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Kalmar CL, Montorfano L, Thayer WP, Kassis S, Higdon KK, Perdikis G. Timing of Autologous Tissue Breast Reconstruction Does Not Affect Free Flap Failure. Ann Plast Surg 2024; 92:663-666. [PMID: 38717156 DOI: 10.1097/sap.0000000000003900] [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: 05/21/2024]
Abstract
ABSTRACT This study aimed to determine whether there is a difference in free flap failure based on the decision to undergo immediate versus delayed autologous tissue breast reconstruction after mastectomy. The National Surgical Quality Improvement Program database was queried for breast free flap procedures performed between 2015 and 2020. This study demonstrates that the decision to undergo immediate versus delayed autologous tissue breast reconstruction does not have a significant association with free flap failure. This remains true regardless of whether patients undergo unilateral mastectomy with reconstruction or whether patients choose to also undergo contralateral prophylactic mastectomy with reconstruction.
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Affiliation(s)
- Christopher L Kalmar
- From the Department of Plastic Surgery, Vanderbilt University Medical Center, Nashville, TN
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2
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Parmeshwar N, Barnes L, Martins D, Nicholas C, Piper M. The impact of post-mastectomy radiation timing on overall outcomes of autologous free-flap breast reconstruction. Microsurgery 2024; 44:e31091. [PMID: 37469230 DOI: 10.1002/micr.31091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 06/07/2023] [Accepted: 07/06/2023] [Indexed: 07/21/2023]
Abstract
BACKGROUND The optimal timing of post-mastectomy radiation therapy (PMRT) in autologous breast reconstruction is controversial. Our study compares overall reconstructive outcomes in patients who received post-mastectomy radiation therapy either before or after the autologous flap. METHODS A single-center retrospective review was performed for patients who underwent free flap breast reconstruction and post-mastectomy radiation from January 2004 through January 2021. Demographic, intraoperative, and post-operative variables were recorded. RESULTS A total of 452 free flaps were identified, and 82 underwent PMRT. 59.8% were radiated with an expander prior to free flap surgery (PreFlap), and 40.2% flaps underwent PMRT (PostFlap). PostFlap patients were significantly younger (43.0 vs. 47.9 years, p = .016). There were no significant differences in free flap outcomes between the two cohorts including thrombosis, venous congestion, flap loss, takebacks, fat necrosis, seroma, or infection. Mastectomy skin flap necrosis was significantly higher in the PostFlap cohort (9.1% vs. 0%, p = .032), but nipple necrosis rates did not differ. There were no significant differences in number or need for revision surgeries, fat necrosis, or fat grafting between groups. However, there were significantly more total reconstructive complications, including infection and wound breakdown, experienced by the PreFlap cohort (46.9% vs. 24.2%, p = .038). CONCLUSIONS Timing of PMRT did not impact free flap outcomes, but those who had the expander radiated experienced significantly more complications overall. For the 34.7% of patients in the preFlap group who planned for autologous reconstruction form initial consultation, radiation after the flap may have improved their overall outcomes. As added complications cause delays in cancer therapy and final reconstruction, our results suggest that PMRT of the flap when possible may improve the overall experience for breast cancer patients.
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Affiliation(s)
- Nisha Parmeshwar
- Division of Plastic and Reconstructive Surgery, University of California San Francisco, San Francisco, California, USA
| | - Laura Barnes
- Division of Plastic and Reconstructive Surgery, University of California San Francisco, San Francisco, California, USA
| | - Deborah Martins
- Division of Plastic and Reconstructive Surgery, University of California San Francisco, San Francisco, California, USA
| | - Catherine Nicholas
- School of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Merisa Piper
- Division of Plastic and Reconstructive Surgery, University of California San Francisco, San Francisco, California, USA
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3
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Tomita S, Nagai K, Matsunaga N, Kerckhove MD, Fujii M, Terao Y. Detailed Analysis of Three Major Breast Reconstructions Using BREAST-Q Responses From 1001 Patients. Aesthet Surg J 2023; 43:NP888-NP897. [PMID: 37392431 DOI: 10.1093/asj/sjad205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Revised: 06/22/2023] [Accepted: 06/22/2023] [Indexed: 07/03/2023] Open
Abstract
BACKGROUND Patient-reported outcomes have become as important as mortality and morbidity in the postoperative evaluation of breast reconstruction surgery. The BREAST-Q is one of the most widely used patient-reported outcomes for breast reconstruction. OBJECTIVES A comparative analysis of the scores on each of the BREAST-Q modules could help analyze different reconstruction methods. However, few studies have utilized BREAST-Q for this purpose. The aim of this study was therefore to compare breast reconstruction methods in terms of BREAST-Q module ratings. METHODS The authors retrospectively reviewed the data of 1001 patients who had been followed for more than 1 year after breast reconstruction. The 6 BREAST-Q modules were rated on a scale of 0 to 100 and statistically analyzed by multiple regression. In addition, Fisher's exact test was performed after dividing the responses to each question into high- and low-rating groups. RESULTS Microvascular abdominal flap reconstruction scored significantly better than implant-based reconstruction on all modules, except psychosocial and sexual well-being. In terms of satisfaction with the breast, latissimus dorsi flap reconstruction was superior to implant-based reconstruction. However, in terms of the reconstruction method, there were no differences in patients' willingness to make the same choice again or whether they regretted having surgery. CONCLUSIONS The results highlight the superiority of autologous breast reconstruction. Reconstruction methods should only be performed after a thorough explanation of their characteristics to achieve results that meet patient expectations. The findings are useful for facilitating patient decision-making in breast reconstruction. LEVEL OF EVIDENCE: 4
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Halani SH, Jones K, Liu Y, Teotia SS, Haddock NT. Reconstructive Burnout after Mastectomy: Implications for Patient Selection. Plast Reconstr Surg 2023; 151:13e-19e. [PMID: 36194054 DOI: 10.1097/prs.0000000000009776] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND The reconstructive journey after mastectomy can be a long road, with many hurdles to achieve an ideal aesthetic result. Cancer therapy, operative complications, and comorbidities impact patients physically and emotionally. This study introduces the term reconstructive burnout and aims to evaluate which factors predict and contribute to patients prematurely stopping reconstruction. METHODS The authors performed a retrospective review of patients undergoing breast reconstruction after skin-sparing mastectomy from 2014 to 2017 performed by two senior surgeons (N.T.H. and S.S.T.) at a single institution. Reconstructive burnout is defined as either no breast mound creation or completion of the breast mound without completion of all major revisions. RESULTS A total of 530 patients were included, with 76.6% completing reconstruction. In patients undergoing delayed-immediate reconstruction, patients with wounds ( P = 0.004), infections ( P = 0.037), or a complication requiring operative intervention ( P < 0.001) were correlated with incomplete reconstruction; explantation of expanders was highly correlated with reconstructive burnout ( P < 0.001). Implant-based and autologous reconstruction had comparable burnout rates (17.1% versus 19.1%; P = 0.58). Logistic regression models found high body mass index, radiation therapy, any tissue expander complication, and tissue expander explantation to be significant predictors of burnout. Autologous reconstruction was the strongest predictor of completion of reconstruction in both univariable and multivariable models. CONCLUSIONS Reconstructive burnout in breast reconstruction is associated with tissue expander complications, high body mass indices, and radiation therapy. Overall rates of burnout were comparable between autologous and implant-based reconstruction, with autologous reconstruction being the strongest predictor of completion of reconstruction. It is critical to tailor each patient's reconstructive journey to meet both their emotional and physical needs to avoid reconstructive burnout.
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Affiliation(s)
| | | | - Yulun Liu
- Population and Data Sciences, University of Texas Southwestern Medical Center
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5
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Abstract
Breast reconstruction is becoming increasingly recognized as a fundamental component in comprehensive breast cancer treatment. The primary goal for any reconstruction is to safely restore a natural appearing breast. When it comes to achieving the elements of size, shape, symmetry, and softness, the use of autologous tissue has many advantages. The approach to autologous breast reconstruction has changed substantially over the years as microsurgical free tissue transplants become more routine and accessible. While a variety of flap donor sites exist, careful flap selection based on surgical history and the availability of donor tissue is critical in achieving reliable results. This article reviews the clinical considerations in patient evaluation, donor site selection, and surgical approach taken at the Buncke Clinic.
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Affiliation(s)
- Rudolf Buntic
- Division of Microsurgery, The Buncke Clinic, San Francisco, California
| | - Alexander Y. Li
- Division of Plastic and Reconstructive Surgery, Stanford University, Stanford, California
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6
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Haaren ERM, Spiekerman van Weezelenburg MA, Poodt IGM, Feijen MMW, Janssen A, Bastelaar J, Vissers YLJ. Influence of the sentinel node outcome analysed by one‐step nucleic acid amplification on the risk for postmastectomy radiation therapy and the scheduling of immediate breast reconstruction. J Surg Oncol 2022; 126:443-449. [DOI: 10.1002/jso.26916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 04/19/2022] [Accepted: 04/25/2022] [Indexed: 11/07/2022]
Affiliation(s)
| | | | | | | | - Alfred Janssen
- Department of Surgery Zuyderland Medical Center Sittard The Netherlands
| | - James Bastelaar
- Department of Surgery Zuyderland Medical Center Sittard The Netherlands
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Letsiou E, Tsakatikas S, Vakis G, Tsapakidis K, Charalampakis N, Diamantis A, Poultsidi A, Michelakis D, de Bree E, Mauri D, Tsoukalas N, Antoniades C, Tolia M. Radiotherapy and Breast Reconstruction: What Is the Ideal Timing? A Narrative Review. Rev Recent Clin Trials 2022; 17:73-85. [PMID: 35289255 DOI: 10.2174/1574887117666220314161609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 11/13/2021] [Accepted: 12/24/2021] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Women undergoing mastectomy choose to pursue breast reconstruction (BR) in order to reduce their body image distress.Adjuvant chest wall irradiation is associated with a negative cosmetic outcome. The aim of our review was to identify the optimal timing of BR relating to radiotherapy delivery. MATERIALS AND METHODS Using Cochrane Library, Embase, PubMed, Springer, Wanfang and CNKI, we performed a non-systematic review of articles published up to August 2021. RESULTS There is no hard evidence in favor of immediate, delayed or 2-stage BR when post-mastectomy radiation is indicated. Immediate and 2-stage BR seem to be valid alternatives to delayed BR. CONCLUSIONS Further research is essential in order to assess clinician and patient reported aesthetic outcomes and determine the optimal timing of BR in view of post-mastectomy radiotherapy, in breast cancer survivors.
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Affiliation(s)
| | - Sergios Tsakatikas
- Department of Medical Oncology, Metaxa Cancer Hospital, 185 37 Athens, Greece
| | - George Vakis
- Plastic Surgery Clinic, Evangelismos General Hospital, Ipsilantou 45-47, 106 76, Athens, Greece
| | - Konstantinos Tsapakidis
- Department of Oncology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Biopolis, 41500, Larisa, Greece
| | | | - Alexandros Diamantis
- Department of Surgery, Medical School, University of Thessaly, 415 00 Larissa, Greece
| | - Antigoni Poultsidi
- Department of Surgery, Medical School, University of Thessaly, 415 00 Larissa, Greece
| | - Dimosthenis Michelakis
- Department of Surgical Oncology, Medical School of Crete University Hospital, 711 10 Heraklion, Greece
| | - Eelco de Bree
- Department of Surgical Oncology, Medical School of Crete University Hospital, 711 10 Heraklion, Greece
| | - Davide Mauri
- Faculty of Medicine, School of Health Sciences, University of Ioannina, Ioannina, Greece.,Department of Medical, Oncology, Greece Society for Study of Clonal Heterogeneity of Neoplasia (EMEKEN), University Hospital of Ioannina, Ioannina, Greece
| | - Nikolaos Tsoukalas
- Department of Oncology, 401 General Military Hospital of Athens, 115 25, Athens, Greece
| | - Chrysostomos Antoniades
- Department of Radiotherapy, School of Medicine, University of Crete, 711 10, Heraklion, Greece
| | - Maria Tolia
- Department of Radiotherapy, School of Medicine, University of Crete, 711 10, Heraklion, Greece
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Tomita S, Matsunaga N, Fujita Y, de Kerckhove M, Fujii M, Honda Y, Tokisawa H, Aruga T, Terao Y. Safety evaluation of immediate breast reconstruction for locally advanced breast cancer in Japanese patients. J Plast Reconstr Aesthet Surg 2022; 75:2526-2534. [PMID: 35599220 DOI: 10.1016/j.bjps.2022.04.021] [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: 10/20/2021] [Revised: 02/27/2022] [Accepted: 04/12/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND While breast reconstruction often improves the quality of life of patients with locally advanced breast cancer, there is still no consensus on its safety. This retrospective report aimed to verify the safety of immediate breast reconstruction for locally advanced breast cancer. METHODS We retrospectively analyzed 500 breast cancer surgeries performed between January 2005 and December 2019 at our hospital, including 120 immediate breast reconstructions. The following five items were analyzed: the patients' choice of reconstruction method, rate of chemotherapy and radiotherapy, surgical margin positivity rate, complications associated with surgery, overall survival rate, and breast cancer-free survival rate. RESULTS Sixty-three of the 120 patients underwent autologous breast reconstruction. Of those who underwent reconstruction surgery, 95.8% received chemotherapy and 78.3% underwent post-mastectomy radiation therapy. Reconstruction failed in 8 cases with tissue expander and in 1 case with free TRAM flap. Breast reconstruction surgery was not a factor in delaying adjuvant therapy, but complications requiring intervention tended to increase the duration of adjuvant therapy. There was no statistically significant difference in the rate of surgical margin positivity, overall survival rate, or breast cancer-free survival rate. CONCLUSIONS Although complications associated with reconstructive surgery occurred, appropriate intervention prevented delays in breast cancer treatment, and the complications did not negatively affect the overall or breast cancer-free survival rates. Our study found no evidence to avoid primary breast reconstruction in patients with locally advanced breast cancer.
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Affiliation(s)
- Shoichi Tomita
- Department of Plastic and Reconstructive Surgery, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, 3-18-22 Honkomagome, Bunkyo-ku, Tokyo, 113-8677, Japan.
| | - Noriko Matsunaga
- Department of Plastic and Reconstructive Surgery, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, 3-18-22 Honkomagome, Bunkyo-ku, Tokyo, 113-8677, Japan
| | - Yoshihiko Fujita
- Department of Plastic and Reconstructive Surgery, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, 3-18-22 Honkomagome, Bunkyo-ku, Tokyo, 113-8677, Japan
| | - Maiko de Kerckhove
- Department of Plastic and Reconstructive Surgery, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, 3-18-22 Honkomagome, Bunkyo-ku, Tokyo, 113-8677, Japan
| | - Miwako Fujii
- Department of Plastic and Reconstructive Surgery, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, 3-18-22 Honkomagome, Bunkyo-ku, Tokyo, 113-8677, Japan
| | - Yayoi Honda
- Department of Breast Surgery, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, 3-18-22 Honkomagome, Bunkyo-ku, Tokyo, 113-8677, Japan
| | - Hiromi Tokisawa
- Department of Breast Surgery, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, 3-18-22 Honkomagome, Bunkyo-ku, Tokyo, 113-8677, Japan
| | - Tomoyuki Aruga
- Department of Breast Surgery, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, 3-18-22 Honkomagome, Bunkyo-ku, Tokyo, 113-8677, Japan
| | - Yasunobu Terao
- Department of Plastic and Reconstructive Surgery, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, 3-18-22 Honkomagome, Bunkyo-ku, Tokyo, 113-8677, Japan
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9
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Christopher AN, Morris MP, Broach RB, Serletti JM. A Comparative Analysis of Immediate and Delayed-immediate Breast Reconstruction after Postmastectomy Radiation Therapy. J Reconstr Microsurg 2021; 38:499-505. [PMID: 34921369 DOI: 10.1055/s-0041-1740123] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Postmastectomy radiation therapy (PMRT) is an important component in the treatment of locally advanced breast cancer. Optimal timing of therapy in relation to autologous breast reconstruction (ABR) remains clinically debated. Herein, we comparatively analyze short- and long-term outcomes between immediate ABR (I-ABR) and delayed-immediate ABR (DI-ABR) in the setting of PMRT. METHODS Adult patients undergoing ABR with PMRT were separated into cohorts based on reconstructive timeline: I-ABR or DI-ABR. The groups were propensity matched 1:1 by age, body mass index, and comorbidities. Surgical site events and long-term clinical outcomes (readmissions, reoperations, and revision procedures) were collected. Univariate analyses were completed using Pearson's chi-squared tests and Fisher's exact tests, and statistical significance was set at p < 0.05. RESULTS One hundred and thirty-two flaps (66 in each cohort) were identified for inclusion. Patients with I-ABR were more likely to experience fat necrosis (p = 0.034) and skin necrosis (p < 0.001), require additional office visits (p < 0.001) and outpatient surgeries (p = 0.015) to manage complications, and undergo revision surgery after reconstruction (p < 0.001). DI-ABR patients, however, had a 42.4% incidence of complications following tissue expander placement prior to reconstruction, with 16.7% of patients requiring reoperation during this time. Only one patient (I-ABR) experienced flap loss due to a vascular complication. CONCLUSION The complications encountered in both of these groups were not prohibitive to offering either treatment. Patients should be made aware of the specific and unique risks of these reconstruction timelines and involved throughout the entire decision-making process. Plastic surgeons should continue to strive to elucidate innovative approaches that facilitate enhanced quality of life without compromising oncologic therapy.
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Affiliation(s)
- Adrienne N Christopher
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania.,Department of Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Martin P Morris
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Robyn B Broach
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joseph M Serletti
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
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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: 0] [Impact Index Per Article: 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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11
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Dickey RM, Amaya J, Teotia SS, Haddock NT. Influence of Triple-Negative versus Luminal A Breast Cancer Subtype on Choice of Autologous versus Implant-Based Delayed-Immediate Breast Reconstruction. J Reconstr Microsurg 2021; 39:264-271. [PMID: 34666408 DOI: 10.1055/s-0041-1736319] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Triple-negative (TN) and luminal A breast cancer molecular subtypes have divergent clinical and prognostic characteristics for breast cancer patients. Our study aims to compare the reconstructive choice of these two groups from the time they receive a tissue expander (TE) to the time they complete autologous or implant-based breast reconstruction. METHODS A total of 255 patients who underwent delayed-immediate breast reconstruction with TE placement from 2013 to 2017 diagnosed with either TN (n = 73) or luminal A (n = 182) invasive breast cancer subtype seen by two surgeons at a single institution were identified. Preference of autologous and implant-based reconstruction was analyzed, along with TE complications, race, age, body mass index (BMI), smoking, adjuvant therapy, and comorbidities. RESULTS There was a significant difference in the choice of implant- or autologous-based reconstruction among these two groups (p < 0.05). A greater proportion of luminal A patients underwent implant-based reconstruction (63.47%) and a greater proportion of TN patients underwent autologous-based reconstruction (53.13%). With regard to TE outcomes, there was no significant difference between the two groups with regard to duration of TE placement by reconstructive type or TE surgical complications. Significantly, more TN patients underwent radiation therapy (p < 0.01) and neoadjuvant chemotherapy (p < 0.0001) than luminal A patients. BMI, comorbidities, radiation therapy, and overall TE complications were identified as predictive factors of patients electing for autologous reconstruction over implants. CONCLUSION TN breast cancer patients mostly chose autologous-based reconstruction, while luminal A patients chose implant-based reconstruction. Both patient groups carried their TEs for similar duration with similar complication profile. Radiation therapy is likely a major factor in the decision for the type of delayed-immediate reconstruction among this population.
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Affiliation(s)
- Ryan M Dickey
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Joshua Amaya
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Sumeet S Teotia
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Nicholas T Haddock
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
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Influence of Hypofractionated Versus Conventional Fractionated Postmastectomy Radiation Therapy in Breast Cancer Patients With Reconstruction. Int J Radiat Oncol Biol Phys 2021; 112:445-456. [PMID: 34610389 DOI: 10.1016/j.ijrobp.2021.09.031] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 09/17/2021] [Accepted: 09/25/2021] [Indexed: 11/23/2022]
Abstract
PURPOSE We aimed to compare breast-related complications between hypofractionated adjuvant postmastectomy radiation therapy (PMRT) and conventional fractionated radiation therapy (RT) in patients with breast cancer undergoing reconstruction by reconstruction surgery type. METHODS AND MATERIALS Data from a total of 396 patients with breast cancer who underwent breast reconstruction after mastectomy between 2009 and 2018 were retrospectively reviewed. All patients received adjuvant PMRT according to either a conventional fractionation or hypofractionation schedule. We analyzed breast-related complications according to the timing of breast reconstruction (immediate or delayed). In cases of delayed reconstruction, only PMRT delivered before final delayed reconstruction was included. A major breast complication was defined as a breast-related toxicity that required reoperation or rehospitalization after the end of RT. RESULTS The median follow-up time was 35.3 months (range, 8.8-122.7 months). Of all patients, 267 received immediate breast reconstruction and 129 received delayed breast reconstruction. In patients with immediate breast reconstruction, 91 were treated with conventional RT and 176 received hypofractionated RT. The occurrence of major breast-related complications did not differ significantly between the 2 fractionation regimens. Hypofractionated RT did not increase major wound problems (infection and dehiscence) compared with conventional RT. Furthermore, major contracture occurred significantly less frequently in hypofractionated RT. Of the patients who had delayed breast reconstruction, 48 received conventional RT and 81 received hypofractionated RT. There was no difference in the incidence of major breast complications between these 2 RT groups, and no difference in major breast complications were reported for either 1- or 2-stage delayed reconstruction. A time interval of >10 months between PMRT and final definitive reconstruction had a significantly lower incidence of major breast complications. CONCLUSIONS Hypofractionated RT appears to be comparable with conventional fractionated RT in terms of breast-related complications in patients with breast cancer undergoing reconstruction, regardless of breast reconstruction type. An ongoing prospective randomized trial should confirm our findings.
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13
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Does post-mastectomy radiation therapy worsen outcomes in immediate autologous breast flap reconstruction? A systematic review and meta-analysis. J Plast Reconstr Aesthet Surg 2021; 74:3260-3280. [PMID: 34565703 DOI: 10.1016/j.bjps.2021.08.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 08/25/2021] [Indexed: 01/25/2023]
Abstract
BACKGROUND There is great uncertainty regarding the practice of immediate autologous breast reconstruction (IBR) when post-mastectomy radiotherapy (PMRT) is indicated. Plastic surgery units differ in their treatment protocols, with some recommending delayed breast reconstruction (DBR) following PMRT. IBR offers significant cosmetic and psychosocial benefits; however, the morbidity of flap exposure to radiation remains unclear. OBJECTIVE The aim of this review was to comprehensively analyze the existing literature comparing autologous flaps exposed to PMRT and flaps with no radiation exposure. METHODS A comprehensive search in MEDLINE, EMBASE and CENTRAL databases was conducted in November 2020. Primary studies comparing IBR with and without adjuvant PMRT were assessed for the following primary outcomes: clinical complications, observer-reported outcomes and patient-reported satisfaction rates. Meta-analysis was performed to obtain pooled risk ratios of individual complications. RESULTS Twenty-one articles involving 3817 patients were included. Meta-analysis of pooled data gave risk ratios for fat necrosis (RR = 1.91, p < 0.00001), secondary surgery (RR = 1.62, p = 0.03) and volume loss (RR = 8.16, p < 0.00001) favoring unirradiated flaps, but no significant difference was observed in all other reported complications. The no-PMRT group scored significantly higher in observer-reported measures. However, self-reported aesthetic and general satisfaction rates were similar between groups. CONCLUSION IBR should be offered after mastectomy to patients requiring PMRT. The higher risks of fat necrosis and contracture appear to be less clinically relevant as corroborated by positive scores from patients developing these complications. Preoperative and intraoperative measures should be taken to further optimize reconstruction and mitigate post-radiation sequel. Careful management of patients' expectations is also imperative. LEVEL OF EVIDENCE Level III.
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14
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Nepon H, Safran T, Reece EM, Murphy AM, Vorstenbosch J, Davison PG. Radiation-Induced Tissue Damage: Clinical Consequences and Current Treatment Options. Semin Plast Surg 2021; 35:181-188. [PMID: 34526866 PMCID: PMC8432995 DOI: 10.1055/s-0041-1731464] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Radiation therapy is a valuable tool in the treatment of numerous malignancies but, in certain cases, can also causes significant acute and chronic damage to noncancerous neighboring tissues. This review focuses on the pathophysiology of radiation-induced damage and the clinical implications it has for plastic surgeons across breast reconstruction, osteoradionecrosis, radiation-induced skin cancers, and wound healing. The current understanding of treatment modalities presented here include hyperbaric oxygen therapy, autologous fat grafting and stem cells, and pharmaceutical agents.
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Affiliation(s)
- Hillary Nepon
- Division of Experimental Surgery, McGill University, Montreal, Quebec, Canada
| | - Tyler Safran
- Division of Plastic Surgery, McGill University, Montreal, Quebec, Canada
| | - Edward M. Reece
- Michael E. DeBakey Department of Surgery, Division of Plastic Surgery, Baylor College of Medicine, Houston, Texas
| | - Amanda M. Murphy
- Division of Plastic Surgery, McGill University, Montreal, Quebec, Canada
| | | | - Peter G. Davison
- Division of Plastic Surgery, McGill University, Montreal, Quebec, Canada
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15
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Ly CL, Khetpal S, Heller DR, Higgins SA, Killelea B, Alperovich M, Avraham T. Comparing complications in irradiated and non-irradiated free-flaps in patients with bilateral immediate breast reconstruction and unilateral post-mastectomy radiotherapy. Microsurgery 2021; 41:615-621. [PMID: 33886127 DOI: 10.1002/micr.30747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 03/27/2021] [Accepted: 04/09/2021] [Indexed: 11/11/2022]
Abstract
BACKGROUND Numerous studies have evaluated the effect of post-mastectomy radiotherapy (PMRT) on autologous breast reconstruction, but the variability of PMRT regimens and inadequate controls have made results difficult to interpret. Therefore, in this study, irradiated free-flaps are compared to non-irradiated internal controls in patients who underwent immediate bilateral reconstruction followed by unilateral PMRT to better delineate the effect of PMRT. The role of regional nodal irradiation (RNI) is also specifically assessed. METHODS Appropriate patients were identified through retrospective review. Complications such as fat necrosis, fibrosis, infection, delayed healing, and flap loss, as well as revision surgeries, among the irradiated free-flaps were compared to those on the contralateral non-irradiated side. Additional analyses were performed to evaluate the effect of patient demographics and treatment characteristics, such as RNI, on complications involving the irradiated free-flaps. RESULTS Seventy-three women were included. There was no significant difference between complication rates for the irradiated and non-irradiated free-flaps (39.7% vs. 38.4%, p = .78), although irradiated free-flaps were more likely to have fibrosis (17.0% vs. 0.0%; p < .0001) and multiple complications (9.6% vs. 0.0%; p = .02). Both groups underwent a similar number of revision surgeries (42.5% vs. 41.1%; p = .29). Looking at the irradiated free-flaps, internal mammary node (IMN) irradiation was the only factor predictive of complications (IRR 3.80, CI 1.32-10.97; p = .01). CONCLUSIONS PMRT may contribute to free-flap fibrosis, but does not appear to affect the overall risk of complications or revision surgeries. However, additional counseling is warranted if IMN irradiation is likely, as it is potentially associated with increased complications.
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Affiliation(s)
- Catherine L Ly
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Yale University, School of Medicine, New Haven, Connecticut, USA
| | - Sumun Khetpal
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Yale University, School of Medicine, New Haven, Connecticut, USA
| | - Danielle R Heller
- Department of Surgery, Yale University, School of Medicine, New Haven, Connecticut, USA
| | - Susan A Higgins
- Department of Therapeutic Radiology, Yale University, School of Medicine, New Haven, Connecticut, USA
| | - Brigid Killelea
- Department of Surgery, Yale University, School of Medicine, New Haven, Connecticut, USA
| | - Michael Alperovich
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Yale University, School of Medicine, New Haven, Connecticut, USA
| | - Tomer Avraham
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Yale University, School of Medicine, New Haven, Connecticut, USA
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16
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Saheb-Al-Zamani M, Cordeiro E, O'Neill AC, Hofer SO, Cil TD, Zhong T. Early Postoperative Complications From National Surgical Quality Improvement Program: A Closer Examination of Timing and Technique of Breast Reconstruction. Ann Plast Surg 2021; 86:S159-S164. [PMID: 33208650 PMCID: PMC7969155 DOI: 10.1097/sap.0000000000002590] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 09/13/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Despite the recent surge in rates of immediate breast reconstruction, there is a paucity of large multicenter studies to compare differences in morbidity after immediate versus delayed breast reconstruction. This study used the National Surgical Quality Improvement Program (NSQIP) to study the association between timing of breast reconstruction and complication rates, stratified by reconstructive modality. STUDY DESIGN The NSQIP database was used to identify breast reconstructions from 2005 to 2012. Rates of major complications were compared by timing within each reconstructive modality (implant vs autologous). Cohort differences in baseline characteristics and variables associated with increased complication rates were identified in bivariate analyses. A multivariable model was created to compare the association between the timing of reconstruction and major complications. RESULTS Of 24,506 postmastectomy reconstructions, 85.8% were immediate, 14.2% were delayed, 84% were implant, and 16% were autologous reconstructions. Overall, 10.0% of patients suffered a major complication. After stratification, only implant reconstructions showed a statistically higher complication rate with immediate (8.8%) reconstruction compared with delayed (5.3%) (odds ratio, 1.7, P < 0.01). There was no significant difference in complication rates between autologous immediate (18.4%) or delayed (19.0%) reconstructions. After controlling for baseline cohort differences and other risk factors, immediate reconstruction remained as an independent significant predictor of major complications in implant reconstructions (odds ratio, 1.8, P < 0.01). CONCLUSIONS Immediate rather than delayed breast reconstruction is associated with a significantly higher rate of major complications in implant reconstruction but not in autologous reconstruction. It is important to include these findings in the routine preoperative surgeon-patient discussion of reconstructive options.
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Affiliation(s)
| | | | - Anne C. O'Neill
- From the Division of Plastic and Reconstructive Surgery, University of Toronto, Toronto
| | - Stefan O.P. Hofer
- From the Division of Plastic and Reconstructive Surgery, University of Toronto, Toronto
| | - Tulin D. Cil
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Toni Zhong
- From the Division of Plastic and Reconstructive Surgery, University of Toronto, Toronto
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17
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Sayan M, Yehia ZA, Ohri N, Haffty BG. Hypofractionated Postmastectomy Radiation Therapy. Adv Radiat Oncol 2021; 6:100618. [PMID: 33490735 PMCID: PMC7809517 DOI: 10.1016/j.adro.2020.11.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 10/21/2020] [Accepted: 11/09/2020] [Indexed: 02/09/2023] Open
Abstract
Purpose To provide an overview of the major randomized trials that support the use of hypofractionated post-mastectomy radiation therapy for locally advanced breast cancer patients. Methods and Materials PubMed was systematically reviewed for publications reporting use of of hypofractionated radiation therapy in patients requiring post-mastectomy radiation. Results Standard fractionation, which is typically delivered over 5 to 7 weeks, is considered the standard of care in setting of post-mastectomy radiation therapy (PMRT). Modern data has helped to establish hypofractionated whole breast irradiation, which consists of a 3- to 4-week regimen, as a new standard of care for early-stage breast cancer. Hypofractionated whole breast irradiation has also laid the groundwork for the exploration of a hypofractionated approach in the setting of hypofractionated post-mastectomy radiation therapy. Conclusions While standard fractionation remains the most commonly utilized regimen for PMRT, recently published trials support the safety and efficacy of a hypofractionated approach. Ongoing trials are further investigating the use of hypofractionated PMRT.
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Affiliation(s)
- Mutlay Sayan
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Rutgers University, New Brunswick, New Jersey
| | - Zeinab Abou Yehia
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Rutgers University, New Brunswick, New Jersey
| | - Nisha Ohri
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Rutgers University, New Brunswick, New Jersey
| | - Bruce G Haffty
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Rutgers University, New Brunswick, New Jersey
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18
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Hershenhouse KS, Bick K, Shauly O, Kondra K, Ye J, Gould DJ, Patel KM. "Systematic review and meta-analysis of immediate versus delayed autologous breast reconstruction in the setting of post-mastectomy adjuvant radiation therapy". J Plast Reconstr Aesthet Surg 2020; 74:931-944. [PMID: 33423976 DOI: 10.1016/j.bjps.2020.11.027] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Revised: 11/03/2020] [Accepted: 11/22/2020] [Indexed: 01/29/2023]
Abstract
BACKGROUND Immediate post-mastectomy autologous breast reconstruction in breast cancer patients requiring post-mastectomy radiation therapy (PMRT) minimizes the number of operations that patients must undergo and alleviates the psychological impact of living without a breast. However, the safety and impact of radiation on the reconstructed breast remains to be established. This study aimed to compare immediate versus delayed autologous reconstruction in the setting of PMRT to determine the optimal sequencing of reconstruction and adjuvant radiation. METHODS A systematic review of the literature identified 292 studies meeting criteria for full-text review, 44 of which underwent meta-analysis. This represented data on 1,927 immediate reconstruction (IR) patients and 1,546 delayed reconstruction (DR) patients (3,473 total patients). Early complications included flap loss, fat necrosis, thrombosis, seroma, hematoma, infection, and skin dehiscence. Late complications included fibrosis or contracture, severe asymmetry, hyperpigmentation, and decreased flap volume. RESULTS Immediate breast reconstruction did not demonstrate significantly increased complication rates. Reported mean complication rates in IR versus DR groups, respectively, were fat necrosis 14.91% and 8.12% (p = 0.076), flap loss 0.99% and 1.80% (p = 0.295), hematoma 1.91% and 1.14% (p = 0.247), infection 11.66% and 4.68% (p = 0.155), and thrombosis 1.51% and 3.36% (p = 0.150). Seroma rates were significantly lower in the immediate cohort at 2.69% versus 10.57% in the delayed cohort (p = 0.042). CONCLUSION Complication rates are comparable between immediate and delayed breast reconstruction in the setting of PMRT. Given the patient benefits incurred by an IR algorithm, immediate autologous breast reconstruction should be considered as a viable treatment option in patients requiring PMRT.
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Affiliation(s)
| | - Katherine Bick
- Keck School of Medicine of USC, Los Angeles, California, USA
| | - Orr Shauly
- Keck School of Medicine of USC, Los Angeles, California, USA
| | - Katelyn Kondra
- Department of Surgery, Keck Hospital of USC, Los Angeles, California, USA
| | - Jason Ye
- Radiation Oncology, Keck School of Medicine of USC, Los Angeles, California, USA
| | | | - Ketan M Patel
- Department of Plastic and Reconstructive Surgery, Keck Hospital of USC, Los Angeles, California, USA.
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19
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Is Tissue Expansion Worth It? Comparative Outcomes of Skin-preserving versus Delayed Autologous Breast Reconstruction. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e3217. [PMID: 33299693 PMCID: PMC7722539 DOI: 10.1097/gox.0000000000003217] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 09/03/2020] [Indexed: 11/26/2022]
Abstract
Background: The requirement for postmastectomy radiation therapy (PMRT) at the time of mastectomy is often unknown. Autologous reconstruction is preferred in the setting of radiotherapy by providing healthy vascularized tissue to the chest. To maximize mastectomy skin preservation, tissue expander (TE) placement maintains the breast pocket until definitive reconstruction. This study aims to compare outcomes of skin-preserving delayed versus standard delayed autologous breast reconstruction in the setting of PMRT. Methods: A retrospective review of a prospective database was performed of two patient cohorts at a single center between 2006 and 2016. Inclusion criteria were locally advanced breast cancer patients who completed PMRT and free autologous reconstruction. Primary outcomes were major intraoperative and postoperative TE and flap complications. Results: Over 10 years, 241 patients underwent mastectomy and PMRT. Standard delayed autologous breast reconstruction was performed in 131 breasts (non-TE group). Skin-preserving delayed autologous reconstruction was performed in 113 breasts (TE group). The TE group was associated with a higher incidence of intraoperative complications during flap reconstruction (P = 0.002) and had a higher venous thrombosis incidence than the non-TE cohort (P = 0.007). Other major postoperative complications were not significantly different between the two groups. TE patients had 7.5 times higher risk of intraoperative complications and an 18.6% TE loss rate. Conclusions: We identified higher intraoperative flap complications and a high rate of TE loss in patients who underwent skin-preserving delayed autologous breast reconstruction. The benefit of mastectomy skin preservation needs to be weighed against the increased risk of TE loss and higher rates of flap thrombosis.
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20
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Heiman AJ, Gabbireddy SR, Kotamarti VS, Ricci JA. A Meta-Analysis of Autologous Microsurgical Breast Reconstruction and Timing of Adjuvant Radiation Therapy. J Reconstr Microsurg 2020; 37:336-345. [PMID: 32957153 DOI: 10.1055/s-0040-1716846] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Postmastectomy radiation therapy (PMRT) decreases loco-regional recurrence and improves survival in patients with locally advanced breast cancer. Autologous free flap reconstruction, while more durable in the setting of radiation than alloplastic reconstruction, is still susceptible to radiation-induced fibrosis, contracture, fat necrosis, volume loss, and distortion of breast shape. Options for reconstruction timing (immediate vs. delayed) have been discussed to mitigate these effects, but a clear optimum is not known. METHODS A systematic review of the literature was conducted according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines using search terms "breast reconstruction AND (radiation OR irradiation OR radiotherapy)" were used. Inclusion criteria consisted of studies reporting complications for free flap breast reconstruction in the setting of PMRT. Patients who underwent PMRT were pooled into two groups: those who underwent immediate free flap reconstruction prior to PMRT and those who underwent delayed reconstruction after PMRT. RESULTS Out of the 23 studies, 12 focused on immediate reconstruction, seven focused on delayed reconstruction, and four studies included both groups. Overall, 729 patients underwent immediate reconstruction, while 868 underwent delayed reconstruction. Complete and partial flap loss rates were significantly higher in patients undergoing delayed reconstruction, while infection and wound-healing complication rates were higher in those undergoing immediate reconstructions. Rates of unplanned reoperations, vascular complications, hematoma/seroma, and fat necrosis did not differ significantly between the two groups. However, rates of planned revision surgeries were higher in the delayed reconstruction group. CONCLUSION Immediate free flap breast reconstruction is associated with superior flap survival compared with delayed reconstruction. Rates of complications are largely comparable, and rates of revision surgeries are equivalent. The differences in long-term aesthetic outcomes are not, however, clearly assessed by the available literature. Even in the face of PMRT, immediate free flap breast reconstruction is an effective approach.
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Affiliation(s)
- Adee J Heiman
- Division of Plastic Surgery, Albany Medical Center, Albany, New York
| | | | | | - Joseph A Ricci
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Montefiore Medical Center, Bronx, New York
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21
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Hayek G, Winslow M, Maier M, Corsetti R, Rivere A, Mackey A, Tanaka S, Fuhrman G. Use of Postmastectomy Radiation in Patients Treated for Invasive Breast Cancer with Mastectomy and Immediate Reconstruction. Am Surg 2020. [DOI: 10.1177/000313481908501140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Immediate reconstruction after mastectomy helps women manage the psychological impact of deforming surgery. Postmastectomy radiation therapy (PMRT) can negatively impact the aesthetic result after breast reconstruction. We performed this study to achieve a better understanding of how PMRT is used after reconstruction in our institution. We conducted a retrospective review of a pro-spectively maintained database of all women who underwent mastectomy for invasive breast cancer followed by immediate reconstruction from 2006 to 2017. Patients were divided into two groups depending on whether PMRT was included in their treatment, and we compared clinical and pathologic characteristics to determine which factors were likely to lead to PMRT. A total of 315 women treated with mastectomy and immediate reconstruction were identified. A total of 96 were treated with PMRT; 219 had mastectomy and immediate reconstruction without radiotherapy. Tumor characteristics, tumor stage, demographics, and comorbidities did not predict the use of PMRT. Neoadjuvant chemotherapy (NAC) was the most powerful predictor for using PMRT. In 47 of 81 (58%) patients treated with NAC, PMRT was used. Whereas 49 of 234 (21%) patients who did not receive NAC were treated with PMRT ( P = 0.0001, risk ratio 2.77, 95 per cent confidence interval 2.03–3.77). In our institution, patients treated with NAC followed by mastectomy and immediate reconstruction are significantly more likely to receive PMRT. The increased use of PMRTafter NAC should be factored into the preoperative discussion with patients choosing mastectomy and immediate reconstruction.
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Affiliation(s)
- Genevieve Hayek
- Department of Surgery, Ochsner Clinic Foundation, New Orleans, Louisiana and
| | - Mary Winslow
- Faculty of Medicine, Ochsner Clinical School, The University of Queensland, New Orleans, Louisiana
| | - Morgan Maier
- Faculty of Medicine, Ochsner Clinical School, The University of Queensland, New Orleans, Louisiana
| | - Ralph Corsetti
- Department of Surgery, Ochsner Clinic Foundation, New Orleans, Louisiana and
| | - Amy Rivere
- Department of Surgery, Ochsner Clinic Foundation, New Orleans, Louisiana and
| | - Aimee Mackey
- Department of Surgery, Ochsner Clinic Foundation, New Orleans, Louisiana and
| | - Shoichiro Tanaka
- Department of Surgery, Ochsner Clinic Foundation, New Orleans, Louisiana and
| | - George Fuhrman
- Department of Surgery, Ochsner Clinic Foundation, New Orleans, Louisiana and
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22
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Shumway DA, Momoh AO, Sabel MS, Jagsi R. Integration of Breast Reconstruction and Postmastectomy Radiotherapy. J Clin Oncol 2020; 38:2329-2340. [PMID: 32442071 DOI: 10.1200/jco.19.02850] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
- Dean A Shumway
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | - Adeyiza O Momoh
- Section of Plastic Surgery, University of Michigan, Ann Arbor, MI
| | - Michael S Sabel
- Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Reshma Jagsi
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI
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23
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Yoon WS, Rim CH, Yang DS, Lee JA, Son GS, Chang YW, Woo SU, Kim DW, Dhong ES. Long-term outcomes of immediate autologous breast reconstruction after definite adjuvant therapy in intermediate and locally advanced breast cancer. ANNALS OF TRANSLATIONAL MEDICINE 2020; 7:743. [PMID: 32042759 DOI: 10.21037/atm.2019.11.129] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Background To analyze oncologic outcomes and reconstruction quality in locally advanced stage breast cancer after performing immediate autologous breast reconstruction (IABR). Methods From 2007 to 2014, data of patients aged ≤70 years old with stage II-III breast cancer who received total mastectomy (TM) were extracted from medical records. Exclusion criteria were: previous contralateral breast cancer, follow-up loss before adjuvant therapy completion, and artificial reconstruction. Patients were divided into two groups: (I) TM alone, and (II) TM + IABR. Overall survival (OS) and loco-regional recurrence free survival (LRRFS) were calculated. Times of minor revision, abnormal image findings in breast, and change of breast height were observed. Results Sixty-one of 188 patients received IABR after TM. Stage IIIB-C was the most important prognostic factor for OS (P<0.001) and LRRFS (P<0.001). For stage II, five-year TM and TM + IABR OS rates were 96.8% and 100% (P=0.324), respectively. For stage IIIB-C, five-year TM and TM + IABR OS rates were 57.6% and 62.5% (P=0.544), respectively. For stage II, five-year TM and TM + IABR LRRFS were 98.1% and 95.7% (P=0.998), respectively. For stage IIIB-C, five-year TM and TM + IABR LRRFS were 70.8% and 62.5% (P=0.378), respectively. Two major complications were observed after IABR. Minor revisions, abnormal image findings, and change of breast height were common without showing significant relation with adjuvant radiotherapy or tumor stage. Conclusions IABR showed feasible oncologic outcomes in 5-year follow-up. Adjuvant radiotherapy had little effect on quality of reconstruction. However, IABR in advanced stage should be cautiously applied considering expected survival and minor problems after IABR.
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Affiliation(s)
- Won Sup Yoon
- Department of Radiation Oncology, Ansan Hospital, Korea University Medical Center, Ansan, Republic of Korea
| | - Chai Hong Rim
- Department of Radiation Oncology, Ansan Hospital, Korea University Medical Center, Ansan, Republic of Korea
| | - Dae Sik Yang
- Department of Radiation Oncology, Guro Hospital, Korea University Medical Center, Seoul, Republic of Korea
| | - Jung Ae Lee
- Department of Radiation Oncology, Guro Hospital, Korea University Medical Center, Seoul, Republic of Korea
| | - Gil Soo Son
- Department of Surgery, Ansan Hospital, Korea University Medical Center, Ansan, Republic of Korea
| | - Young Woo Chang
- Department of Surgery, Ansan Hospital, Korea University Medical Center, Ansan, Republic of Korea
| | - Sang Uk Woo
- Department of Surgery, Guro Hospital, Korea University Medical Center, Seoul, Republic of Korea
| | - Deok-Woo Kim
- Department of Plastic Surgery, Ansan Hospital, Korea University Medical Center, Ansan, Republic of Korea
| | - Eun-Sang Dhong
- Department of Plastic Surgery, Guro Hospital, Korea University Medical Center, Ansan, Republic of Korea
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24
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Practical Applications of Delayed-Immediate Autologous Breast Reconstruction: A Flexible and Safe Operative Strategy. Ann Plast Surg 2019; 80:S299-S302. [PMID: 29620551 DOI: 10.1097/sap.0000000000001380] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Timing is an important consideration in patients undergoing mastectomy for breast cancer. While immediate reconstruction results in superior aesthetic outcomes, the need for postmastectomy radiation can often only be ascertained after review of surgical pathology. Delayed-immediate autologous reconstruction (DIAR) is a reconstructive approach that consists of mastectomy with tissue expander placement in the first stage and flap-based breast reconstruction in the second stage. We describe our institution's experience with DIAR to characterize the reasons in which patients opt for this reconstructive approach and analyze its ultimate outcomes. METHODS We conducted an institutional review board-approved retrospective chart review of all consecutive patients undergoing DIAR performed by the senior author from 2007 to 2016. Data gathered included demographics, operative techniques, and postoperative outcomes. RESULTS In our study, 17 patients and 26 breasts underwent DIAR. Seven patients initially planned for and eventually underwent DIAR. Ten patients initially planned for implant-based reconstructions but ultimately underwent DIAR instead. Flap types included deep inferior epigastric perforator (n = 6), superficial inferior epigastric artery (n = 2), and muscle-sparing free transverse rectus abdominis myocutaneous (n = 18). The mean time between mastectomy and reconstruction was 208 days. Complications included tissue expander infection, vascular compromise, abscess formation, hematoma, and skin necrosis. CONCLUSIONS The delayed-immediate approach allows for breast reconstruction with aesthetic and psychosocial benefits, while enabling postmastectomy radiation in patients with advanced disease. We describe modifications to DIAR, including use of a flap skin paddle and prolonged time between stages, which allow for broader applicability. We show that DIAR accommodates a range of patient preferences with few complications.
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25
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Dewael S, Vandevoort M, Fabré G, Nanhekhan L. Immediate versus delayed autologous breast reconstruction: A retrospective matched cohort study of irradiated patients. J Plast Reconstr Aesthet Surg 2019; 72:1769-1775. [DOI: 10.1016/j.bjps.2019.05.054] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Revised: 05/05/2019] [Accepted: 05/30/2019] [Indexed: 10/26/2022]
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26
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Giatsidis G, Succar J, Waters TD, Liu W, Rhodius P, Wang C, Nilsen TJ, Chnari E, Orgill DP. Tissue-Engineered Soft-Tissue Reconstruction Using Noninvasive Mechanical Preconditioning and a Shelf-Ready Allograft Adipose Matrix. Plast Reconstr Surg 2019; 144:884-895. [PMID: 31568297 DOI: 10.1097/prs.0000000000006085] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Adipose tissue defects leading to severe functional (disability) and morphologic (disfigurement) morbidity are often treated in plastic surgery with fat grafting, which can be limited by resorption, necrosis, and cyst formation. This study aimed to assess whether adipose scaffolds could provide an environment for in situ autologous fat grafting, and to study whether adipose cell migration and proliferation (adipogenesis) within scaffolds could be enhanced by preliminarily increasing the vascularity (preconditioning) of the surrounding tissue receiving the scaffolds. METHODS Using an established rodent model of subcutaneous tissue/scaffold grafting, the authors tested the potential of a human-derived, shelf-ready, injectable, decellularized allograft adipose matrix to reconstruct soft-tissue defects when used in combination with noninvasive mechanical (suction-induced) skin preconditioning. RESULTS Combined use of the allograft adipose matrix and noninvasive skin preconditioning significantly improved long-term volume retention (50 to 80 percent higher at a 12-week follow-up) and histologic quality of reconstructed tissues compared with standard of care (autologous adipose grafts). The components of the allograft adipose matrix supported adipogenesis and angiogenesis. Combining the allograft adipose matrix with living adipose grafts mitigated negative outcomes (lower long-term volume retention, higher presence of cystic-like areas). CONCLUSIONS This study suggests that the synergistic use of the allograft adipose matrix and noninvasive tissue preconditioning provides an effective solution for improving fat grafting. These strategies can easily be tested in clinical trials and could establish the basis for a novel therapeutic paradigm in reconstructive surgery.
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Affiliation(s)
- Giorgio Giatsidis
- From the Tissue Engineering and Wound Healing Laboratory, Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School; Department of Molecular Medicine, University of Padova; Preventive Medicine, University of New Mexico; Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College; and the Musculoskeletal Transplant Foundation
| | - Julien Succar
- From the Tissue Engineering and Wound Healing Laboratory, Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School; Department of Molecular Medicine, University of Padova; Preventive Medicine, University of New Mexico; Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College; and the Musculoskeletal Transplant Foundation
| | - Trevon D Waters
- From the Tissue Engineering and Wound Healing Laboratory, Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School; Department of Molecular Medicine, University of Padova; Preventive Medicine, University of New Mexico; Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College; and the Musculoskeletal Transplant Foundation
| | - Wenyue Liu
- From the Tissue Engineering and Wound Healing Laboratory, Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School; Department of Molecular Medicine, University of Padova; Preventive Medicine, University of New Mexico; Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College; and the Musculoskeletal Transplant Foundation
| | - Patrick Rhodius
- From the Tissue Engineering and Wound Healing Laboratory, Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School; Department of Molecular Medicine, University of Padova; Preventive Medicine, University of New Mexico; Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College; and the Musculoskeletal Transplant Foundation
| | - Chenglong Wang
- From the Tissue Engineering and Wound Healing Laboratory, Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School; Department of Molecular Medicine, University of Padova; Preventive Medicine, University of New Mexico; Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College; and the Musculoskeletal Transplant Foundation
| | - Todd J Nilsen
- From the Tissue Engineering and Wound Healing Laboratory, Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School; Department of Molecular Medicine, University of Padova; Preventive Medicine, University of New Mexico; Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College; and the Musculoskeletal Transplant Foundation
| | - Evangelia Chnari
- From the Tissue Engineering and Wound Healing Laboratory, Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School; Department of Molecular Medicine, University of Padova; Preventive Medicine, University of New Mexico; Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College; and the Musculoskeletal Transplant Foundation
| | - Dennis P Orgill
- From the Tissue Engineering and Wound Healing Laboratory, Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School; Department of Molecular Medicine, University of Padova; Preventive Medicine, University of New Mexico; Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College; and the Musculoskeletal Transplant Foundation
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27
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Samiei S, van Kaathoven BN, Boersma L, Granzier RWY, Siesling S, Engelen SME, de Munck L, van Kuijk SMJ, van der Hulst RRJW, Lobbes MBI, Smidt ML, van Nijnatten TJA. Risk of Positive Sentinel Lymph Node After Neoadjuvant Systemic Therapy in Clinically Node-Negative Breast Cancer: Implications for Postmastectomy Radiation Therapy and Immediate Breast Reconstruction. Ann Surg Oncol 2019; 26:3902-3909. [PMID: 31359276 PMCID: PMC6787110 DOI: 10.1245/s10434-019-07643-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Indexed: 12/27/2022]
Abstract
Background Residual axillary lymph node involvement after neoadjuvant systemic therapy (NST) is the determining factor for postmastectomy radiation therapy (PMRT). Preoperative identification of patients needing PMRT is essential to enable shared decision-making when choosing the optimal timing of breast reconstruction. We determined the risk of positive sentinel lymph node (SLN) after NST in clinically node-negative (cN0) breast cancer. Methods All cT1-3N0 patients treated with NST followed by mastectomy and SLNB between 2010 and 2016 were identified from the Netherlands Cancer Registry. Rate of positive SLN for different breast cancer subtypes was determined. Logistic regression analysis was performed to determine correlated clinicopathological variables with positive SLN. Results In total 788 patients were included, of whom 25.0% (197/788) had positive SLN. cT1-3N0 ER+HER2+, cT1-3N0 ER−HER2+ , and cT1-2N0 triple-negative patients had the lowest rate of positive SLN: 7.2–11.5%, 0–6.3%, and 2.9–6.2%, respectively. cT1-3N0 ER+HER2− and cT3N0 triple-negative patients had the highest rate of positive SLN: 23.8–41.7% and 30.4%, respectively. Multivariable regression analysis showed that cT2 (odds ratio [OR] 1.93; 95% confidence interval [CI] 1.01–3.96), cT3 (OR 2.56; 95% CI 1.30–5.38), grade 3 (OR 0.44; 95% CI 0.21–0.91), and ER+HER2− subtype (OR 3.94; 95% CI 1.77–8.74) were correlated with positive SLN. Conclusions In cT1-3N0 ER+HER2+, cT1-3N0 ER−HER2+, and cT1-2N0 triple-negative patients treated with NST, immediate reconstruction can be considered an acceptable option due to low risk of positive SLN. In cT1-3N0 ER+HER2− and cT3N0 triple-negative patients treated with NST, risks and benefits of immediate reconstruction should be discussed with patients due to the relatively high risk of positive SLN.
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Affiliation(s)
- S Samiei
- Department of Surgery, Maastricht University Medical Center+, Maastricht, The Netherlands. .,Department of Radiology and Nuclear Medicine, Maastricht University Medical Center+, Maastricht, The Netherlands. .,GROW - School for Oncology and Developmental Biology, Maastricht University Medical Center+, Maastricht, The Netherlands.
| | - B N van Kaathoven
- Department of Surgery, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - L Boersma
- GROW - School for Oncology and Developmental Biology, Maastricht University Medical Center+, Maastricht, The Netherlands.,Department of Radiation Oncology, Maastricht University Medical Center+ (MAASTRO Clinic), Maastricht, The Netherlands
| | - R W Y Granzier
- Department of Surgery, Maastricht University Medical Center+, Maastricht, The Netherlands.,GROW - School for Oncology and Developmental Biology, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - S Siesling
- Department of Research, Netherlands Comprehensive Cancer Organization, Utrecht, The Netherlands.,Department of Health Technology and Services Research, Technical Medical Center, University of Twente, Enschede, The Netherlands
| | - S M E Engelen
- Department of Surgery, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - L de Munck
- Department of Research, Netherlands Comprehensive Cancer Organization, Utrecht, The Netherlands
| | - S M J van Kuijk
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - R R J W van der Hulst
- Department of Plastic, Reconstructive, and Hand Surgery, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - M B I Lobbes
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center+, Maastricht, The Netherlands.,GROW - School for Oncology and Developmental Biology, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - M L Smidt
- Department of Surgery, Maastricht University Medical Center+, Maastricht, The Netherlands.,GROW - School for Oncology and Developmental Biology, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - T J A van Nijnatten
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center+, Maastricht, The Netherlands
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5000 Free Flaps and Counting: A 10-Year Review of a Single Academic Institution's Microsurgical Development and Outcomes. Plast Reconstr Surg 2018; 141:855-863. [PMID: 29595720 DOI: 10.1097/prs.0000000000004200] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND The establishment of an effective clinical and academic culture within an institution is a multifactorial process. This process is cultivated by dynamic elements such as recruitment of an accomplished and diverse faculty, patient geographic outreach, clinical outcomes research, and fundamental support from all levels of an institution. This study reviews the academic evolution of a single academic plastic surgery practice, and summarizes a 10-year experience of microsurgical development, clinical outcomes, and academic productivity. METHODS A 10-year retrospective institutional review was performed from fiscal years 2006 to 2016. Microsurgical flap type and operative volume were measured across all microsurgery faculty and participating hospitals. Microvascular compromise and flap salvage rates were noted for the six highest volume surgeons. Univariate and multivariable predictors of flap salvage were determined. RESULTS The 5000th flap was performed in December of 2015 within this institutional study period. Looking at the six highest volume surgeons, free flaps were examined for microvascular compromise, with an institutional mean take-back rate of 1.53 percent and flap loss rate of 0.55 percent across all participating hospitals. Overall, 74.4 percent of cases were breast flaps, and the remaining cases were extremity and head and neck flaps. CONCLUSIONS Focused faculty and trainee recruitment has resulted in an academically and clinically productive practice. Collaboration among faculty, staff, and residents contributes to continual learning, innovation, and quality patient care. This established framework, constructed based on experience, offers a workable and reproducible model for other academic plastic surgery institutions. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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Three-dimensional Analysis of How Radiation Affects Deep Inferior Epigastric Perforator (DIEP) Flap Volume, Projection, and Position in Breast Cancer Reconstruction. Ann Plast Surg 2018; 81:235-239. [DOI: 10.1097/sap.0000000000001462] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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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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Herrera de la Muela M, García López E, Frías Aldeguer L, Gómez-Campelo P. Protocol for the BRECAR study: a prospective cohort follow-up on the impact of breast reconstruction timing on health-related quality of life in women with breast cancer. BMJ Open 2017; 7:e018108. [PMID: 29259059 PMCID: PMC5778343 DOI: 10.1136/bmjopen-2017-018108] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION The completion of postmastectomy breast reconstruction (BR) in women with breast cancer can last from months to years, and to our knowledge, there is a lack of studies that analyse how the different types and times of reconstruction impact on the patient's quality of life and psychosocial adjustment.The primary aim of the BREast Cancer Reconstruction (BRECAR Study) is twofold. First, to describe health-related quality of life (HRQoL), overall satisfaction with surgery and psychological impact (body image, self-esteem, depression and anxiety) on women who will have undergone a mastectomy with planned BR, considering the varied timing of BR procedures (immediate BR (iBR), delayed BR (dBR) and two-stage BR (2sBR)). To measure the impact on surgical outcomes, we will obtain data prior to and after surgery (6-9 and at 18 months of follow-up). Second, to analyse sociodemographic, clinical and psychosocial factors associated with HRQoL, satisfaction with surgery and psychological impact. METHODS AND ANALYSIS A prospective, observational, clinical cohort study of women diagnosed with breast cancer who have an indication for mastectomy treated at La Paz University Hospital (Madrid, Spain).Patients will be classified into one of three groups under conditions of routine clinical practice, based on the type of BR planned: the iBR group, the dBR group and the 2sBR group.Under typical clinical practice conditions, we will perform three visits: baseline visit (presurgery), V1 (6-9 months after diagnosis) and V2 (18 months after diagnosis). A sample size of 210 patients is estimated. ETHICS AND DISSEMINATION The study protocol and informed consent form have been reviewed and approved by the Institutional Review Board of La Paz Hospital (no. PI-2036). Dissemination of results will be via journal articles and conference presentations.
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Affiliation(s)
- Maria Herrera de la Muela
- Breast Pathology Unit, Department of Gynecology, Hospital Universitario La Paz, Madrid, Spain
- Hospital La Paz Institute for Health Research (IdiPAZ), La Paz University Hospital, Madrid, Spain
| | - Enrique García López
- Breast Pathology Unit, Department of Gynecology, Hospital Universitario La Paz, Madrid, Spain
| | - Laura Frías Aldeguer
- Breast Pathology Unit, Department of Gynecology, Hospital Universitario La Paz, Madrid, Spain
| | - Paloma Gómez-Campelo
- Hospital La Paz Institute for Health Research (IdiPAZ), La Paz University Hospital, Madrid, Spain
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Abstract
With the indications for radiation therapy in the treatment of breast cancer continuing to expand, many patients present for reconstruction having previously had radiation or having a high likelihood of requiring radiation following mastectomy. Both situations are challenging for the plastic surgeon, with different variables impacting the surgical outcome. To date, multiple studies have been performed examining prosthetic and autologous reconstruction in this setting. The purpose of this article was to provide a general platform for understanding the literature as it relates to reconstruction and radiation through an examination of recent systematic reviews and relevant recent publications. We examined this with a focus on the timing of the radiation, and within this context, examined the data from the traditional surgical outcomes standpoint as well as from a patient-reported outcomes perspective. The data provided within will aid in patient counseling and the informed consent process.
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Should Immediate Autologous Breast Reconstruction Be Considered in Women Who Require Postmastectomy Radiation Therapy? A Prospective Analysis of Outcomes. Plast Reconstr Surg 2017; 139:1279-1288. [PMID: 28198770 DOI: 10.1097/prs.0000000000003331] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND In women who require postmastectomy radiation therapy, immediate autologous breast reconstruction is often discouraged. The authors prospectively evaluated postoperative morbidity and satisfaction reported by women undergoing delayed or immediate autologous breast reconstruction in the setting of postmastectomy radiation therapy. METHODS Patients enrolled in the Mastectomy Reconstruction Outcomes Consortium study, who received postmastectomy radiotherapy and underwent immediate or delayed free abdominally based autologous breast reconstruction, were identified. Postoperative complications at 1 and 2 years after reconstruction were assessed. Patient-reported outcomes were evaluated using the BREAST-Q questionnaire preoperatively and at 1 and 2 years postoperatively. Bivariate analyses and mixed-effects regression models were used to compare outcomes. RESULTS A total of 175 patients met the authors' inclusion criteria. Immediate reconstructions were performed in 108 patients and delayed reconstructions in 67 patients; 93.5 percent of immediate reconstructions were performed at a single center. Overall complication rates were similar based on reconstructive timing (25.9 percent immediate and 26.9 percent delayed at 1 year; p = 0.54). Patients with delayed reconstruction reported significantly lower prereconstruction scores (p < 0.0001) for Satisfaction with Breasts and Psychosocial and Sexual Well-being than did patients with immediate reconstruction. At 1 and 2 years postoperatively, both groups reported comparable levels of satisfaction in assessed BREAST-Q domains. CONCLUSIONS From this prospective cohort, immediate autologous breast reconstruction in the setting of postmastectomy radiation therapy appears to be a safe option that may be considered in select patients and centers. Breast aesthetics and quality of life, evaluated from the patient's perspective, were not compromised by flap exposure to radiation therapy. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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Reconstruction of the Irradiated Breast: A National Claims-Based Assessment of Postoperative Morbidity. Plast Reconstr Surg 2017; 139:783-792. [PMID: 28002254 DOI: 10.1097/prs.0000000000003168] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Implant-based reconstruction rates have risen among irradiation-treated breast cancer patients in the United States. This study aims to assess the morbidity associated with various breast reconstruction techniques in irradiated patients. METHODS From the MarketScan Commercial Claims and Encounters database, the authors selected breast cancer patients who had undergone mastectomy, irradiation, and breast reconstruction from 2009 to 2012. Demographic and clinical treatment data, including data on the timing of irradiation relative to breast reconstruction were recorded. Complications and failures after implant and autologous reconstruction were also recorded. A multivariable logistic regression model was developed with postoperative complications as the dependent variable and patient demographic and clinical variables as independent variables. RESULTS Four thousand seven hundred eighty-one irradiated patients who met the inclusion criteria were selected. A majority of the patients [n = 3846 (80 percent)] underwent reconstruction with implants. Overall complication rates were 45.3 percent and 30.8 percent for patients with implant and autologous reconstruction, respectively. Failure of reconstruction occurred in 29.4 percent of patients with implant reconstruction compared with 4.3 percent of patients with autologous reconstruction. In multivariable logistic regression, irradiated patients with implant reconstruction had two times the odds of having any complication and 11 times the odds of failure relative to patients with autologous reconstruction. CONCLUSIONS Implant-based breast reconstruction in the irradiated patient, although popular, is associated with significant morbidity. Failures of reconstruction with implants in these patients approach 30 percent in the short term, suggesting a need for careful shared decision-making, with full disclosure of the potential morbidity. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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An Innovative Risk-Reducing Approach to Postmastectomy Radiation Delivery after Autologous Breast Reconstruction. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2017; 5:e1265. [PMID: 28507844 PMCID: PMC5426863 DOI: 10.1097/gox.0000000000001265] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Accepted: 01/20/2017] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Postmastectomy radiation therapy (PMRT) has known deleterious side effects in immediate autologous breast reconstruction. However, plastic surgeons are rarely involved in PMRT planning. Our institution has adopted a custom bolus approach for all patients receiving PMRT. This offers uniform distribution of standard radiation doses, thereby minimizing radiation-induced changes while maintaining oncologic safety. We present our 8-year experience with the custom bolus approach for PMRT delivery in immediate autologous breast reconstruction. METHODS All immediate autologous breast reconstruction patients requiring PMRT after 2006 were treated with the custom bolus approach. Retrospective chart review was performed to compare the postirradiation complications, reconstruction outcomes, and oncologic outcomes of these patients with those of previous patients at our institution who underwent standard bolus, and to historical controls from peer-reviewed literature. RESULTS Over the past 10 years, of the 29 patients who received PMRT, 10 were treated with custom bolus. Custom bolus resulted in fewer radiation-induced skin changes and less skin tethering/fibrosis than standard bolus (0% vs 10% and 20% vs 35%, respectively), and less volume loss and contour deformities compared with historical controls (10% vs 22.8% and 10% vs 30.7%, respectively). CONCLUSIONS Custom bolus PMRT minimizes radiation delivery to the internal mammary vessels, anastomoses, and skin; uniformly doses the surgical incision; and provides the necessary radiation dose to prevent recurrence. Because custom bolus PMRT may reduce the deleterious effects of radiation on reconstructive outcomes while maintaining safe oncologic results, we encourage all plastic surgeons to collaborate with radiation oncologists to consider this technique.
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Sacotte R, Fine N, Kim JY, Alghoul M, Bethke K, Hansen N, Khan SA, Kulkarni S, Strauss J, Hayes JP, Donnelly ED. Assessing long-term complications in patients undergoing immediate postmastectomy breast reconstruction and adjuvant radiation. Pract Radiat Oncol 2017; 7:e91-e97. [DOI: 10.1016/j.prro.2016.10.017] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2016] [Revised: 10/14/2016] [Accepted: 10/26/2016] [Indexed: 11/16/2022]
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Terao Y, Taniguchi K, Fujii M, Moriyama S. Postmastectomy radiation therapy and breast reconstruction with autologous tissue. Breast Cancer 2017; 24:505-510. [PMID: 28229358 DOI: 10.1007/s12282-017-0760-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Accepted: 11/02/2016] [Indexed: 11/30/2022]
Abstract
Immediate breast reconstruction is an important tool for patients to accept and overcome their breast cancer, as well as for cosmetic reasons. However, its use in patients who require postmastectomy radiation therapy (PMRT) is not yet clear. The purpose of this study was to analyze the effects of PMRT and reconstruction on each other. The time of initiation of PMRT, the prognosis, and the cosmetic results were investigated in patients who underwent immediate reconstruction using autologous tissue. In the case of delayed reconstruction using autologous tissue after PMRT, radiation damage of the chest skin, design of the flap, and cosmetic results were investigated. In 38 patients who underwent immediate reconstruction and PMRT between 2006 and 2015, 20 patients received neoadjuvant chemotherapy, and their mean time before starting PMRT was 9.7 weeks after surgery (range 7-18 weeks). Three patients underwent delayed PMRT (more than 12 weeks) due to partial flap necrosis and wound infection. Of 28 patients (2006-2010), 23 were disease free (stage I: 2/2, stage II: 15/16, stage III: 6/10), one patient (stage III) had distant metastases, and 4 patients died of primary disease (stage II: 1/16, stage III: 3/10). Unacceptable deformation of the reconstructed breast was observed in 4 patients who had partial fat necrosis of the grafted flap or skin necrosis of the mastectomy flap. In 20 patients who underwent delayed reconstruction between 2006 and 2015, 15 (75%) patients underwent replacement of irradiated chest skin with flap skin to reconstruct a soft and natural shape breast. The flap survival rate was 100%, and unacceptable deformation of the reconstructed breast was not seen. In the case of immediate reconstruction using autologous tissue, it is important to graft a flap with a good blood supply to avoid delaying PMRT and achieving a good cosmetic result, because flap necrosis or wound infection delays PMRT and causes scar contracture after PMRT. In the case of delayed reconstruction after PMRT, chest wall skin with radiation damage should be resected and replaced by flap skin.
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Affiliation(s)
- Yasunobu Terao
- Department of Plastic and Reconstructive Surgery, Tokyo Metropolitan Cancer and Infectious Disease Center, Komagome Hospital, 3-18-22 Honkomagome, Bunkyo-ku, Tokyo, Japan.
| | - Koichiro Taniguchi
- Department of Plastic and Reconstructive Surgery, Tokyo Metropolitan Cancer and Infectious Disease Center, Komagome Hospital, 3-18-22 Honkomagome, Bunkyo-ku, Tokyo, Japan
| | - Miwako Fujii
- Department of Plastic and Reconstructive Surgery, Tokyo Metropolitan Cancer and Infectious Disease Center, Komagome Hospital, 3-18-22 Honkomagome, Bunkyo-ku, Tokyo, Japan
| | - So Moriyama
- Department of Plastic and Reconstructive Surgery, Tokyo Metropolitan Cancer and Infectious Disease Center, Komagome Hospital, 3-18-22 Honkomagome, Bunkyo-ku, Tokyo, Japan
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Kuerer HM, Cordeiro PG, Mutter RW. Optimizing Breast Cancer Adjuvant Radiation and Integration of Breast and Reconstructive Surgery. Am Soc Clin Oncol Educ Book 2017; 37:93-105. [PMID: 28561684 DOI: 10.1200/edbk_175342] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Postmastectomy radiotherapy (PMRT) reduces the risk of locoregional and distant recurrence and improves overall survival in women with lymph node-positive breast cancer. Because of stage migration and improvements in systemic therapy and other aspects of breast cancer care, the absolute benefit of PMRT and regional nodal irradiation may be small in some favorable subsets of patients with very low nodal burden, and newer consensus guidelines do not mandate PMRT in all node-positive cases. The use and need for PMRT may considerably complicate breast reconstruction after mastectomy and therefore mandates multidisciplinary input that takes into account patient choice given potential risk of acute and long-term toxicities, benefits, life expectancy, the biology of the tumor, plans for systemic therapy, and actual tumor burden. Management of axillary lymph node metastases is changing with selective use of axillary lymph node dissection for advanced disease, sentinel lymph node biopsy alone for clinically and pathologic node-negative cases receiving mastectomy, and targeted axillary dissection alone among patients with eradication of initial biopsy-proven nodal metastases with neoadjuvant systemic therapy use. In general, when the need for PMRT is anticipated, autologous reconstruction should be delayed. This comprehensive article reviews the current indications and implications regarding integration of breast cancer surgery and timing of reconstruction with optimum radiation delivery to achieve the best possible patient outcomes.
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Affiliation(s)
- Henry M Kuerer
- From the Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX; Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, NY; Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | - Peter G Cordeiro
- From the Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX; Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, NY; Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | - Robert W Mutter
- From the Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX; Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, NY; Department of Radiation Oncology, Mayo Clinic, Rochester, MN
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Nestle-Krämling C, Bölke E, Budach W, Andree C. Breast reconstruction after neoadjuvant radio chemotherapy: review and personal technique IDEAL concept REV-EJMR-D-15-00268. Eur J Med Res 2016; 21:24. [PMID: 27287332 PMCID: PMC4902933 DOI: 10.1186/s40001-016-0219-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Accepted: 05/26/2016] [Indexed: 12/31/2022] Open
Abstract
Neoadjuvant radio chemotherapy and immediate reconstruction for breast cancer are still under debate. But there are recent abstracts and articles which show that neoadjuvant radio chemotherapy is feasible and could improve the clinical outcome of breast cancer patients. The aim of this review is to present the authors’ techniques and approaches with regard to neoadjuvant radiation of breast cancer patients. It seems that the concept of immediate implant delayed autologous breast reconstruction could be a safe procedure that is at least equivalent to primary autologous reconstruction.
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Affiliation(s)
- Carolin Nestle-Krämling
- Department of Senology, Sana Kliniken Düsseldorf-Gerresheim, Graeulinger Straße 120, 40625, Düsseldorf, Germany
| | - Edwin Bölke
- Department of Radiation Oncology, Heinrich Heine University, Moorenstrasse 5, 40225, Düsseldorf, Germany.
| | - Wilfried Budach
- Department of Radiation Oncology, Heinrich Heine University, Moorenstrasse 5, 40225, Düsseldorf, Germany
| | - Christoph Andree
- Department of Plastic and Reconstructive Surgery, Sana Kliniken Düsseldorf-Gerresheim, Graeulinger Straße 120, 40625, Düsseldorf, Germany
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El-Sabawi B, Carey JN, Hagopian TM, Sbitany H, Patel KM. Radiation and breast reconstruction: Algorithmic approach and evidence-based outcomes. J Surg Oncol 2016; 113:906-12. [DOI: 10.1002/jso.24143] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2015] [Accepted: 12/14/2015] [Indexed: 11/07/2022]
Affiliation(s)
- Bassim El-Sabawi
- Division of Plastic and Reconstructive Surgery; Keck School of Medicine of the University of Southern California; Los Angeles California
| | - Joseph N. Carey
- Division of Plastic and Reconstructive Surgery; Keck School of Medicine of the University of Southern California; Los Angeles California
| | - Thomas M. Hagopian
- Division of Plastic and Reconstructive Surgery; Keck School of Medicine of the University of Southern California; Los Angeles California
| | - Hani Sbitany
- Division of Plastic and Reconstructive Surgery; University of California San Francisco; San Francisco California
| | - Ketan M. Patel
- Division of Plastic and Reconstructive Surgery; Keck School of Medicine of the University of Southern California; Los Angeles California
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Duraes EFR, Schwarz G, Durand P, Moreira-Gonzalez A, Duraes LC, de Sousa JB, Djohan RS, Zins J, Bernard SL. Complications Following Abdominal-Based Free Flap Breast Reconstruction: Is a 30 days Complication Rate Representative? Aesthetic Plast Surg 2015. [PMID: 26206499 DOI: 10.1007/s00266-015-0534-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
PURPOSE The purpose of this study was to analyze timing and frequency of complications following free tissue autologous reconstruction in a single tertiary care institution. METHODS From August 2012 to December 2013, all patients operated on for abdominal-based free flap breast reconstruction at a single institution were included. Complications were identified and risk factors associated with them were analyzed using SPSS software. RESULTS The total number of patients was 130 with a total of 191 flaps (69 for unilateral and 61 for bilateral reconstructions). Mean surgery time was 570.5 min (±151.24). Fifty-nine of the reconstructed breasts (30.8 %) had early complications. Reoperations due to complications were required in 16 (8.3 %) of the breasts during the first 30 days with seven patients requiring multiple reoperations. Twenty-eight patients required reoperations after 30 days, the most frequent reason being delayed wound healing and abdominal hernia. The most significant complication was a case of disseminated infection with loss of skin coverage of the breasts. Early complications and donor-site complications were higher in active smokers (p = 0.005 and p < 0.001, respectively). Patients with a BMI < 25 had fewer total early complications (p = 0.05), as well as fewer complications on the breast area (p = 0.02). A longer time in the operating room was associated with an increase in late complications (p = 0.018). Bilateral/unilateral operation, immediate/delayed surgery, radiotherapy, age, hypertension, diabetes, and surgery time were not associated with early complications, late complications, or reoperations (p > 0.05). CONCLUSIONS Active smoking was found to be a significant risk factor for early complications, reoperations, and donor-site complications. Patients with a normal BMI had fewer early complications, reoperations at 30 days, and complications on the breast area. As a significant number of complications occurred beyond the standard 30-day reporting period, it is important to consider reoperations during an extended period. 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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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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Rochlin DH, Jeong AR, Goldberg L, Harris T, Mohan K, Seal S, Canner J, Sacks JM. Postmastectomy radiation therapy and immediate autologous breast reconstruction: Integrating perspectives from surgical oncology, radiation oncology, and plastic and reconstructive surgery. J Surg Oncol 2014; 111:251-7. [DOI: 10.1002/jso.23804] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Accepted: 09/05/2014] [Indexed: 11/06/2022]
Affiliation(s)
- Danielle H. Rochlin
- Department of Plastic and Reconstructive Surgery; Johns Hopkins University School of Medicine; Baltimore Maryland
| | - Ah-Reum Jeong
- Keck School of Medicine of University of Southern California; Los Angeles California
| | - Leah Goldberg
- Department of Plastic and Reconstructive Surgery; Johns Hopkins University School of Medicine; Baltimore Maryland
| | - Timothy Harris
- Department of Radiation Oncology; Johns Hopkins University School of Medicine; Baltimore Maryland
| | - Kriti Mohan
- Division of Plastic Surgery; Baylor College of Medicine; Houston Texas
| | - Stella Seal
- Welch Medical Library; Johns Hopkins University; Baltimore Maryland
| | - Joe Canner
- Center for Surgical Trials and Outcomes Research (CSTOR); Johns Hopkins University School of Medicine; Baltimore Maryland
| | - Justin M. Sacks
- Department of Plastic and Reconstructive Surgery; Johns Hopkins University School of Medicine; Baltimore Maryland
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Nelson JA, Fischer JP, Radecki MA, Pasick C, McGrath J, Serletti JM, Wu LC. Delayed autologous breast reconstruction: factors which influence patient decision making. J Plast Reconstr Aesthet Surg 2013; 66:1513-20. [PMID: 23886556 DOI: 10.1016/j.bjps.2013.06.020] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2012] [Revised: 03/20/2013] [Accepted: 06/04/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Autologous breast reconstruction timing continues to be controversial. The purpose of this study was to examine delayed autologous breast reconstruction at a center favouring immediate reconstruction to better understand factors driving the decision to delay reconstruction. METHODS We performed a retrospective cohort study of all free autologous breast reconstruction patients between 2005 and 2009, focussing on ethnicity, cancer stage, unilateral or bilateral reconstructions, initial management, distance from the institution, and average income. Delayed reconstructions were compared to immediate reconstructions. All delayed reconstructions were surveyed to examine treatment and reconstruction decisions and satisfaction. RESULTS Of 709 patients, 169 (24%) underwent delayed treatment. Delayed reconstruction patients had higher cancer stages (p < 0.001), higher rates of pre-reconstruction radiation therapy (64% vs. 20%, p < 0.0001) and higher rates of unilateral reconstruction (64% vs. 48%, p < 0.001). Seventy delayed patients responded to the survey (41%), with 75% having had their initial mastectomy at an outside health system. Only 51% discussed immediate reconstruction prior to electing delayed treatment and 41% had no discussion regarding advantages or disadvantages to reconstructive options. Approximately 30% noted no choice in their reconstructive timing. Forty five percent would elect immediate reconstruction if given the option. CONCLUSIONS This study demonstrates that women may not be receiving all available information prior to undergoing mastectomy for initial breast cancer treatment. As a significant portion of women electing delayed reconstruction would elect immediate autologous reconstruction if given the option again, there is room for improvement in pre-operative patient education and in the education of our oncology colleagues.
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Affiliation(s)
- Jonas A Nelson
- Division of Plastic Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States.
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