, P.O. Box 5800, 6202 AZ, Maastricht, The Netherlands.
- GROW - School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands.
| | - L Bod
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - S M J van Kuijk
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Center, Maastricht, The Netherlands
| | - S S Qiu
- Department of Plastic, Reconstructive and Hand Surgery, Maastricht University Medical Centre, P.O. Box 5800, 6202 AZ, Maastricht, The Netherlands
| | - S M H Tuinder
- Department of Plastic, Reconstructive and Hand Surgery, Maastricht University Medical Centre, P.O. Box 5800, 6202 AZ, Maastricht, The Netherlands
| | - E M Heuts
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - A Piatkowski
- Department of Plastic, Reconstructive and Hand Surgery, Maastricht University Medical Centre, P.O. Box 5800, 6202 AZ, Maastricht, The Netherlands
- Department of Plastic, Reconstructive and Hand Surgery, VieCuri Medical Center, Venlo, The Netherlands
| | - R R W J van der Hulst
- Department of Plastic, Reconstructive and Hand Surgery, Maastricht University Medical Centre, P.O. Box 5800, 6202 AZ, Maastricht, The Netherlands
- Department of Plastic, Reconstructive and Hand Surgery, VieCuri Medical Center, Venlo, The Netherlands
- Department of Plastic, Reconstructive and Hand Surgery, Zuyderland Medical Center, Sittard-Geleen, The Netherlands
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Multicentre study of patient-reported and clinical outcomes following immediate and delayed Autologous Breast Reconstruction And Radiotherapy (ABRAR study). J Plast Reconstr Aesthet Surg 2018; 71:185-193. [DOI: 10.1016/j.bjps.2017.10.030] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2017] [Revised: 10/08/2017] [Accepted: 10/13/2017] [Indexed: 11/30/2022]
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17
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Considering the Optimal Timing of Breast Reconstruction With Abdominal Flaps With Adjuvant Irradiation in 370 Consecutive Pedicled Transverse Rectus Abdominis Myocutaneous Flap and Free Deep Inferior Epigastric Perforator Flap Performed in a Chinese Oncology Center: Is There a Significant Difference Between Immediate and Delayed? Ann Plast Surg 2018; 78:633-640. [PMID: 27798424 PMCID: PMC5434969 DOI: 10.1097/sap.0000000000000927] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE There is an ongoing debate on the optimal sequence of radiation and breast reconstruction. The purpose of this article was to (a) assess the impact of radiation on autologous breast reconstruction and (b) analyze the best timing for autologous breast reconstruction in the setting of radiation in a Chinese population. METHODS A retrospective review of patients undergoing breast reconstruction with autologous lower abdominal flaps between 2001 and 2014 in the Tianjin Medical University and Cancer Hospital was performed. Patients were grouped by their irradiation status (irradiated vs nonirradiated). The irradiated group was further stratified into 2 groups by the timing of irradiation (immediate breast reconstruction followed by radiation vs prior radiation and delayed breast reconstruction). The primary outcomes were early and late breast complications, secondary and revision surgeries to the reconstructed breast, whereas the secondary outcomes were aesthetic and psychological evaluations of the patients. Logistic regression was used to assess the potential association between irradiation, patient and treatment variables, and surgical outcomes. RESULTS Three hundred sixty patients with 370 reconstructed breasts were included in the study. Two hundred seventy-eight cases were nonirradiated, of which 158 were immediate and 120 were delayed. Ninety-two cases were irradiated, of which 61 were immediate, and 31 were delayed. Three hundred thirty-two cases underwent pedicled transverse rectus abdominis myocutaneous flap, 38 had deep inferior epigastric perforator flap. The irradiated group had a significant increase in secondary surgery due to fat necrosis (P < 0.001) and in late complications (P = 0.011). A significant increase in flap contracture (P = 0.043) and an increasing trend in the severity of fat necrosis were observed when radiation was performed after breast reconstruction. However, radiation and its timing did not have an adverse impact on patients' aesthetic and psychological evaluations by the Breast-Q survey. CONCLUSIONS Radiation administered to the reconstructed breast mound increased the rate of late complications and the need for secondary surgery with increased abdominal flap shrinkage and contracture and the severity of flap fat necrosis. Irradiation on the reconstructed breast did not lead to worse aesthetic outcomes due to the generally different expectation in the Chinese female patients in that they were more focused on the breast shape when clothed. Immediate breast reconstruction followed by irradiated was a generally successful treatment sequence in the Chinese module.
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18
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Khan AA, Paget JT, McLaughlin M, Kyula JN, Wilkinson MJ, Pencavel T, Mansfield D, Roulstone V, Seth R, Halle M, Somaiah N, Boult JKR, Robinson SP, Pandha HS, Vile RG, Melcher AA, Harris PA, Harrington KJ. Genetically modified lentiviruses that preserve microvascular function protect against late radiation damage in normal tissues. Sci Transl Med 2018; 10:eaar2041. [PMID: 29367346 PMCID: PMC6020074 DOI: 10.1126/scitranslmed.aar2041] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2016] [Revised: 10/15/2017] [Accepted: 11/08/2017] [Indexed: 12/25/2022]
Abstract
Improvements in cancer survival mean that long-term toxicities, which contribute to the morbidity of cancer survivorship, are being increasingly recognized. Late adverse effects (LAEs) in normal tissues after radiotherapy (RT) are characterized by vascular dysfunction and fibrosis causing volume loss and tissue contracture, for example, in the free flaps used for immediate breast reconstruction after mastectomy. We evaluated the efficacy of lentivirally delivered superoxide dismutase 2 (SOD2) overexpression and connective tissue growth factor (CTGF) knockdown by short hairpin RNA in reducing the severity of LAEs in an animal model of free flap LAEs. Vectors were delivered by intra-arterial injection, ex vivo, to target the vascular compartment. LVSOD2 and LVshCTGF monotherapy before irradiation resulted in preservation of flap volume or reduction in skin contracture, respectively. Flaps transduced with combination therapy experienced improvements in both volume loss and skin contracture. Both therapies reduced the fibrotic burden after irradiation. LAEs were associated with impaired vascular perfusion, loss of endothelial permeability, and stromal hypoxia, which were all reversed in the treatment model. Using a tumor recurrence model, we showed that SOD2 overexpression in normal tissues did not compromise the efficacy of RT against tumor cells but appeared to enhance it. LVSOD2 and LVshCTGF combination therapy by targeted, intravascular delivery reduced LAE severities in normal tissues without compromising the efficacy of RT and warrants translational evaluation as a free flap-targeted gene therapy.
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Affiliation(s)
- Aadil A Khan
- Targeted Therapy Team, Division of Radiotherapy and Imaging, The Institute of Cancer Research, London SW3 6JB, UK
- Department of Plastic Surgery, The Royal Marsden Hospital, London SW3 6JJ, UK
| | - James T Paget
- Targeted Therapy Team, Division of Radiotherapy and Imaging, The Institute of Cancer Research, London SW3 6JB, UK
- Department of Plastic Surgery, The Royal Marsden Hospital, London SW3 6JJ, UK
| | - Martin McLaughlin
- Targeted Therapy Team, Division of Radiotherapy and Imaging, The Institute of Cancer Research, London SW3 6JB, UK
| | - Joan N Kyula
- Targeted Therapy Team, Division of Radiotherapy and Imaging, The Institute of Cancer Research, London SW3 6JB, UK
| | - Michelle J Wilkinson
- Targeted Therapy Team, Division of Radiotherapy and Imaging, The Institute of Cancer Research, London SW3 6JB, UK
| | - Timothy Pencavel
- Targeted Therapy Team, Division of Radiotherapy and Imaging, The Institute of Cancer Research, London SW3 6JB, UK
| | - David Mansfield
- Targeted Therapy Team, Division of Radiotherapy and Imaging, The Institute of Cancer Research, London SW3 6JB, UK
| | - Victoria Roulstone
- Targeted Therapy Team, Division of Radiotherapy and Imaging, The Institute of Cancer Research, London SW3 6JB, UK
| | - Rohit Seth
- Targeted Therapy Team, Division of Radiotherapy and Imaging, The Institute of Cancer Research, London SW3 6JB, UK
| | - Martin Halle
- Department of Molecular Medicine and Surgery, Section of Plastic Surgery, Karolinska Institute, Stockholm 17176, Sweden
- Department of Reconstructive Plastic Surgery, Karolinska University Hospital, Stockholm 17176, Sweden
| | - Navita Somaiah
- Targeted Therapy Team, Division of Radiotherapy and Imaging, The Institute of Cancer Research, London SW3 6JB, UK
| | - Jessica K R Boult
- Magnetic Resonance Team, Division of Radiotherapy and Imaging, The Institute of Cancer Research, London SM2 5NG, UK
| | - Simon P Robinson
- Magnetic Resonance Team, Division of Radiotherapy and Imaging, The Institute of Cancer Research, London SM2 5NG, UK
| | - Hardev S Pandha
- Postgraduate Medical School, University of Surrey, Guildford GU2 7XH, UK
| | - Richard G Vile
- Molecular Medicine Program, Mayo Clinic, Rochester, MN 55905, USA
| | - Alan A Melcher
- Translational Immunotherapy Team, Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, SW3 6JB, UK
| | - Paul A Harris
- Department of Plastic Surgery, The Royal Marsden Hospital, London SW3 6JJ, UK
| | - Kevin J Harrington
- Targeted Therapy Team, Division of Radiotherapy and Imaging, The Institute of Cancer Research, London SW3 6JB, UK.
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19
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Mohiuddin W, Chevrollier G, Greaney P, Jenkins M, Copit S. Optimizing Results of Postmastectomy Radiation Therapy Utilizing the Latissimus Dorsi Flap and Tissue Expander Technique: A Single-Center Experience. EPLASTY 2017; 17:e40. [PMID: 29308108 PMCID: PMC5741561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Objective: Postmastectomy radiation therapy is a well-established risk factor for complications after breast reconstruction. Even if the surgeon has a suspicion that radiation therapy may be needed, it may be beneficial to place tissue expanders during the mastectomy procedure as a temporizing measure, complete radiation therapy, and then reconstruct the breast with a latissimus flap. The purpose of this study was to examine the complication rates of the latissimus dorsi flap as compared with the complication rates of implant-based reconstruction in the setting of radiation therapy. Methods: A 16-year retrospective chart review from 2000 to 2016 was conducted. All patients who underwent temporizing tissue expander placement for radiotherapy with subsequent latissimus flap reconstruction were included in the study. Patients who did not follow up for implant exchange were excluded from the study. Results: Fifty-five patients were identified with an average age of 46.0 years (range, 27-67 years) and an average body mass index of 24.2 (range, 18.9-31.9). Five patients (9.1%) developed capsular contractures amenable to surgical intervention. One patient (1.8%) developed infection of the tissue expander, requiring removal. There were no incidences of flap failure or wound dehiscence. The average follow-up after latissimus flap reconstruction was 25.3 months (range, 3.7-121.6 months). Conclusions: We feel that the latissimus dorsi flap after postmastectomy radiation therapy represents the preferred implant-based reconstruction option to consider when the need for postmastectomy radiation therapy is anticipated. The latissimus dorsi flap remains a safe, effective solution to postmastectomy radiation therapy that every plastic surgeon should offer.
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Affiliation(s)
- Waseem Mohiuddin
- Division of Plastic Surgery, Thomas Jefferson University Hospital, Philadelphia, Pa Presented at: The Northwest Society of Plastic Surgeons Annual Meeting, February 18-22, 2017, Big Sky, Mont.,Correspondence:
| | - Guillaume S. Chevrollier
- Division of Plastic Surgery, Thomas Jefferson University Hospital, Philadelphia, Pa Presented at: The Northwest Society of Plastic Surgeons Annual Meeting, February 18-22, 2017, Big Sky, Mont
| | - Patrick J. Greaney
- Division of Plastic Surgery, Thomas Jefferson University Hospital, Philadelphia, Pa Presented at: The Northwest Society of Plastic Surgeons Annual Meeting, February 18-22, 2017, Big Sky, Mont
| | - Matthew P. Jenkins
- Division of Plastic Surgery, Thomas Jefferson University Hospital, Philadelphia, Pa Presented at: The Northwest Society of Plastic Surgeons Annual Meeting, February 18-22, 2017, Big Sky, Mont
| | - Steven E. Copit
- Division of Plastic Surgery, Thomas Jefferson University Hospital, Philadelphia, Pa Presented at: The Northwest Society of Plastic Surgeons Annual Meeting, February 18-22, 2017, Big Sky, Mont
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20
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Jagsi R, Momoh AO, Qi J, Hamill JB, Billig J, Kim HM, Pusic AL, Wilkins EG. Impact of Radiotherapy on Complications and Patient-Reported Outcomes After Breast Reconstruction. J Natl Cancer Inst 2017; 110:4157682. [PMID: 28954300 DOI: 10.1093/jnci/djx148] [Citation(s) in RCA: 154] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Accepted: 06/27/2017] [Indexed: 01/30/2023] Open
Abstract
Background Patients considering postmastectomy radiation and reconstruction require information regarding expected outcomes to make preference-concordant decisions. Methods A prospective multicenter cohort study of women diagnosed with breast cancer at 11 centers between 2012 and 2015 compared complications and patient-reported outcomes of 622 irradiated and 1625 unirradiated patients who received reconstruction. Patient characteristics and outcomes between irradiated and unirradiated patients were analyzed using ttests for continuous variables and chi-square tests for categorical variables. Multivariable mixed-effects regression modelsassessed the impact of reconstruction type and radiotherapy on outcomes after adjusting for relevant covariates. All statistical tests were two-sided. Results Autologous reconstruction was more commonly received by irradiated patients (37.9% vs 25.0%, P < .001). Immediate reconstruction was less common in irradiated patients (83.0% vs 95.7%, P < .001). At least one breast complication had occurred by two years in 38.9% of irradiated patients with implant reconstruction, 25.6% of irradiated patients with autologous reconstruction, 21.8% of unirradiated patients with implant reconstruction, and 28.3% of unirradiated patients with autologous reconstruction. Multivariable analysis showed bilateral treatment and higher body mass index to be predictive of developing a complication, with a statistically significant interaction between radiotherapy receipt and reconstruction type. Among irradiated patients, autologous reconstruction was associated with a lower risk of complications than implant-based reconstruction at two years (odds ratio [OR] = 0.47, 95% confidence interval [CI] = 0.27 to 0.82, P = .007); no between-procedure difference was found in unirradiated patients. The interaction was also statistically significant for satisfaction with breasts at two years (P = .002), with larger adjusted difference in satisfaction between autologous vs implant approaches (63.5, 95% CI = 55.9 to 71.1, vs 47.7, 95% CI = 40.2 to 55.2, respectively) in irradiated patients than between autologous vs implant approaches (67.6, 95% CI = 60.3 to 74.9, vs 60.5, 95% CI = 53.6 to 67.4) in unirradiated patients. Conclusions Autologous reconstruction appears to yield superior patient-reported satisfaction and lower risk of complications than implant-based approaches among patients receiving postmastectomy radiotherapy.
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Affiliation(s)
- Reshma Jagsi
- Department of Radiation Oncology, Section of Plastic Surgery, Center for Statistical Consultation and Research, University of Michigan, Ann Arbor, MI; Division of Plastic and Reconstructive Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Adeyiza O Momoh
- Department of Radiation Oncology, Section of Plastic Surgery, Center for Statistical Consultation and Research, University of Michigan, Ann Arbor, MI; Division of Plastic and Reconstructive Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Ji Qi
- Department of Radiation Oncology, Section of Plastic Surgery, Center for Statistical Consultation and Research, University of Michigan, Ann Arbor, MI; Division of Plastic and Reconstructive Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Jennifer B Hamill
- Department of Radiation Oncology, Section of Plastic Surgery, Center for Statistical Consultation and Research, University of Michigan, Ann Arbor, MI; Division of Plastic and Reconstructive Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Jessica Billig
- Department of Radiation Oncology, Section of Plastic Surgery, Center for Statistical Consultation and Research, University of Michigan, Ann Arbor, MI; Division of Plastic and Reconstructive Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Hyungjin M Kim
- Department of Radiation Oncology, Section of Plastic Surgery, Center for Statistical Consultation and Research, University of Michigan, Ann Arbor, MI; Division of Plastic and Reconstructive Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Andrea L Pusic
- Department of Radiation Oncology, Section of Plastic Surgery, Center for Statistical Consultation and Research, University of Michigan, Ann Arbor, MI; Division of Plastic and Reconstructive Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Edwin G Wilkins
- Department of Radiation Oncology, Section of Plastic Surgery, Center for Statistical Consultation and Research, University of Michigan, Ann Arbor, MI; Division of Plastic and Reconstructive Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
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Cooke AL, Diaz-Abele J, Hayakawa T, Buchel E, Dalke K, Lambert P. Radiation Therapy Versus No Radiation Therapy to the Neo-breast Following Skin-Sparing Mastectomy and Immediate Autologous Free Flap Reconstruction for Breast Cancer: Patient-Reported and Surgical Outcomes at 1 Year—A Mastectomy Reconstruction Outcomes Consortium (MROC) Substudy. Int J Radiat Oncol Biol Phys 2017; 99:165-172. [DOI: 10.1016/j.ijrobp.2017.05.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Revised: 04/19/2017] [Accepted: 05/01/2017] [Indexed: 11/12/2022]
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22
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Coady-Fariborzian L, Anstead C, Leyngold M, McGuire J. Assessment of Free Flap Breast Reconstructions. Fed Pract 2017; 34:33-36. [PMID: 30766297 PMCID: PMC6370455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Free flap breast reconstruction may be offered as a treatment option at federal facilities with appropriate patient selection and planning.
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Affiliation(s)
| | - Christy Anstead
- and are surgeons, and is a nurse practitioner, all at Malcom Randall VAMC in Gainesville, Florida
| | - Mark Leyngold
- and are surgeons, and is a nurse practitioner, all at Malcom Randall VAMC in Gainesville, Florida
| | - James McGuire
- and are surgeons, and is a nurse practitioner, all at Malcom Randall VAMC in Gainesville, Florida
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Multivariate Preoperative and Intraoperative Predictors of Postmastectomy Radiation Therapy in Patients for Whom Immediate Breast Reconstruction Is Planned. Plast Reconstr Surg 2017; 139:599e-605e. [DOI: 10.1097/prs.0000000000003052] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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24
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Fewer Revisions in Abdominal-based Free Flaps than Latissimus Dorsi Breast Reconstruction after Radiation. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2016; 4:e866. [PMID: 27757331 PMCID: PMC5054997 DOI: 10.1097/gox.0000000000000811] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Accepted: 05/17/2016] [Indexed: 02/04/2023]
Abstract
The most commonly chosen flaps for delayed breast reconstruction after postmastectomy radiation therapy (PMRT) are abdominal-based free flaps (ABFFs) and pedicled latissimus dorsi (LD) musculocutaneous flaps. The short-and long-term advantages and disadvantages of delayed ABFFs versus LD flaps after PMRT remain unclear. We hypothesized that after PMRT, ABFFs would result in fewer postoperative complications and a lower incidence of revision surgery than LD flaps.
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25
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O'Grady B. Surgical Options for Post-Mastectomy Breast Reconstruction. PHYSICIAN ASSISTANT CLINICS 2016. [DOI: 10.1016/j.cpha.2016.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Huang NS, Quan CL, Ma LXX, Si J, Chen JJ, Yang BL, Huang XY, Liu GY, Shen ZZ, Shao ZM, Wu J. Current status of breast reconstruction in China: an experience of 951 breast reconstructions from a single institute. Gland Surg 2016; 5:278-86. [PMID: 27294034 DOI: 10.21037/gs.2016.03.01] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Since mastectomy remained the primary strategy for treating breast cancer in China, post-mastectomy reconstruction is of great importance in the Chinese population. The current study aimed to assess the current status of breast reconstruction in China. METHODS We reviewed all patients who received breast reconstruction from August 2000 to July 2015 in the Department of Breast Surgery in our institute. Patients' baseline characteristics, reconstruction strategy, final pathology and loco-regional recurrence (LRR) information were collected. RESULTS A total of 951 breast reconstructions were conducted during the past 15 years, among which 247 (27.0%) were abdominal flap reconstruction; 471 (51.5%) were latissimus dorsi myocutaneous ± implant; and 233 (25.5%) were prosthesis-based reconstruction. The majority of cases (78.1%) were invasive breast cancer and up to 894 cases (94.0%) were immediate reconstruction. Prosthesis-based reconstruction rapidly increased in recent years, and was associated with bilateral reconstruction, contralateral augmentation and higher complications. 18 patients (2.0%) developed local-regional recurrence at the median follow-up time of 26.6 months (range, 3.7-62.0 months). A total of 66 nipple-areolar complex-sparing mastectomies (NSMs) (6.9%) were performed, none of which developed recurrence. CONCLUSIONS Breast reconstruction cases increased over the 15 years with the change of paradigm. Most strikingly, prosthesis-based reconstruction rapidly gained its prevalence and became the most common strategy. NSM was only performed for highly selected patients. Patients with breast reconstruction were able to achieve satisfactory loco-regional control in our cohort.
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Affiliation(s)
- Nai-Si Huang
- 1 Department of Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China ; 2 Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China ; 3 Collaborative Innovation Center for Cancer Medicine, Guangzhou 510060, China
| | - Chen-Lian Quan
- 1 Department of Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China ; 2 Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China ; 3 Collaborative Innovation Center for Cancer Medicine, Guangzhou 510060, China
| | - Lin-Xiao-Xi Ma
- 1 Department of Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China ; 2 Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China ; 3 Collaborative Innovation Center for Cancer Medicine, Guangzhou 510060, China
| | - Jing Si
- 1 Department of Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China ; 2 Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China ; 3 Collaborative Innovation Center for Cancer Medicine, Guangzhou 510060, China
| | - Jia-Jian Chen
- 1 Department of Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China ; 2 Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China ; 3 Collaborative Innovation Center for Cancer Medicine, Guangzhou 510060, China
| | - Ben-Long Yang
- 1 Department of Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China ; 2 Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China ; 3 Collaborative Innovation Center for Cancer Medicine, Guangzhou 510060, China
| | - Xiao-Yan Huang
- 1 Department of Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China ; 2 Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China ; 3 Collaborative Innovation Center for Cancer Medicine, Guangzhou 510060, China
| | - Guang-Yu Liu
- 1 Department of Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China ; 2 Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China ; 3 Collaborative Innovation Center for Cancer Medicine, Guangzhou 510060, China
| | - Zhen-Zhou Shen
- 1 Department of Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China ; 2 Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China ; 3 Collaborative Innovation Center for Cancer Medicine, Guangzhou 510060, China
| | - Zhi-Min Shao
- 1 Department of Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China ; 2 Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China ; 3 Collaborative Innovation Center for Cancer Medicine, Guangzhou 510060, China
| | - Jiong Wu
- 1 Department of Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China ; 2 Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China ; 3 Collaborative Innovation Center for Cancer Medicine, Guangzhou 510060, China
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Complications After Mastectomy and Immediate Breast Reconstruction for Breast Cancer: A Claims-Based Analysis. Ann Surg 2016; 263:219-27. [PMID: 25876011 DOI: 10.1097/sla.0000000000001177] [Citation(s) in RCA: 129] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVE To evaluate complications after postmastectomy breast reconstruction, particularly in the setting of adjuvant radiotherapy. BACKGROUND Most studies of complications after breast reconstruction have been conducted at centers of excellence; relatively little is known about complication rates in irradiated patients treated in the broader community. This information is relevant for decision making in patients with breast cancer. METHODS Using the claims-based MarketScan database, we described complications in 14,894 women undergoing mastectomy for breast cancer from 1998 to 2007 and who underwent immediate autologous reconstruction (n = 2637), immediate implant-based reconstruction (n = 3007), or no reconstruction within the first 2 postoperative years (n = 9250). We used a generalized estimating equation to evaluate associations between complications and radiotherapy over time. RESULTS Wound complications were diagnosed within the first 2 postoperative years in 2.3% of patients without reconstruction, 4.4% patients with implants, and 9.5% patients with autologous reconstruction (P < 0.001). Infection was diagnosed within the first 2 postoperative years in 12.7% of patients without reconstruction, 20.5% with implants, and 20.7% with autologous reconstruction (P < 0.001). A total of 5219 (35%) women received radiation. Radiation was not associated with infection in any surgical group within the first 6 months but was associated with an increased risk of infection in months 7 to 24 in all 3 groups (each P < 0.001). In months 7 to 24, radiation was associated with higher odds of implant removal in patients with implant reconstruction (odds ratio = 1.48; P < 0.001) and fat necrosis in those with autologous reconstruction (odds ratio = 1.55; P = 0.01). CONCLUSIONS Complication risks after immediate breast reconstruction differ by approach. Radiation therapy seems to modestly increase certain risks, including infection and implant removal.
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Patient-reported Quality of Life and Satisfaction With Cosmetic Outcomes After Breast Conservation and Mastectomy With and Without Reconstruction: Results of a Survey of Breast Cancer Survivors. Ann Surg 2016; 261:1198-206. [PMID: 25654742 DOI: 10.1097/sla.0000000000000908] [Citation(s) in RCA: 173] [Impact Index Per Article: 21.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Although breast conservation is therapeutically equivalent to mastectomy for most patients with early-stage breast cancer, an increasing number of patients are pursuing mastectomy, which may be followed by breast reconstruction. We sought to evaluate long-term quality of life and cosmetic outcomes after different locoregional management approaches, as perceived by patients themselves. METHODS We surveyed women with a diagnosis of nonmetastatic breast cancer from 2005 to 2007, as reported to the Los Angeles and Detroit population-based Surveillance, Epidemiology, and End Results registries. We received responses from 2290 women approximately 9 months after diagnosis (73% response rate) and from 1536 of these 4 years later. We evaluated quality of life and patterns and correlates of satisfaction with cosmetic outcomes overall and, more specifically, within the subgroup undergoing mastectomy with reconstruction, using multivariable linear regression. RESULTS Of the 1450 patients who responded to both surveys and experienced no recurrence, 963 underwent breast-conserving surgery, 263 mastectomy without reconstruction, and 222 mastectomy with reconstruction. Cosmetic satisfaction was similar between those receiving breast conservation therapy and those receiving mastectomy with reconstruction. Among patients receiving mastectomy with reconstruction, reconstruction type and radiation receipt were associated with satisfaction (P < 0.001), with an adjusted scaled satisfaction score of 4.7 for patients receiving autologous reconstruction without radiation, 4.4 for patients receiving autologous reconstruction and radiation therapy, 4.1 for patients receiving implant reconstruction without radiation therapy, and 2.8 for patients receiving implant reconstruction and radiation therapy. CONCLUSIONS Patient-reported cosmetic satisfaction was similar after breast conservation and after mastectomy with reconstruction. In patients undergoing postmastectomy radiation, the use of autologous reconstruction may mitigate the deleterious impact of radiation on cosmetic outcomes.
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Hanson S. ‘Reconstruction: Before or after postmastectomy radiotherapy?’ A systematic review of the literature. ACTA ACUST UNITED AC 2016. [DOI: 10.1016/j.breastdis.2016.01.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Does post-mastectomy radiotherapy affect the outcome and prevalence of complications in immediate DIEP breast reconstruction? A prospective cohort study. J Plast Reconstr Aesthet Surg 2015. [DOI: 10.1016/j.bjps.2015.06.003] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Butler PD, Wu LC. Abdominal perforator vs. muscle sparing flaps for breast reconstruction. Gland Surg 2015; 4:212-21. [PMID: 26161306 DOI: 10.3978/j.issn.2227-684x.2015.03.08] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2015] [Accepted: 03/30/2015] [Indexed: 11/14/2022]
Abstract
Abdominally based free flaps have become the mainstay for women that desire to use their own tissue as a means of breast reconstruction after mastectomy. As the techniques have evolved, significant effort has been invested in finding the best means of minimizing morbidity to the abdominal donor site while ensuring a viable reconstructed breast that is aesthetically pleasing. This manuscript reviews and compares the muscle sparing free transverse rectus abdominis myocutaneous (MsfTRAM), the deep inferior epigastric artery perforator (DIEP), and the superficial inferior epigastric artery (SIEA) flaps, regarding flap success rate, operative times, abdominal donor site morbidity and residual functionality, hospital lengths of stay and associated costs, impact of co-morbid conditions, and resilience after adjuvant radiation treatment.
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Affiliation(s)
- Paris D Butler
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, Philadelphia, PA 19104, USA
| | - Liza C Wu
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, Philadelphia, PA 19104, USA
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Clemens MW, Kronowitz SJ. Current perspectives on radiation therapy in autologous and prosthetic breast reconstruction. Gland Surg 2015; 4:222-31. [PMID: 26161307 PMCID: PMC4461707 DOI: 10.3978/j.issn.2227-684x.2015.04.03] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2014] [Accepted: 03/20/2015] [Indexed: 01/08/2023]
Abstract
BACKGROUND Postmastectomy radiation therapy (PMRT) has a well-established deleterious effect on both prosthetic and autologous breast reconstruction. The purpose of this study was to perform a literature review of the effects of PMRT on breast reconstruction and to determine predictive or protective factors for complications. METHODS The MEDLINE and EMBASE databases were reviewed for articles published between January 2008 and January 2015 including the keywords "breast reconstruction" and "radiation therapy" to identify manuscripts focused on the effects of radiation on both prosthetic and autologous breast reconstruction. This subgroup of articles was reviewed in detail. RESULTS Three hundred and twenty articles were identified and 43 papers underwent full text review. The 16 papers provided level III evidence; 10 manuscripts provided level I or II evidence. Seventeen case series provided level IV evidence and were included because they presented novel perspectives. The majority of studies focused on the injurious effects of radiation therapy and increased complications and concomitant lower patient satisfaction. CONCLUSIONS Prosthetic based breast reconstruction and immediate autologous reconstruction are associated with lower patient satisfaction in the setting of radiation therapy. Autologous reconstructions can improve patient satisfaction as well as lower revision surgery and long term complications when performed in a delayed fashion after PMRT.
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Affiliation(s)
- Mark W Clemens
- Department of Plastic Surgery, The University of Texas M.D. Anderson Cancer Center, Houston, TX 77030, USA
| | - Steven J Kronowitz
- Department of Plastic Surgery, The University of Texas M.D. Anderson Cancer Center, Houston, TX 77030, USA
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Nahabedian MY. Achieving ideal breast aesthetics with autologous reconstruction. Gland Surg 2015; 4:134-44. [PMID: 26005645 DOI: 10.3978/j.issn.2227-684x.2015.03.03] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Accepted: 03/05/2015] [Indexed: 11/14/2022]
Abstract
Achieving ideal breast aesthetic has become a top priority for women considering breast reconstruction following mastectomy. The use of autologous tissue is generally regarded as providing the most natural results because donor tissues quality and consistency is similar to that of the native breast. There are several donor sites that are particularly useful for autologous reconstruction that include the abdomen, gluteal region, posterior thorax, and the thigh. Traditional and microsurgical techniques can be used. Shaping is a critical component and involves a basic understanding of the footprint, conus, and skin envelope. This manuscript will review many aspects of breast shaping in-order to achieve aesthetically pleasing results in a predictable manner.
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Affiliation(s)
- Maurice Y Nahabedian
- Department of Plastic Surgery, Georgetown University Hospital, Washington DC 20007, USA
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Abstract
This article reviews the surgical options for breast cancer with emphasis on factors that influence decision making and the data that have driven changes in clinical practice.
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Affiliation(s)
- Jessica Salmans LaCross
- Jessica Salmans LaCross is an instructor at Baylor College of Medicine and practices in Baylor's Michael E. DeBakey Department of Surgery, both in Houston, Tex. The author has disclosed no potential conflicts of interest, financial or otherwise
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Abstract
Women considering breast ablative therapy are confronted with a variety of decisions that include the type of mastectomy (partial, total, skin sparing, nipple areolar sparing), the type of reconstruction (prosthetic, autologous, oncoplastic) and the need for adjuvant therapy (chemotherapy, radiation). The parameters for each are multifactorial and require significant thought and counseling. Therapeutic options are essentially individualized and dependent upon a variety of factors such as tumor size and location, lymph node involvement, comorbidities, expectations and body characteristics. The role of reconstructive surgery is now well appreciated and an integral component of the multidisciplinary care of the patient and is influenced by the opinions and recommendations of surgical, medical and radiation oncologists. This manuscript will review the role of reconstructive surgery and the many factors to consider.
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Affiliation(s)
- Maurice Y Nahabedian
- Department of Plastic Surgery, Georgetown University Hospital, 3800 Reservoir Rd, NW, Washington, DC 20007, USA, Tel.: +1 202 444 6576,
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Thomas K, Rahimi A, Spangler A, Anderson J, Garwood D. Radiation practice patterns among United States radiation oncologists for postmastectomy breast reconstruction and oncoplastic breast reduction. Pract Radiat Oncol 2014; 4:466-71. [DOI: 10.1016/j.prro.2014.04.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2013] [Revised: 03/19/2014] [Accepted: 04/15/2014] [Indexed: 01/23/2023]
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Wenz F, Sperk E, Budach W, Dunst J, Feyer P, Fietkau R, Haase W, Harms W, Piroth MD, Sautter-Bihl ML, Sedlmayer F, Souchon R, Fussl C, Sauer R. DEGRO practical guidelines for radiotherapy of breast cancer IV: radiotherapy following mastectomy for invasive breast cancer. Strahlenther Onkol 2014; 190:705-14. [PMID: 24888511 DOI: 10.1007/s00066-014-0687-0] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND AND PURPOSE Since the last recommendations from the Breast Cancer Expert Panel of the German Society for Radiation Oncology (DEGRO) in 2008, evidence for the effectiveness of postmastectomy radiotherapy (PMRT) has grown. This growth is based on updates of the national S3 and international guidelines, as well as on new data and meta-analyses. New aspects were considered when updating the DEGRO recommendations. METHODS The authors performed a comprehensive survey of the literature. Data from recently published (meta-)analyses, randomized clinical trials and international cancer societies' guidelines yielding new aspects compared to 2008 were reviewed and discussed. New aspects were included in the current guidelines. Specific issues relating to particular PMRT constellations, such as the presence of risk factors (lymphovascular invasion, blood vessel invasion, positive lymph node ratio >20 %, resection margins <3 mm, G3 grading, young age/premenopausal status, extracapsular invasion, negative hormone receptor status, invasive lobular cancer, size >2 cm or a combination of ≥ 2 risk factors) and 1-3 positive lymph nodes are emphasized. RESULTS The evidence for improved overall survival and local control following PMRT for T4 tumors, positive resection margins, >3 positive lymph nodes and in T3 N0 patients with risk factors such as lymphovascular invasion, G3 grading, close margins, and young age has increased. Recently identified risk factors such as invasive lobular subtype and negative hormone receptor status were included. For patients with 1-3 positive lymph nodes, the recommendation for PMRT has reached the 1a level of evidence. CONCLUSION PMRT is mandatory in patients with T4 tumors and/or positive lymph nodes and/or positive resection margins. PMRT should be strongly considered in patients with T3 N0 tumors and risk factors, particularly when two or more risk factors are present.
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Affiliation(s)
- Frederik Wenz
- Klinik für Strahlentherapie und Radioonkologie, Universitätsmedizin Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany,
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Immediate Implant-Based Breast Reconstruction following Total Skin-Sparing Mastectomy. Plast Reconstr Surg 2014; 134:396-404. [DOI: 10.1097/prs.0000000000000466] [Citation(s) in RCA: 86] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Delayed versus Delayed-Immediate Autologous Breast Reconstruction: A Blinded Evaluation of Aesthetic Outcomes. Arch Plast Surg 2014; 41:264-70. [PMID: 24883278 PMCID: PMC4037773 DOI: 10.5999/aps.2014.41.3.264] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Revised: 02/25/2014] [Accepted: 03/06/2014] [Indexed: 11/22/2022] Open
Abstract
Background The technique of delayed-immediate breast reconstruction includes immediate insertion of a tissue expander, post-mastectomy radiation, followed by reconstruction. The aesthetic benefits of delayed-immediate reconstruction compared to delayed reconstruction are postulated but remain unproven. The purpose of this study was to compare aesthetic outcomes in patients following delayed and delayed-immediate autologous breast reconstruction. Methods A retrospective analysis was performed of all patients who underwent delayed or delayed-immediate autologous breast reconstruction by the senior author from 2005 to 2011. Postoperative photographs were used to evaluate aesthetic outcomes: skin quality, scar formation, superior pole contour, inferior pole contour, and overall aesthetic outcome. Ten non-biased reviewers assessed outcomes using a 5-point Likert scale. Fisher's Exact and Wilcoxon-Mann-Whitney tests were used for comparative analysis. Results Patient age and body mass index were similar between delayed (n=20) and delayed-immediate (n=20) cohorts (P>0.05). Skin and scar quality was rated significantly higher in the delayed-immediate cohort (3.74 vs. 3.05, P<0.001 and 3.41 vs. 2.79, P<0.001; respectively). Assessment of contour-related parameters, superior pole and inferior pole, found significantly improved outcomes in the delayed-immediate cohort (3.67 vs. 2.96, P<0.001 and 3.84 vs. 3.06, P<0.001; respectively). Delayed-immediate breast reconstruction had a significantly higher overall score compared to delayed breast reconstructions (3.84 vs. 2.94, P<0.001). Smoking and the time interval from radiation to reconstruction were found to affect aesthetic outcomes (P<0.05). Conclusions Preservation of native mastectomy skin may allow for improved skin/scar quality, breast contour, and overall aesthetic outcomes following a delayed-immediate reconstructive algorithm as compared to delayed breast reconstruction.
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Outcomes of Breast Reconstruction in Breast Cancer Patients With a History of Mantle Radiation for Hodgkin Lymphoma. Ann Plast Surg 2014; 72 Suppl 1:S46-50. [DOI: 10.1097/sap.0000000000000167] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Garvey PB, Clemens MW, Hoy AE, Smith B, Zhang H, Kronowitz SJ, Butler CE. Muscle-sparing TRAM flap does not protect breast reconstruction from postmastectomy radiation damage compared with the DIEP flap. Plast Reconstr Surg 2014; 133:223-233. [PMID: 24469158 DOI: 10.1097/01.prs.0000436845.92623.9a] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Irradiation to free flaps following immediate breast reconstruction has been shown to compromise outcomes. The authors hypothesized that irradiated muscle-sparing free transverse rectus abdominis musculocutaneous (TRAM) flaps experience less fat necrosis than irradiated deep inferior epigastric perforator (DIEP) flaps. METHODS The authors performed a retrospective study of all consecutive patients undergoing immediate, autologous, abdomen-based free flap breast reconstruction with muscle-sparing free TRAM or DIEP flaps over a 10-year period at their institution. Irradiated flaps (external-beam radiation therapy) after immediate breast reconstruction were compared with nonirradiated flaps. Logistic regression analysis identified potential associations between patient, tumor, and reconstructive characteristics and surgical outcomes. RESULTS The analysis included 625 flaps: 40 (6.4 percent) irradiated versus 585 (93.6 percent) nonirradiated. Mean follow-up for the irradiated and nonirradiated flaps was 60.0 and 48.5 months, respectively (p = 0.02). Overall complication rates were similar for both the irradiated and nonirradiated flaps. Irradiated flaps (i.e., both DIEP and muscle-sparing free TRAM flaps) developed fat necrosis at a significantly higher rate (22.5 percent) than the nonirradiated flaps (9.2 percent; p = 0.009). There were no differences in fat necrosis rates between the DIEP and muscle-sparing free TRAM flaps in both the irradiated and nonirradiated groups. CONCLUSIONS Both DIEP and muscle-sparing free TRAM flap reconstructions had much higher rates of fat necrosis when irradiated. Contrary to our hypothesis, the authors found that immediate breast reconstruction with a muscle-sparing free TRAM flap does not result in a lower rate of fat necrosis than reconstruction with a DIEP flap. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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Affiliation(s)
- Patrick B Garvey
- Houston, Texas From the Departments of Plastic Surgery and Radiation Oncology, The University of Texas M. D. Anderson Cancer Center
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Ribuffo D, Atzeni M, Guerra M, Bucher S, Politi C, Deidda M, Atzori F, Dessi M, Madeddu C, Lay G. Treatment of irradiated expanders: protective lipofilling allows immediate prosthetic breast reconstruction in the setting of postoperative radiotherapy. Aesthetic Plast Surg 2013; 37:1146-52. [PMID: 24114295 DOI: 10.1007/s00266-013-0221-2] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2013] [Accepted: 09/06/2013] [Indexed: 12/20/2022]
Abstract
BACKGROUND Immediate two-stage prosthetic breast reconstruction in the setting of postmastectomy radiotherapy (PMRT) currently is hardly achieved with the fast-track expander exchange proposed by Cordeiro and colleagues or the delayed-immediate breast reconstruction proposed by Kronowitz and Robb. Each of these techniques has important drawbacks and complications. To overcome these problems, the authors in 2011 described lipofilling on irradiated expanders in patients undergoing unplanned PMRT (Cagliari University Hospital [CUH] protocol) for early breast cancers with specific risk factors. The authors report their experience after expanding the use of such a protocol for any immediate expander/implant reconstruction in a patient undergoing PMRT. METHODS The timing for advanced breast cancer involves immediate reconstruction with a tissue expander, complete tissue expansion, radiotherapy (RT) after neoadjuvant chemotherapy starting 2-3 months after mastectomy, one or two fresh fat-grafting sessions at least 6 weeks after RT, and an expander-implant exchange with anterior capsulectomy at least 3 months after the completion of fat grafting. The timing for early breast cancers with specific risk factors involves immediate reconstruction with a tissue expander, complete tissue expansion during postoperative chemotherapy, RT 6 months after mastectomy, one or two fat-grafting sessions 6 weeks after RT, and an expander-implant exchange with anterior capsulectomy at least 3 months after the completion of fat grafting. From 2008 to 2012, 16 patients undergoing total mastectomy and immediate expander-implant breast reconstruction with subsequent PMRT were treated according to the CUH protocol. RESULTS The results have been extremely encouraging, with rates of ulceration and implant exposure in the radiotreated area dropping to 0 %. These results were retrospectively compared with those for a control group of 16 patients who underwent immediate implantation of an expander. In this latter group, the extrusion rate of the implant in the end was 31.25 %, and this was statistically significant (p < 0.03). The shape and symmetry also were significantly better in the lipofilled patients. CONCLUSION Protective lipofilling on irradiated expanders appears to be a valid technique for avoiding ulceration and implant exposure after PMRT while allowing a complete expansion. LEVEL OF EVIDENCE IV 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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Quan ML, Osman F, McCready D, Fernandes K, Sutradhar R, Paszat L. Postmastectomy radiation and recurrence patterns in breast cancer patients younger than age 35 years: a population-based cohort. Ann Surg Oncol 2013; 21:395-400. [PMID: 24145994 DOI: 10.1245/s10434-013-3319-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2013] [Indexed: 11/18/2022]
Abstract
BACKGROUND The utility of post mastectomy radiotherapy in very young women is understudied. The objective of this study was to evaluate the use of PMRT in very young women to determine the effect on recurrence and survival. METHODS All women aged ≤35 years diagnosed with invasive breast cancer from 1994 to 2003 were identified from the Ontario Cancer Registry. Patient, tumour, treatment and outcome data were abstracted from primary chart review. Local or regional recurrence was the primary endpoint with contralateral, distant recurrence/death treated as competing risks. Propensity score methods were incorporated into multivariable Cox proportional hazards models to evaluate the effect of radiation therapy on the time to local/regional, distant recurrence or death. RESULTS 588 patients were identified during the study period, of which 382 were eligible for analysis. Overall, 182 (48%) of patients sustained a recurrence after a median follow-up of 2.72 years. The use of PMRT significantly reduced locoregional recurrence (HR 0.54, 95% CI 0.29-0.996) compared with those who did not receive PMRT. There was no significant effect of PMRT on contralateral, distant recurrences, or death without recurrence (HR 0.98, 95% CI 0.66-1.47). Of the patients with known node status (N = 451), isolated local recurrence occurred in 5, 2.5, and 8.5% in patients with N0, N1-3, and N4 positive nodes respectively. CONCLUSIONS We have found a significant reduction in locoregional recurrence with PMRT but no survival benefit in very young women with breast cancer.
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Affiliation(s)
- May Lynn Quan
- Division of Surgery, Foothills Medical Centre, Calgary, AB, Canada,
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Microvascular autologous breast reconstruction in the context of radiation therapy: comparing two reconstructive algorithms. Plast Reconstr Surg 2013; 132:251-257. [PMID: 23897324 DOI: 10.1097/prs.0b013e31829586e2] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND When postmastectomy radiation therapy is anticipated, delaying autologous reconstruction prevents radiation delivery issues and radiation-induced contour irregularities. Delayed-immediate autologous breast reconstruction may allow for maintenance of the breast skin envelope as compared with delayed reconstruction with the temporary insertion of a tissue expander. The authors compared perioperative complications and revision surgery rates of comparative cohorts to determine which method is preferable. METHODS Delayed-immediate reconstruction was defined as placement of a temporary tissue expander in the first stage at the time of mastectomy before flap reconstruction, which occurred following postmastectomy radiation therapy. Delayed reconstruction was categorized as mastectomy with primary closure in the first stage followed by flap reconstruction. RESULTS One hundred fifty-two patients and 192 breasts met the study criteria for this retrospective review (delayed reconstruction, 118 breasts; delayed-immediate autologous breast reconstruction, 74 breasts). Patient age and body mass index were similar between groups (p>0.05). Perioperative first-stage complication rates were 8.5 percent in the delayed group and 10.8 percent in the delayed-immediate cohort (p=0.81). Total flap loss (2.5 versus 4.1 percent; p=0.68) and arterial (1.7 versus 1.4 percent; p=0.82) and venous (4.3 versus 5.4 percent; p=0.73) anastomotic revision rates were similar between the cohorts, respectively. Reoperative surgery occurred in 11.9 percent versus 9.6 percent in the delayed and delayed-immediate cohorts, respectively (p=0.69). CONCLUSIONS In comparing two treatment algorithms, flap-related complication rates are comparable. First-stage surgery results in a slightly increased complication rate in the delayed-immediate cohort. Improved overall results with delayed-immediate reconstruction are implied, given significantly decreased rates of revision surgery following flap reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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Comparison of Irradiated Versus Nonirradiated DIEP Flaps in Patients Undergoing Immediate Bilateral DIEP Reconstruction with Unilateral Postmastectomy Radiation Therapy (PMRT). Ann Plast Surg 2013; 71:250-4. [DOI: 10.1097/sap.0b013e31828986ec] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Schaverien MV, Macmillan RD, McCulley SJ. Is immediate autologous breast reconstruction with postoperative radiotherapy good practice?: a systematic review of the literature. J Plast Reconstr Aesthet Surg 2013; 66:1637-51. [PMID: 23886555 DOI: 10.1016/j.bjps.2013.06.059] [Citation(s) in RCA: 83] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2013] [Revised: 05/11/2013] [Accepted: 06/18/2013] [Indexed: 01/28/2023]
Abstract
BACKGROUND There remains controversy as to whether immediate autologous breast reconstruction with postoperative radiotherapy is associated with acceptable complications and aesthetic outcomes. This systematic review analyses the literature regarding outcomes of immediate autologous breast reconstruction with postoperative radiotherapy compared with no radiotherapy, as well as with delayed autologous breast reconstruction following post-mastectomy irradiation. METHODS Pubmed (1966 to October 2012), Ovid MEDLINE (1966 to October 2012), EMBASE (1980 to October 2012), and the Cochrane Database of Systematic Reviews (Issue 10, 2012) were searched. Overall complications (including fat necrosis), fat necrosis, revisional surgery, loss of volume, and aesthetic outcome, were analysed individually. Comparable data from observational studies were combined for meta-analysis where possible and quality assessment of the studies was performed. RESULTS The majority of studies of immediate autologous breast reconstruction and postoperative radiotherapy reported satisfactory outcomes (19 of 25 studies; n=1,247 patients). Meta-analysis of observational studies demonstrated no significant differences in total prevalence of complications (p=0.59) or revisional surgery (p=0.38) and a summary measure for fat necrosis favouring the group without radiotherapy (OR 2.82, 95% CI 1.35-5.92, p=0.006). The majority of studies comparing immediate reconstruction and postoperative radiotherapy with delayed reconstruction following post-mastectomy radiotherapy (10 of 12 observational studies; n=1,633 patients) reported satisfactory outcomes following immediate reconstruction. Meta-analysis of observational studies demonstrated no significant difference in overall incidence of complications (p=0.53) and fat necrosis (OR 0.63, 95% CI 0.29-1.38, p=0.25), and a summary measure for revisional surgery (OR 0.15, 95% CI 0.05-0.48, p=0.001) favouring the delayed surgery group. No randomised-controlled trials met the inclusion criteria, and all of the observational studies included were missing more than one important component for reporting of observational studies. DISCUSSION The majority of studies reported satisfactory outcomes and a similar incidence of complications for immediate autologous breast reconstruction and adjuvant radiotherapy when compared with no radiotherapy or delayed reconstruction following radiotherapy; the proportion that required revisional surgery was higher though for immediate than delayed breast reconstruction. The findings are limited by the paucity of high quality data in the published literature, and until better data is available the findings of this review suggest that immediate autologous breast reconstruction should at least be considered when adjuvant chest wall radiotherapy is anticipated.
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Affiliation(s)
- Mark V Schaverien
- Department of Plastic Surgery, Nottingham City Hospital, Hucknall Road, Nottingham NG5 1PB, UK; Department of Breast Surgery, Nottingham Breast Institute, City Hospital, Hucknall Road, Nottingham, NG5 1PB, UK.
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Tansley P, Ramsey K, Wong S, Guerrieri M, Pitcher M, Grinsell D. New treatment sequence protocol to reconstruct locally advanced breast cancer. ANZ J Surg 2013; 83:630-5. [DOI: 10.1111/ans.12110] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/19/2013] [Indexed: 11/28/2022]
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