Breast Reconstruction and Radiation Therapy

Delayed breast reconstruction with autologous free flap after radiation therapy: vascular complications and aesthetic outcomes

BACKGROUND

The safety and outcome of breast reconstruction after radiotherapy are controversial, and the aesthetic aspects have not been studied extensively. We compared the results of vascular anastomosis, the incidence of postoperative complications, and aesthetic appearance between patients who had and had not received radiotherapy who then had undergone delayed breast reconstruction with autologous free flaps from the abdomen, thighs, and buttocks.

METHODS

In total, 257 flaps in 241 patients were investigated; 194 and 63 flaps implanted in patients who did not receive radiotherapy and who received radiotherapy before breast reconstruction, respectively. Of the 257 flaps, 221, 20, 14, and 2 came from the abdomen, thighs, buttocks, and other anatomic locations, respectively. We evaluated aesthetic outcomes in 105 patients who had not received radiotherapy and 35 who had.

RESULTS

We found no significant differences between the two groups in the incidence of vascular reanastomosis, the time required for anastomosis, or the incidence of unplanned reoperation. Complications such as flap necrosis were rare in both groups. Aesthetic outcomes were significantly better in the patients who had not received radiotherapy.

CONCLUSIONS

Breast reconstruction with autologous free flaps can be performed safely in patients who have received radiotherapy, but the aesthetic result is slightly inferior to that in patients who had not received radiotherapy.

'Rosebud' inset of DIEP flap in delayed breast reconstruction for consistent projection, lateral flow, and ptosis

Here we describe a template of DIEP flap inset that prioritises projection, lateral flow and natural ptosis; key elements of an aesthetically successful delayed breast reconstruction. By not excising the full length of the mastectomy scar, and preserving the scar laterally, we increase the 3-dimensional aesthetic of the breast, moving the final reconstructed breast aesthetic further away from an unintentional 2-dimensional resurfacing. Through controlling the initial take-off around the whole circumference of the breast footprint, a favourable and durable breast conus is consistently achieved. This technique employs designated segments of comparatively more rigid irradiated mastectomy skin flaps, to positively influence reconstructed breast aesthetics at the time of flap inset. Conceptually, this reminds the authors of how the green sepals of a rose shape the bud of petals.

Modifiable Postmastectomy Radiation Therapy Factors and Impact on Implant-Based Breast Reconstruction Outcomes

BACKGROUND

Intensity-modulated radiation therapy and other modifiable radiation factors have been associated with decreased radiation toxicity. These factors could allow for improved reconstructive outcomes in patients requiring postmastectomy radiation therapy (PMRT). However, they have not yet been well studied in implant-based breast reconstruction.

METHODS

The authors performed a retrospective chart review of patients who underwent mastectomy with immediate tissue expander placement followed by PMRT. Radiation characteristics were collected, including radiation technique, bolus regimen, x-ray energy, fractionation, maximum radiation hot spot, and tissue volume receiving more than 105% or more than 107% of the prescription dose. Reconstructive complications occurring after initiation of PMRT were analyzed with respect to these radiation characteristics.

RESULTS

Sixty-eight patients (70 breasts) were included in this study. The overall complication rate was 28.6%, with infection being the most common complication (24.3%), requiring removal of the tissue expander or implant in greater than half of infections (15.7%). Maximum radiation hot spot was greater in patients who required explantation after PMRT, and this approached statistical significance (114.5% ± 7.2% versus 111.4% ± 4.4%; P = 0.059). Tissue volume receiving more than 105% and 107% were also greater in patients who required explantation after PMRT (42.1% ± 17.1% versus 33.0% ± 20.9% and 16.4% ± 14.5% versus 11.3% ± 14.6%, respectively); however, this was not statistically significant ( P = 0.176 and P = 0.313, respectively). There were no significant differences in complication rates between patients with respect to radiation technique or other radiation characteristics studied.

CONCLUSION

Minimizing the radiation hot spots and volumes of tissue receiving greater than the prescription dose of radiation may improve reconstructive outcomes in patients undergoing implant-based breast reconstruction followed by PMRT.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Risk factors for severe complications and salvage management in direct-to-implant immediate breast reconstruction: A retrospective study

Controversies regarding the risk factors affecting direct-to-implant (DTI) immediate breast reconstruction still exist. This study aimed to evaluate the risk factors for severe complications in DTI breast reconstruction and explore potential salvage management strategies. We conducted a retrospective review of 238 patients (240 breasts) who underwent DTI immediate breast reconstruction between 2011 and 2020. Multivariate logistic regression analyses were used to identify the risk factors predicting severe complications. Seventeen (7.08%) reconstructed breasts experienced severe complications, of which only 5 were successfully salvaged through surgical revision, while the others failed and resulted in implant removal. Multivariate analyses demonstrated that mesh use [odds ratio (OR) = 4.054, 95% confidence interval: 1.376-11.945, P = .011] and post-mastectomy radiotherapy (odds ratio = 4.383, 95% confidence interval 1.142-16.819, P = .031) were independent predictors of severe complications. Mesh use and post-mastectomy radiotherapy for breast reconstruction increase the risk of severe complications. Despite positive surgical treatment, the successful salvage rate was poor.

Six steps for a successful aesthetic free flap reconstruction after minimally invasive mastectomy: a retrospective case-control study

OBJECTIVE

Breast cancer treatment has evolved to the modern skin-sparing mastectomy and nipple-sparing mastectomy. To better perform these surgeries, minimally invasive techniques using the endoscope, or Da Vinci Robotic Surgery platform have been developed. The deep inferior epigastric perforator (DIEP) flap is the gold standard in breast reconstruction, but it is still not commonly performed after minimally invasive mastectomy due technical difficulty. Here the authors introduced six key steps to a successful aesthetic autologous free flap reconstruction in in minimally invasive mastectomies.

METHODS

There are six main steps to our technique: placement of mastectomy incision, precise flap design after angiography studies, trial of shaping, transcutaneous medial suture, footprint recreation and postoperative shaping with bra. Between November 2018 and July 2022, a total of 67 immediate breast reconstructions using free perforator flaps were performed in 63 patients after minimally invasive nipple-sparing mastectomy.

RESULTS

The results from the minimally invasive mastectomy group were compared with a group of conventional mastectomy patients ( n= 41) performed during the same period. There were no significant differences in flap exploration rates. One hundred percent of the flaps survived. In the minimally invasive group, the final scar was placed in the lateral region, where it would be hidden from the anterior view. Only 70.7% of the conventional mastectomy group could achieve a hidden lateral scar ( P <0.001). The aesthetic revision rates were similar between two groups.

CONCLUSION

With attention to the six steps above, autologous free flap reconstruction can be offered reliably in the setting of minimally invasive mastectomy.

Addressing radiotherapy-induced fibrosis: the potential of platelet-rich plasma and infliximab for improved breast cancer management

Breast cancer treatment encompasses various therapeutic modalities, including surgery, radiotherapy, and chemotherapy. Breast-conserving surgery has been an integral part of breast cancer management. However, radiotherapy, an important component of breast cancer management, can lead to complications, particularly fibrosis, affecting reconstructive surgery outcomes. We conducted an in vivo study using 48 female Wistar Albino rats, employing segmental mastectomy and radiotherapy to simulate post-mastectomy conditions. The rats were divided into six groups: control, mastectomy, mastectomy + radiotherapy, mastectomy + platelet-rich plasma (PRP) + radiotherapy, mastectomy + infliximab + radiotherapy, and mastectomy + infliximab + PRP + radiotherapy. Edema, hyperemia, inflammation, and fibrosis were assessed as indicators of tissue response. Histopathological analysis revealed that mastectomy + infliximab and mastectomy + infliximab + PRP groups showed significant reductions in fibrosis compared to other groups. Edema, hyperemia, and inflammation were also less severe in these groups compared to the control group. Radiotherapy-induced fibrosis is a major concern in breast reconstruction. Our study suggests that local PRP application and systemic infliximab administration, either alone or in combination, could mitigate the adverse effects of radiotherapy. This approach has the potential to improve reconstructive outcomes in patients undergoing or having the possibility to undergo radiotherapy. This is the first study showing the effectiveness of infliximab and PRP combination on wound healing. The provided experimental rat model might offer guidance for further research. This study provides insights into optimizing outcomes in reconstructive breast surgery, paving the way for further research and clinical studies.

Gram-Positive Bacteria Increase Breast Implant-Related Complications: Prospective Analysis of 100 Revised Implants

BACKGROUND

Breast implant-related complications can be reduced by strict antiseptic precautions during insertion, but bacteria can often be found on implant surfaces on the occasion of revision surgery. The authors prospectively analyzed the association of bacteria found on breast implant surfaces with implant-related complications in breast implant revision cases.

METHODS

The authors analyzed a total of 100 breast implant revisions in 66 patients between August of 2018 and January of 2021. Capsular swabs and capsular samples were taken intraoperatively. Analyses on the occurrence of bacteria and the occurrence of implant-related complications were performed. In addition, correlations between bacteria-contaminated breast implant surfaces and implant-related complications were performed.

RESULTS

Implant-related complications (perforation, rupture, capsular contraction) were observed in 42 implant sites: eight unilateral and 34 bilateral cases. In total, 16 swabs showed positive bacterial growth, 10 of which were associated with a breast implant-related complication (χ 2 = x, y, and z; P = 0.006). The most common implant-based complication at contaminated prosthetics was implant rupture. The association of contaminated breast implants and implant rupture was statistically significant.

CONCLUSIONS

The authors identified a correlation between implant complications and Gram-positive bacteria found on breast implant surfaces. The most common implant-based complication seen at simultaneously positive samples was implant rupture in 50% of the authors' cases. No capsular contraction or other complications were seen.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Immediate versus delayed breast reconstruction: Long-term follow-up on health-related quality of life and satisfaction with breasts

INTRODUCTION

Health-related quality of life (HRQL) can be improved by breast reconstruction following mastectomy. The optimal timing of the reconstruction remains unclear.

METHODS

A cross-sectional study on 338 women who had undergone immediate or delayed breast reconstruction between 08/2017 and 07/2019 was performed. The postoperative HRQL was assessed using the BREAST-Q Reconstruction Module and the 36-Item Short Form Survey (SF-36). Regression analysis was performed for group-wise comparison.

RESULTS

A total of 146 (43%) patients participated. Seventy-seven patients (53%) had undergone immediate, and 69 patients (47%) had delayed reconstruction. The median age was 55 years (interquartile ratio [IQR] 50-62) for the Immeda group te, and 60 years (IQR 54-65) for the delayed reconstruction group. The median follow-up time was 2.3 years (IQR 1.8-2.9). No difference between the groups was detected in satisfaction with breasts (median 61, IQR 53-71 vs. 62, IQR 46-71, p = 0.62), physical well-being of the chest (median 100, IQR 80-100 vs. 100, IQR 80-100, p = 0.95) or psychosocial well-being (median 69, IQR 54-83 vs. 62, IQR 54-74, p = 0.19). No difference was detected in the SF-36 domains either.

CONCLUSIONS

The timing of the breast reconstruction does not affect the postoperative HRQL. Patients with both immediate and delayed breast reconstruction reported high satisfaction with the breast and psychosocial well-being.

Impact of Adjuvant Radiotherapy on Free Flap Volume in Autologous Breast Reconstruction: A Scoping Review

In autologous breast reconstruction, a sufficient flap volume is fundamental to restore breast shape and ensure an aesthetic outcome. After mastectomy, postoperative irradiation is regularly indicated in the oncological treatment algorithm. When administering radiation therapy after autologous reconstruction, the tissue transferred is inherently irradiated. Although there is evidence that points to a reduction in flap volume after adjuvant radiotherapy, the data have been contradicting and inconclusive. To address this anecdotal evidence, we performed a scoping review of the current literature that addresses the effect of radiotherapy on breast flap volume. Six two-armed studies, comprising a total of 462 patients, reported on the effect of adjuvant radiotherapy on free flap volume changes. Of those, two studies found a significant negative impact of radiotherapy on free flap volume, while the other four studies did not. Reported flap volume changes ranged from no change to a reduction of 26.2%, measured up to two years postoperatively. The selected studies contain varying patient numbers, follow-up timepoints, types of flaps, and measuring methods, contributing to a relatively high heterogeneity. While we present some evidence suggesting a significant impact of adjuvant radiotherapy on breast flap volume, future studies are needed to further investigate this potential correlation.

Surgical treatment of breast cancer related lymphedema-the combined approach: a literature review

Background and Objective

Breast cancer therapy is a common cause of lymphedema, a chronic condition resulting from impaired fluid drainage through the lymphatic system. The accumulation of fluid in the affected limb leads to swelling, inflammation, and fibrosis, causing irreversible changes. While conservative therapy is the initial treatment for lymphedema, it may prove ineffective for advanced-stage cases that require surgical intervention. Physiological approaches such as lymphaticovenous anastomosis (LVA) and vascularized lymph node transfer (VLNT) aim to restore lymphatic circulation, while reductive approaches such as excision of excess tissue and liposuction (LS) aim to eliminate fibrofatty tissue. In advanced stages of breast cancer-related lymphedema, a treatment that incorporates both physiological and reductive methods is advantageous. The timing of these approaches varies, and recent simultaneous procedures have been introduced to address both aspects in one surgery. Additionally, lymphedema treatment can be combined with breast reconstruction. Current imaging techniques provide a better assessment of the lymphedematous limb, aiding in the tailoring of a personalized combined approach within a single surgery. This study aims to review the combined approach for breast cancer-related lymphedema treatment and propose a new therapeutic algorithm based on recent literature. The research aims to optimize the management of breast cancer-related lymphedema and improve patient outcomes.

Methods

PubMed/MEDLINE was used as the database to conduct a review of the currently available literature concerning combined surgical techniques for treating breast cancer related lymphedema (BCRL).

Key Content and Findings

In our review, we discuss imaging methods for assessing lymphatic system anatomy and function in surgical preparation and decision-making. Simultaneously, we examine a range of combined surgical techniques for treating BCRL, encompassing the combined physiologic approach, breast reconstruction with physiologic surgery, and the combination of reductive and physiologic procedures. Our emphasis remains on key parameters, including patient demographics, lymphedema staging, procedure types, follow-up duration, and objective limb measurements.

Conclusions

Surgical treatment of BCRL can include several surgical modalities that can be performed simultaneously. Current imaging techniques enable the tailoring of a personalized combined one-stage surgery for BCRL patients.

Technical consideration for breast reconstruction in patients requiring neoadjuvant or adjuvant radiotherapy: a narrative review

Background and Objective

Surgical considerations for breast reconstruction (BR) in patients requiring neoadjuvant radiotherapy (NART) or adjuvant radiotherapy (ART) cannot be understated. The management of irradiated tissue leads surgeons to face several challenges. Therefore, it is essential to comprehensively understand the proper patient selection and preoperative planning to ensure the best outcomes and minimize the risk of complications. This narrative review aims to provide an update and summary of the most important technical considerations every breast surgeon must contemplate reconstructing the irradiated breast.

Methods

The search strategy was performed on January 10th, 2023. The PubMed, Embase, Cochrane Library, and Web of Science databases were queried to capture all publications regarding surgical considerations in BR of patients undergoing NART and ART.

Key Content and Findings

This review shows that the effects of radiotherapy (RT) on BR are still being studied. RT represents an essential factor for overall patient survival, and its use is increasing. However, the range of RT treatments across different cancer centers complicates the creation of a single treatment protocol. BR improves women's quality of life, so finding the proper integration of BR and RT is essential. When deciding on the reconstructive method, there are several factors to consider, such as the patient's body characteristics, tumor stage, RT protocol, and chemotherapy. To achieve the best surgical results and the most satisfied patient, using less aggressive and safer RT methods in the treatment sequence is recommended.

Conclusions

The timing of the radiation will influence the selection of the best reconstructive methods to be employed in the breast cancer patient. However, there is clear evidence of preference for immediate autologous-based BR in cases due to the low rate of complications in the long term. But patient individualization is the key. Therefore, the benefits and risks of immediate versus delayed and autologous versus implant-based reconstruction must be weighed in every single case.

Effect of radiation therapy during surgery on postoperative wound complications after breast reconstruction in patients with breast cancer: A meta-analysis

Breast remodelling is a major therapeutic choice in radical mastectomy. Breast reconstruction is regarded as a promising option for the treatment of breast cancer. The purpose of this meta-analysis was to investigate the effect of Post mastectomy radiotherapy (PMRT) on postoperative wound complications in breast carcinoma. A comprehensive review of documents was conducted between the date of establishment and the 28th of August 2023. In all of the trials, patients were treated with breast cancer. The researchers chose 11 publications out of 8068 related studies. Two researchers examined these publications to satisfy the inclusion criteria. Among the 516 patients who had received radiation therapy in the course of the operation, 1772 had not received radiation therapy. The impact of radiation therapy and non-radiation therapy in breast cancer patients after breast reconstruction was reported in 8 studies, and the incidence of postoperative wound infection in non-radiation group was significantly lower (OR, 1.95; 95% CI, 1.26-3.02 p = 0.003). In nine studies, There is not considered to have achieved statistical significance between radiation therapy and non-radiation treatment for post-operation wound dehiscence in breast cancer patients who had received chemotherapy (OR, 1.61; 95% CI, 0.70-3.72 p = 0.27). The results of six trials demonstrated that radiation therapy and non-radiation therapy had no statistical significance on post-operation haemorrhage in breast cancer patients (OR, 1.02; 95% CI, 0.42-2.47 p = 0.96). The results of 7 trials demonstrated that radiation therapy and non-radiation therapy had no significant impact on the post-operation of skin necrosis (OR, 1.22; 95% CI, 0.66-2.28 p = 0.53). Two trials demonstrated that those without radiation therapy were less likely than those who received radiation therapy in skin contracture in patients (OR, 7.24; 95% CI, 1.80-29.10 p = 0.005). Regarding the incidence of wound infection and cutaneous contraction was higher in the radiation group.

Imaging of the Reconstructed Breast

The incidence of breast cancer and, therefore, the need for breast reconstruction are expected to increase. The many reconstructive options available and the changing aspects of the field make this a complex area of plastic surgery, requiring knowledge and expertise. Two major types of breast reconstruction can be distinguished: breast implants and autologous flaps. Both present advantages and disadvantages. Autologous fat grafting is also commonly used. MRI is the modality of choice for evaluating breast reconstruction. Knowledge of the type of reconstruction is preferable to provide the maximum amount of pertinent information and avoid false positives. Early complications include seroma, hematoma, and infection. Late complications depend on the type of reconstruction. Implant rupture and implant capsular contracture are frequently encountered. Depending on the implant type, specific MRI signs can be depicted. In the case of myocutaneous flap, fat necrosis, fibrosis, and vascular compromise represent the most common complications. Late cancer recurrence is much less common. Rarely reported late complications include breast-implant-associated large cell anaplastic lymphoma (BIA-ALCL) and, recently described and even rarer, breast-implant-associated squamous cell carcinoma (BIA-SCC). In this review article, the various types of breast reconstruction will be presented, with emphasis on pertinent imaging findings and complications.

Superb Microvascular Imaging at Evaluation of Nonvisible Buried De-epitelized Flap Vascularization in Breast Reconstruction

OBJECTIVE

Superb microvascular imaging is a Doppler technique that increases the visibility of small vessels and gives quantitative information about tissue blood supply by measuring the vascular index. In this study, it is aimed to evaluate the long-term and postradiotherapy changes in blood flow of buried de-epitelized flaps in breast reconstruction by using the quantitative values obtained through superb microvascular imaging.

MATERIALS AND METHODS

Retrospective review of the 14 patients who underwent nipple-sparing breastconserving surgery and immediately breast reconstruction with a de-epitelized extended latissimus dorsi flap was done. In order to demonstrate the effect of radiotherapy on flaps microvascular circulation, patients were evaluated using superb microvascular imaging postoperative first week, first month, and postradiotherapy first week and sixth month. The normal distribution of the data was evaluated with the Shapiro-Wilk test. Paired samples t-test was used for comparisons.

RESULTS

According to the paired samples t-tests, postoperative first week mean vascular index was higher than postoperative first month and postradiotherapy first week (P < .05). Besides, postradiotherapy first week mean vascular index was higher than postoperative first month and also than postradiotherapy sixth month (P < .05).

CONCLUSION

Radiotherapy can affect the results of breast reconstruction by endothelial and fibrotic injury. In this study, the changes in the microvascular circulation of the latissimus dorsi flap were discussed and found to increase at postoperative and postradiotherapy early period related to inflammation and not decreased significantly at long-term follow-up after radiotherapy.

Surgical outcomes following breast reconstruction in patients with and without a history of chest radiotherapy for Hodgkin lymphoma: a multicentre, matched cohort study

BACKGROUND

Breast cancer is the most common treatment-related second malignancy among women with previous chest radiotherapy for Hodgkin lymphoma (HL). Little is known about the effects of this kind of radiotherapy on the outcomes of postmastectomy breast reconstruction (BR). This study compared adverse outcomes of BR after HL-related chest radiotherapy to matched controls.

METHODS

The authors conducted a retrospective, matched cohort study in two expert cancer centres in the Netherlands. BRs after therapeutic or prophylactic mastectomy in HL survivors who received chest radiotherapy were matched with BRs in nonirradiated patients without HL on age at mastectomy date, date of BR, and type of BR. The primary outcome was complication-related BR failure or conversion and secondary outcomes were complication-related re-operation, capsular contracture, major donor-site complications, and complication-related ICU admission. The authors analyzed all outcomes univariably using Fisher's exact tests and the authors assessed reconstruction failure, complication-related re-operation, and capsular contracture with multivariable Cox regression analysis adjusting for confounding and data clustering.

RESULTS

Seventy BRs in 41 patients who received chest radiotherapy for HL were matched to 121 BRs in 110 nonirradiated patients. Reconstruction failure did not differ between HL survivors (12.9%) and controls (12.4%). The comparison groups showed no differences in number of reoperations, major donor-site complications, or capsular contractures. BR in HL survivors more often let to ICU admission due to complications compared with controls ( P =0.048).

CONCLUSIONS

We observed no increased risk of adverse outcomes following BR after previous chest radiotherapy for HL. This is important information for counselling these patients and may improve shared decision-making.

[Choice of immediate breast reconstructive methods after modified radical mastectomy]

OBJECTIVE

To investigate the choice of immediate breast reconstructive methods and asso-ciated outcomes after modified radical mastectomy.

METHODS

Retrospective analysis of patients undergoing immediate breast reconstruction after modified radical mastectomy in Peking University Third Hospital from January 2009 to May 2019. The reconstructive methods were summarized, and the clinical outcomes and the safety of immediate breast reconstruction were evaluated.

RESULTS

One hundred and twenty-three patients were enrolled in this study. Different reconstructive methods were applied according to the clinical stage, the amount of skin removal, the size of contralateral breasts, the physical condition and the preference of the patients. Seventy-nine cases were performed with tissue expander/implant two-stage reconstruction, twenty-three cases received direct breast implant insertion, seven cases were applied for latissimus dorsi (LD) myocutaneous flap transfer combined with implant insertion, five cases were provided transverse rectus abdominis myocutaneous (TRAM) flap transfer, six cases underwent tissue expander/implant combined with endoscopic LD muscle flap transfer, and three cases chose tissue expander/deep inferior epigastric artery perforator (DIEP) flap transfer. The average follow-up time was (12.3±9.0) months (3.5-41.0 months). One patient with direct implant insertion had partial blood supply distur-bance of the mastectomy flap. One case had necrosis of distal end of TRAM zone Ⅳ. One patient with expander/DIEP reconstruction had partial fat liquefaction. And two cases had expander leakage at the end of the expansion period. The tumor local recurrence occurred in one patient, and the implant was finally removed. The outcomes were evaluated by Harris method, and 90.2% patients were good or above in shape evaluation. Among the patients with implant based reconstruction, there was no obvious capsular contracture, and most of the implants had good or fair mobility.

CONCLUSION

It is safe and feasible of immediate breast reconstruction after modified radical mastectomy for appropriate cases. The reconstructive methods can be individualized according to the individual's different conditions. The appropriate reconstructive methods could achieve satisfactory results.

Czech Women's Point of Views on Immediate Breast Reconstruction after Mastectomy due to BRCA Gene Mutation or Breast Cancer

(1) Objective: Breast cancer is the most common cancer in women, and the incidence of the disease continues to increase. The issue of immediate breast reconstruction (IBR) in women with BRCA mutations and breast cancer is highly topical. This study is based on the long-term experience of our workplace with the diagnosis and treatment of breast cancer in women. We use the possibilities of oncoplastic surgery, including IBR. Our effort involves learning about women's awareness of IBR with a mastectomy at the same time. (2) Methods: The method of quantitative research of women's awareness using a structured anonymous questionnaire was chosen. Out of the total number of 84 respondents who already underwent IBR, 36.9% were due to BRCA mutations, and 63.1% were due to breast cancer. (3) Results: All of the respondents learned about the possibility of IBR before treatment or during treatment planning. The information was first obtained mainly from an oncologist. Women obtained the most information regarding IBR from a plastic surgeon. Before the mastectomy, all of the respondents already knew what IBR meant, as well as about the payment of IBR by the health insurance company. All of the respondents would choose the IBR option again. A total of 94.0% of women cited preservation of body integrity as a reason for undergoing IBR, and 88.1% of women knew about the possibility of performing IBR with their own tissues. (4) Conclusions: There are few specialized centers with a team of experts in reconstructive breast surgery in the Czech Republic, especially those that perform IBR. Research has shown that all of the patients were well informed about IBR, but the vast majority only learned about IBR before the surgical procedure was planned. All of the women wished to maintain body integrity. Our study results in the recommendations for patients and for healthcare management.

Sexual health and treatment-related sexual dysfunction in sexual and gender minorities with prostate cancer

Prostate cancer treatment has substantial effects on sexual health and function. Sexual function is a vital aspect of human health and a critical component of cancer survivorship, and understanding the potential effects of different treatment modalities on sexual health is crucial. Existing research has extensively described the effects of treatment on male erectile tissues necessary for heterosexual intercourse; however, evidence regarding their effects on sexual health and function in sexual and gender minority populations is minimal. These groups include sexual minority - gay and bisexual - men, and transgender women or trans feminine people in general. Such unique effects in these groups might include altered sexual function in relation to receptive anal and neovaginal intercourse and changes to patients' role-in-sex. Sexual dysfunctions following prostate cancer treatment affecting quality of life in sexual minority men include climacturia, anejaculation, decreased penile length, erectile dysfunction, and problematic receptive anal intercourse, including anodyspareunia and altered pleasurable sensation. Notably, clinical trials investigating sexual outcomes after prostate cancer treatment do not collect sexual orientation and gender identity demographic data or outcomes specific to members of these populations, which perpetuates the uncertainty regarding optimal management. Providing clinicians with a solid evidence base is essential to communicate recommendations and tailor interventions for sexual and gender minority patients with prostate cancer.

Stromal Vascular Fraction Cells from Individuals Who Have Previously Undergone Radiotherapy Retain Their Pro-Wound Healing Properties

Beneficial effects have been observed following the transplant of lipoaspirates containing adipose-derived stem cells into chronic wounds caused by oncologic radiotherapy. It is not yet certain whether adipose-derived stem cells are resistant to radiation exposure. Therefore, the aims of this study were to isolate stromal vascular fraction from human breast tissue exposed to radiotherapy and determine the presence of adipose-derived stem cells. Stromal vascular fraction from irradiated donor tissue was compared to commercially sourced pre-adipocytes. Immunocytochemistry was used to determine the presence of adipose-derived stem cell markers. Conditioned media from stromal vascular fraction isolated from irradiated donors was used as a treatment in a scratch wound assay of dermal fibroblasts also isolated from irradiated donors and compared to pre-adipocyte conditioned media and serum free control. This is the first report of human stromal vascular fraction being cultured from previously irradiated breast tissue. Stromal vascular fraction conditioned media from irradiated donors had a similar effect in increasing the migration of dermal fibroblasts from irradiated skin to pre-adipocyte conditioned media from healthy donors. Therefore, the ability of adipose-derived stem cells in the stromal vascular fraction to stimulate dermal fibroblasts in wound healing appears to be preserved following radiotherapy. This study demonstrates that stromal vascular fraction from irradiated patients is viable, functional and may have potential for regenerative medicine techniques following radiotherapy.

Breast Cancer Tumor Board: A Radiologist's Guide to Postmastectomy Radiation Therapy

Radiation therapy represents a pillar in the current management of breast cancer. Historically, postmastectomy radiation therapy (PMRT) has been administered only in patients with locally advanced disease and a poor prognosis. These included patients with large primary tumors at diagnosis and/or more than three metastatic axillary lymph nodes. However, during the past few decades, several factors have prompted a shift in perspective, and recommendations for PMRT have become more fluid. Guidelines for PMRT in the United States are outlined by the National Comprehensive Cancer Network and the American Society for Radiation Oncology. Because evidence to support performing PMRT is frequently discordant, the decision to offer radiation therapy often requires team discussion. These discussions are usually held in multidisciplinary tumor board meetings in which radiologists play a pivotal role by providing critical information such as the location and extent of disease. Breast reconstruction after mastectomy is optional and is safe in cases in which the patient's clinical status allows it. The preferred method in the setting of PMRT is autologous reconstruction. If this is not possible, then a two-step implant-based reconstruction is recommended. Radiation therapy does involve a risk of toxicity. Complications can be seen in acute and chronic settings and range from fluid collections and fractures to radiation-induced sarcomas. Radiologists have a key role in detecting these and other clinically relevant findings and should be prepared to recognize, interpret, and address them. ^© RSNA, 2023 Quiz questions for this article are available in the supplemental material.

Are Radiation Target Volumes for Postmastectomy Radiation Therapy Too Large? Initial Report of the Complication Avoidance of Reconstruction Implant Radiation Therapy (CARIT) Study

Following mastectomy for breast cancer, women may choose implant-based reconstruction for many reasons, such as cosmesis, self-identity, and the ability to wear particular items of clothing. However, postmastectomy radiation therapy (PMRT) can compromise these cosmetic goals, including as much as a 40% loss of implant rate. To minimize the risk of radiation toxicity, it is important to consider how clinical target volumes (CTVs) can be optimized in PMRT to preserve the implant and reduce complications. Typically, guidelines from organizations such as the Radiation Oncology Group are used, which include regions previously encompassed by tangential fields. This includes all structures below the pectoralis muscle, such as the chest wall, where the risk of recurrence is negligible; this technique often requires incidental inclusion of portions of the lung and heart plus circumferential radiation of the implant. We present the preliminary single institution case series of a technique of complication avoidance of reconstruction implant radiation therapy, called CARIT, where the chest wall, and a large proportion of the implant, is not irradiated. In a retrospective review of 30 cases in which CARIT has been attempted, it was found that 24% of patients treated required a second surgery due to Baker grade III/IV capsular contracture. Using the Modified Harvard Harris Cosmetic Scale, 66.5% of patients had cosmetic outcomes rated as "good" or "excellent". CARIT could offer a technique to reduce complications in postmastectomy implant-based reconstruction patients, with our next steps focusing on improving dosimetry, and formally comparing the cosmesis and tumor control aspects with commonly used techniques.

Reconstructive complications and early toxicity in breast cancer patients treated with proton-based postmastectomy radiation therapy

Background

Postmastectomy radiation therapy (PMRT) decreases the risk of locoregional recurrence and increases overall survival rates in patients with high-risk node positive breast cancer. While the number of breast cancer patients treated with proton-based PMRT has increased in recent years, there is limited data on the use of proton therapy in the postmastectomy with reconstruction setting. In this study, we compared acute toxicities and reconstructive complications in patients treated with proton-based and photon-based PMRT.

Methods

A retrospective review of our institutional database was performed to identify breast cancer patients treated with mastectomy with implant or autologous reconstruction followed by PMRT from 2015 to 2020. Baseline clinical, disease, and treatment related factors were compared between the photon-based and proton-based PMRT groups. Early toxicity outcomes and reconstructive complications following PMRT were graded by the treating physician.

Results

A total of 11 patients treated with proton-based PMRT and 26 patients treated with photon-based PMRT were included with a median follow-up of 7.4 months (range, 0.7-33 months). Six patients (55%) in the proton group had a history of breast cancer (3 ipsilateral and 3 contralateral) and received previous RT 38 months ago (median, range 7-85). There was no significant difference in mean PMRT (p = 0.064) and boost dose (p = 0.608) between the two groups. Grade 2 skin toxicity was the most common acute toxicity in both groups (55% and 73% in the proton and photon group, respectively) (p = 0.077). Three patients (27%) in the proton group developed grade 3 skin toxicity. No Grade 4 acute toxicity was reported in either group. Reconstructive complications occurred in 4 patients (36%) in the proton group and 8 patients (31%) in photon group (p = 0.946).

Conclusions

Acute skin toxicity remains the most frequent adverse event in both proton- and photon-based PMRT. In our study, reconstructive complications were not significantly higher in patients treated with proton- versus photon-based PMRT. Longer follow-up is warranted to assess late toxicities.

The Impact of Postmastectomy Radiation Therapy on the Outcomes of Prepectoral Implant-Based Breast Reconstruction: A Systematic Review and Meta-Analysis

BACKGROUND

Breast reconstruction is the mainstay treatment choice for patients subjected to a mastectomy. Prepectoral implant-based breast reconstruction (IBBR) is deemed to be a promising alternative to subpectoral reconstruction. Postmastectomy radiation therapy (PMRT) is necessary for locoregional recurrence control and to improve the disease-free survival rate in locally advanced breast cancer. This systematic review and meta-analysis study was designed to reveal the surgical, aesthetic, and oncological outcomes of prepectoral IBBR after PMRT.

METHODS

An extensive literature search was performed from inception to March 28, 2022. All clinical studies that included patients who were subjected to prepectoral IBBR and PMRT were included. Studies that included patients who received radiation therapy before prepectoral IBBR were excluded.

RESULTS

This systematic review included six articles encompassing 1234 reconstructed breasts. Of them, 391 breasts were subjected to PMRT, while 843 breasts were not subjected. Irradiated breasts were more susceptible to develop wound infection (RR 2.49; 95% 1.43, 4.35; P = 0.001) and capsular contracture (RR 5.17; 95% 1.93, 13.80; P = 0.001) than the non-irradiated breasts. Furthermore, irradiated breasts were more vulnerable to losing implants (RR 2.89; 95% 1.30, 6.39; P = 0.009) than the non-irradiated breast. There was no significant difference between both groups regarding the risk of implant extrusion (RR 1.88; 95% 0.20, 17.63; P = 0.58).

CONCLUSIONS

Patients with prepectorally IBBR and PMRT were more vulnerable to developing poor outcomes. This included a higher risk of breast-related and implant-related adverse events.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Quantifying Complications: An Analysis of Operative Time and Intraoperative Factors in Microsurgical Breast Reconstruction

BACKGROUND

 Analysis of operative flow has been shown to improve efficiency in breast microsurgery. Both complex decision-making skills and technical mastery are required to overcome intraoperative challenges encountered during microsurgical reconstruction. Effects of intraoperative complications on operative time have not yet been reported.

METHODS

 A retrospective chart review of microsurgical breast reconstructions by three surgeons between 2013-2020 analyzed operative variables and duration. Intraoperative complications were determined from the operative report. Correlations between continuous variables were determined using Spearman correlation coefficients. Nonparametric testing was used when comparing operative duration between groups.

RESULTS

 Operative duration was analyzed for 547 autologous breast reconstruction cases; 210 reconstructions were unilateral and 337 were bilateral. Average operative duration was 471.2 SD 132.2 minutes overall (360.1 SD 100.5 minutes for unilateral cases and 530.5 SD 110.5 minutes for bilateral cases). Operative duration decreased with surgeon experience (r = -0.17, p< .001).Regarding intraoperative complications, difficult donor dissection was correlated with an average operative duration increase of 91.7 minutes (n = 43, 7.9%, p< .001), pedicle injury with an additional 67.7 minutes (n = 19, 3.5%, p = .02) and difficult recipient vessel dissection with an increase of 63.0 minutes (n = 35, 6.4%, p = .003). Complications with anastomosis also showed a statistically significant increase in operative duration, with arterial complications resulting in an increase of 104.3 minutes (n = 41, 7.5%, p< .001) and venous complications resulting in an increase in 78.8 minutes (n = 32, 5.8%, p< .001). Intraoperative thrombus resulted in an increase of 125.5 minutes (n = 20, 3.7%, p< .001), and requiring alternative venous outflow added an average of 193.7 minutes (n = 8, 1.5%, p< .001).

CONCLUSION

 Intraoperative complications in autologous breast reconstruction significantly increase operative time. The greatest increase in operative time is seen with intraoperative thrombosis or requiring alternative venous outflow. As these complications are rarely encountered in breast microsurgery, opportunities for simulation and case-based practice exist to improve efficiency.

The therapeutic effect of adipose-derived stem cells on soft tissue injury after radiotherapy and their value for breast reconstruction

Background

Postmastectomy radiotherapy is considered to be a necessary treatment in the therapy of breast cancer, while it will cause soft tissue damage and complications, which are closely related to the success rate and effectiveness of breast reconstruction. After radiotherapy, cutaneous tissue becomes thin and brittle, and its compliance decreases. Component fat grafting and adipose-derived stem cell therapy are considered to have great potential in treating radiation damage and improving skin compliance after radiotherapy.

Main body

In this paper, the basic types and pathological mechanisms of skin and soft tissue damage to breast skin caused by radiation therapy are described. The 2015–2021 studies related to stem cell therapy in PubMed were also reviewed. Studies suggest that adipose-derived stem cells exert their biological effects mainly through cargoes carried in extracellular vesicles and soluble secreted factors. Compared to traditional fat graft breast reconstruction, ADSC therapy amplifies the effects of stem cells in it. In order to obtain a more purposeful therapeutic effect, proper stem cell pretreatment may achieve more ideal and safe results.

Conclusion

Recent research works about ADSCs and other MSCs mainly focus on curative effects in the acute phase of radiation injury, and there is little research about treatment of chronic phase complications. The efficacy of stem cell therapy on alleviating skin fibrosis and its underlying mechanism require further research.

Simultaneous Contralateral Autologous Breast Augmentation during Unilateral Breast Reconstruction Utilizing Deep Inferior Epigastric Flaps

It is predicted that 281,550 new cases of invasive breast cancer and 49,290 new cases of ductal carcinoma in situ will be diagnosed this year. In this study, we will detail our experience with simultaneous contralateral autologous breast augmentation during unilateral breast reconstruction utilizing bilateral deep inferior epigastric perforator (DIEP) flaps.

Methods

A retrospective analysis of patients who underwent simultaneous contralateral autologous breast augmentation during unilateral breast reconstruction utilizing bilateral DIEP flaps by the senior surgeons at Beaumont Health Systems, Royal Oak, was conducted. Demographic data, operative details, complications, medical comorbidities, and patient outcomes were retrospectively analyzed.

Results

Seven patients who met the inclusion criteria were identified. One patient underwent immediate reconstruction with DIEP flaps, one patient had a history of lumpectomy and underwent delayed partial breast reconstruction, three patients had delayed unilateral DIEP breast reconstruction with contralateral breast augmentation, and two patients had previous augmentations that were revised. All patients examined in this review tolerated the procedures well and had clinically viable flaps along with superior aesthetic outcomes.

Conclusions

This technique can be applied to various clinical conditions, including immediate breast reconstruction, delayed breast reconstruction, and salvage for failed implant-based reconstruction, leading to optimal patient outcomes and satisfaction. Unilateral breast reconstruction with simultaneous contralateral autologous breast augmentation utilizing bilateral DIEP flaps is a surgical technique that more plastic surgeons should utilize.

Feasibility of anomaly score detected with deep learning in irradiated breast cancer patients with reconstruction

The aim of this study is to evaluate cosmetic outcomes of the reconstructed breast in breast cancer patients, using anomaly score (AS) detected by generative adversarial network (GAN) deep learning algorithm. A total of 251 normal breast images from patients who underwent breast-conserving surgery were used for training anomaly GAN network. GAN-based anomaly detection was used to calculate abnormalities as an AS, followed by standardization by using z-score. Then, we reviewed 61 breast cancer patients who underwent mastectomy followed by reconstruction with autologous tissue or tissue expander. All patients were treated with adjuvant radiation therapy (RT) after reconstruction and computed tomography (CT) was performed at three-time points with a regular follow-up; before RT (Pre-RT), one year after RT (Post-1Y), and two years after RT (Post-2Y). Compared to Pre-RT, Post-1Y and Post-2Y demonstrated higher AS, indicating more abnormal cosmetic outcomes (Pre-RT vs. Post-1Y, P = 0.015 and Pre-RT vs. Post-2Y, P = 0.011). Pre-RT AS was higher in patients having major breast complications (P = 0.016). Patients with autologous reconstruction showed lower AS than those with tissue expander both at Pre-RT (2.00 vs. 4.19, P = 0.008) and Post-2Y (2.89 vs. 5.00, P = 0.010). Linear mixed effect model revealed that days after baseline were associated with increased AS (P = 0.007). Also, tissue expander was associated with steeper rise of AS, compared to autologous tissue (P = 0.015). Fractionation regimen was not associated with the change of AS (P = 0.389). AS detected by deep learning might be feasible in predicting cosmetic outcomes of RT-treated patients with breast reconstruction. AS should be validated in prospective studies.

[Hybrid Breast Reconstruction Following Mastectomy]

The challenge following mastectomy is to safely reconstruct breasts of adequate size, shape, symmetry, softness, and sensation ("6 S"). Historically, patients have been offered two reconstructive modalities, namely either implant-based or autologous reconstruction. While this binary approach is appropriate for most patients, there remain a subset of patients for whom this simplistic approach is not suitable. For these, hybrid reconstruction, i. e., the combination of an implant with microsurgical tissue transfer, offers the possibility of individualised reconstruction, which avoids some of the limitations of traditional approaches. Hybrid breast reconstruction, thus expands the indications for microsurgical reconstruction and offers the advantages of this reconstructive modality to a larger patient population. In this article, the surgical technique of hybrid breast reconstruction is described, along with a discussion of important parameters related to this reconstructive modality, including plane and timing of implant placement, and the issue of radiotherapy.

[Breast Reconstruction Strategies in Case of Planned Radiotherapy]

INTRODUCTION

The ideal technical and chronological approach of breast reconstruction in case of planned radiotherapy after mastectomy (post-mastectomy radiotherapy, PMRT) continues to be controversially discussed.

METHODS

The authors analysed the MEDLINE Database PubMed for relevant studies concerning PMRT and breast reconstruction. The main theses from these publications were extracted and summarised.

RESULTS

An implant-based approach is the least invasive technique for immediate breast-mound formation in a PMRT setting. Reconstruction in a PMRT setting with a two-stage expander-implant technique or expander-implant-autologous procedure can provide good to excellent cosmetic outcomes. In contrast to the implant-based approach, autologous reconstruction methods provide an improved quality of life as well as haptic and sensory advantages and are usually associated with lower complication rates. PMRT after autologous reconstruction can have a negative impact on the autologous tissue. A delayed autologous approach can be advantageous and should be generally favoured in high-risk patients.

CONCLUSION

Factors influencing a meticulous planning of breast reconstruction including PMRT are surgical, aesthetic and patient characteristics, quality of life, preference and expectation. Ideally, PMRT is completed before autologous reconstruction to avoid radiation-associated side-effects on the final reconstructive result. If PMRT is likely, but potentially not necessary, an immediate-delayed procedure may be of advantage.

Stalled at the intersection: insurance status and disparities in post-mastectomy breast reconstruction

PURPOSE

Post-mastectomy breast reconstruction (PMBR) is an important component of breast cancer treatment, but disparities relative to insurance status persist despite legislation targeting the issue. We aimed to study this relationship in a large health system combining a safety-net hospital and a private academic center.

METHODS

Data were collected on all patients who underwent mastectomy for breast cancer from 2011 to 2019 in a private academic center and an adjacent public safety-net hospital served by the same surgical teams. Multivariable logistic regression was used to assess the effect of insurance status on PMBR, controlling for covariates that included socioeconomic, demographic, and clinical factors.

RESULTS

Of 1554 patients undergoing mastectomy for breast cancer, 753 (48.5%) underwent PMBR, of which 592 (79.9%) were privately insured, 50 (6.7%) Medicare, 68 (9.2%) Medicaid, and 31 (4.2%) uninsured. Multivariable logistic regression showed a significantly higher likelihood of not undergoing PMBR for uninsured (OR 6.0, 95% CI 3.7-9.8; p < 0.0001), Medicare (OR 1.9, (95% CI 1.2-3.0; p = 0.006), and Medicaid (OR 1.5, 95% CI 1.0-2.3; p = 0.04) patients compared with privately insured patients. Age, stage, race and ethnicity, and hospital type confounded this relationship.

CONCLUSION

Patients without health insurance have dramatically reduced access to PMBR compared to those with private insurance. Expanding access to this important procedure is essential to achieve greater health equity for breast cancer patients.

Is There a Difference in the Diagnosis and Prognosis of Local Recurrence between Autologous Tissue and Implant-Based Breast Reconstruction?

Introduction

Breast reconstruction has become common after total mastectomy; however, certain types of breast reconstruction may be associated with delayed local recurrence or poor survival. Here, we investigated whether there are differences in the diagnosis and prognosis of local recurrence between autologous reconstruction and implant reconstruction.

Materials and Methods

A retrospective analysis was performed on patients undergoing breast cancer surgery with autologous tissue or immediate implant reconstruction in a single center (January 2003-December 2017). Patient data including the period from cancer surgery to local recurrence diagnosis, tumor size at the time of recurrence, and survival time after cancer surgery and recurrence detection were analyzed.

Results

There was a significant difference (p = 0.021) in the time from surgery to recurrence between the autologous tissue (1,246 days) and implant (909 days) groups. Recurrence tumor size did not differ (autologous: 1.00 cm² vs. implant: 0.90 cm²; p = 0.813). Survival time after surgery (p = 0.63) and recurrence detection (p = 0.74) did not statistically significant.

Conclusions

Statistical difference in the detection time was observed between autologous tissue and implant group. On the other hand, there is no difference in recurrence tumor size or survival time. A further study is necessary to identify the different detection time of local recurrence.

Immediate Breast Reconstruction Using the Goldilocks Procedure: A Balance between More Surgery and Patient Satisfaction

BACKGROUND

Since its first description in 2012, the Goldilocks procedure has become an option for immediate breast reconstruction, particularly for obese patients who are poor candidates for traditional implant or autologous reconstruction. In this work, the authors performed a longitudinal study of patients who underwent mastectomy with Goldilocks reconstruction to assess the incidence of additional surgical procedures, and to assess surgical outcomes and patient satisfaction.

METHODS

A retrospective review of patients who underwent mastectomy with the Goldilocks procedure only at Mayo Clinic Rochester between January of 2012 and September of 2019 was performed. Demographics, complications, additional breast procedures performed to attain the final results, and patient-reported outcomes using the BREAST-Q were recorded. Univariate and multivariable analyses were performed to identify statistical associations and risk factors.

RESULTS

Sixty-three patients (108 breasts) were included. Mean age was 57.8 years. Mean body mass index was 37.6 kg/m2. Median follow-up time after the mastectomy with the Goldilocks procedure was 15 months. The major complication rate within the first 30 days was 9.3 percent. Forty-four breasts (40.7 percent) underwent additional surgery. Dyslipidemia was significantly associated with an increased risk of additional surgery (adjusted hazard ratio, 2.00; p = 0.045). Scores in the four BREAST-Q domains were not statistically different between patients who had additional procedures and those who did not.

CONCLUSIONS

Based on the results, the authors recommend a thorough preoperative discussion with patients who are candidates for the Goldilocks procedure to explore all options for reconstruction and their expectations, because it is crucial to reduce the necessity for additional operations in this high-risk population.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Critical Factors of Dose Distribution in Breast Cancer Tomotherapy With Metallic Port Breast Tissue Expander: Image Correction, Delivery Mode, and Volume Impact

Objectives: Breast reconstruction helps patients enhance their body image after mastectomy. Metallic ports in tissue expanders lead to dose attenuation during radiotherapy. Tissue expander volume shifts the metallic port position, possibly causing various dose alterations. This study aimed to evaluate the impact of the MAGNA-SITE^TM tissue expander volume on tomotherapy. Methods: Boluses and MAGNA-SITE^TM were placed on a Rando phantom to simulate the tissue expander under the pectoralis major. Computed tomography simulation images were transformed through replacing the electron density of (a) metallic artifact region only (Image metallic port) and (b) metallic port and artifact regions (Image Homo). Planning was calculated using fixed-beam and helical-mode techniques. Radiation was delivered with different volumes of the tissue expander. Results: Integrated 997 dose points were calculated. Planning with Image metallic port provided a calculated dose significantly closer to a realistic dose. The percentage of doses achieving the prescribed dose was significantly higher in the helical mode. In layer 2, the 100-mL tissue expander had a significantly lower measurement dose than all other volumes. Volume 150 mL had the highest increase in the measured dose difference from the plan dose at layer 2. Volume 250 mL had the highest percentage of measurement doses passing the 5% dose difference from plan dose. The coldest dose areas were noted in layers 1 and 2, especially in the metallic port–direct image mode. The average dose reduction of the measured cold areas was 6.03 ± 1.94%. Conclusion: Dose distribution was affected by the volume of the metallic port tissue expander. Tomotherapy with proper image heterogeneity correction and helical mode can reduce the attenuation from the metallic port. A tissue expander volume of 150 to 250 mL is suitable. Patients with high risk at the chest wall should be evaluated carefully to avoid underdosing. Radiation oncologists should closely cooperate with plastic surgeons to optimize treatment for each patient.

Biological Matrix-Assisted One-Stage Implant-Based Breast Reconstruction Versus Two-Stage Implant-Based Breast Reconstruction: Patient-Reported Outcomes and Complications

BACKGROUND

Biological matrix-assisted one-stage implant-based breast reconstruction (IBBR) could improve the inframammary fold to achieve good esthetic results. However, whether biological matrix-assisted one-stage IBBR yields better postoperative outcomes compared with two-stage IBBR remains unclear. We aimed to compare and analyze surgical complications and patient-reported outcomes (PROs) based on the BREAST-Q version 2.0 questionnaire between biological matrix-assisted one-stage IBBR and traditional two-stage IBBR.

METHODS

From May 2015 to June 2019, eligible patients who underwent SIS matrix-assisted one-stage IBBR or two-stage IBBR were enrolled in this retrospective cohort study. PROs were measured with BREAST-Q version 2.0, which scored the health-related quality of life, satisfaction, and experience domains. Complications were divided into major complications (patients requiring reoperation) and minor complications (patients who could be treated in the dressing room). PROs and complications were compared between the SIS matrix-assisted one-stage IBBR and two-stage IBBR groups. A multivariate linear regression analysis was used to identify the social and surgical factors that affected PROs.

RESULTS

At our institution, 124 eligible patients were recruited. Seventy-nine patients (63.7%) underwent SIS matrix-assisted one-stage IBBR reconstruction, and 45 patients (36.3%) underwent tissue expander/implant reconstruction (two-stage IBBR). Postoperative BREAST-Q version 2.0 was completed by 68 of 79 patients (86.1%) in the SIS matrix-assisted one-stage IBBR group and by 35 of 45 patients (77.8%) in the two-stage IBBR group. In the satisfaction-related quality of life domain, satisfaction with breast was 9.27 points higher in the SIS matrix-assisted one-stage IBBR group (p = 0.012) compared with the two-stage IBBR group. The multivariate linear regression analysis showed that implant volume (p = 0.031) and postoperative radiotherapy (p = 0.036) significantly influenced the PRO of satisfaction with breast. However, patients in the SIS matrix-assisted one-stage IBBR group had a higher minor complication rate compared with patients in the two-stage IBBR group (p = 0.026).

CONCLUSIONS

Our retrospective study showed that although patients treated with biological matrix-assisted one-stage IBBR tended to have higher postoperative complication rates, this technique correlated with better PROs compared with two-stage IBBR.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Influence of Hypofractionated Versus Conventional Fractionated Postmastectomy Radiation Therapy in Breast Cancer Patients With Reconstruction

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.

Identifying the top research priorities in postmastectomy breast cancer reconstruction: a James Lind Alliance priority setting partnership

BACKGROUND

Major improvements in breast cancer treatment in the last decade include advancements in postmastectomy breast reconstruction (PMBR). Unfortunately, the studies in PMBR are primarily researcher or industry led with minimal input from patients and caregivers. The aim of this study is to use the James Lind Alliance (JLA) approach to bring together the patients, caregivers and clinicians in a priority setting partnership to identify the most important unanswered research questions in PMBR.

METHODS

The JLA priority setting methodology involved four key stages: gathering research questions on PMBR from patients, caregivers and clinicians; checking these research questions against existing evidence; interim prioritisation and a final consensus meeting to determine the top 10 unanswered research questions using the modified nominal group methodology.

RESULTS

In stage 1, 3168 research questions were submitted from 713 respondents across Canada, of which 73% of the participants were patients or caregivers. Stage 2 confirmed that there were a total of 48 unique unanswered questions. In stage three, 488 individuals completed the interim prioritisation survey and the top 25 questions were taken to a final consensus meeting. In the final stage, the top 10 unanswered research questions were determined. They cover a breadth of topics including personalised surgical treatment, safety of implants and newer techniques, access to PMBR, breast cancer recurrence and rehabilitation.

INTERPRETATION

Identification of the top 10 unanswered research questions is an important first step to generating relevant and impactful research that will ultimately improve the PMBR experience for patients with breast cancer.

Effects of radiation and chemotherapy on adipose stem cells: Implications for use in fat grafting in cancer patients

Autologous fat transplantation is a versatile tool in reconstructive surgery. Adipose-derived stem cells (ASCs) increase survival of fat grafts and thus are increasingly used for breast reconstruction in breast cancer patients. However, radiation and/or chemotherapy have been proposed to inhibit soft tissue regeneration in wound healing thus suggesting alteration in stem cell pathways. Therefore, elucidating effects of radiation and chemotherapy on ASCs is critical if one desires to enhance the survival of fat grafts in patients. This review outlines our work evaluating the function and recoverability of ASCs from radiation or chemotherapy patients, focusing specifically on their availability as a source of autologous stem cells for fat grafting and breast reconstruction in cancer patients. Even though evidence suggests radiation and chemotherapy negatively influence ASCs at the cellular level, the efficiency of the isolation and differentiation capacity did not appear influenced in patients after receiving chemotherapy treatment, although fat from radiated patients exhibited significantly altered ASC differentiation into endothelial-like cells. Further, the in vitro growth rates of patient’s ASCs do not differ significantly before or after treatment. Taken together, these studies suggest ASCs as an important new tool for grafting and reconstruction even when radiation and chemotherapy treatment are involved.

Aesthetic outcomes and complications following post-mastectomy radiation therapy in patients undergoing immediate extended latissimus dorsi flap reconstruction and implant insertion

Background

Complications of radiotherapy after implant-based reconstruction include capsular contracture development, seroma formation, and reoperation for implant removal or replacement. However, there is a lack of studies regarding aesthetic outcomes and complication rates following radiation therapy among patients undergoing latissimus dorsi (LD) flap-based reconstruction with implant insertion for volume shortage. The present study aimed to evaluate clinical and aesthetic outcomes of post-mastectomy radiation therapy (PMRT) among patients receiving both LD flap reconstruction and implant insertion.

Methods

This study comprised 66 patients who underwent mastectomy and breast reconstruction between March 2014 and July 2019. Patient demographics and outcomes were compared among patients who did and did not receive PMRT. Aesthetic outcomes were compared using gross photographs. The incidence of complications, including seroma formation, flap necrosis, nipple-areola complex necrosis, hematoma development, and capsular contractures, was compared between groups.

Results

No differences in aesthetic outcomes using gross photos during outpatient follow-up were observed between the radiation and control groups. No significant difference in the frequency of complications was observed between groups.

Conclusions

The use of implants and LD reconstruction are inevitable in a proportion of patients due to a lack of LD flap volume. For these patients, PMRT could be safe treatment option if the necessary precautions are implemented.

Implant risk failure in patients undergoing postmastectomy 3-week hypofractionated radiotherapy after immediate reconstruction

AIM

To evaluate reconstruction failure (RF) rate in patients receiving implant-based immediate breast reconstruction (IBR) and hypofractionated (HF) postmastectomy radiation therapy (PMRT).

MATERIALS AND METHODS

Stage II-III breast cancer patients, treated with HF-PMRT using intensity modulated radiotherapy were stratified in two groups according to IBR: single-stage direct-to-implant (DTI-group) and two-stage expander and implant (TE/I-group). Irradiated patients were matched with non-irradiated ones who underwent the same IBR during the same period. Prescription dose was 40.05 Gy/15 fractions to chest wall and infra/supraclavicular nodal region. Primary endpoint was RF defined as the need of major revisional surgery (MaRS) for implant removal or conversion to autologous reconstruction. Secondary endpoint was the rate of minor revisional surgeries (MiRS) including implant repositioning or substitution with another implant.

RESULTS

One hundred and seven irradiated patients (62 in TE/I-group, 45 in DTI-group) were matched with 107 non-irradiated subjects. Median follow-up was 4.2 years (0.1-6.1) In the TE/I setting, MaRS was performed in 8/62 irradiated patients (12.9%) of the irradiated TE/I group compared to 1/62 (1.6%) non-irradiated subjects (p = 0.015). In the DTI setting, MaRs occurred in 3/45 irradiated patients (6.7%) compared to 1/45 non-irradiated ones (2.2%) (p = 0.35). Overall MaRS rate was 10.3% in the irradiated group. MiRS was performed in 35.6% and 31.1% of the irradiated and non-irradiated DTI-groups (p = 0.65), respectively, and in 12.9% and 8.1% of the irradiated and non-irradiated TE/I groups (p = 0.38), respectively.

CONCLUSIONS

Compared to the non-irradiated counterparts, the TE/I group showed higher rate of RF, while no statistically significant difference was observed for the DTI group. The use of hypofractionation and IMRT to implant-based IBR did not seem to increase the risk of RF which appeared to be in line with the literature.

Reconstructive Techniques in Melanoma for the Surgical Oncologist

Wounds resulting from wide local excision of melanoma vary in size and complexity, and require individualized solutions to achieve satisfactory closure. Goals of reconstruction include restoration of form, function, and aesthetics while minimizing donor site morbidity without compromising the effectiveness and safety of oncologic melanoma treatment. Optimal reconstruction relies on an in-depth understanding of the defect, locoregional anatomy and vasculature, available donor tissues, and basic wound healing and surgical principles. This article provides a broad overview of preoperative patient, timing, and wound considerations; various surgical techniques for complex reconstruction throughout the body; and postoperative care and complication management.

Temporary Implant Irradiation: Survey of Turkish Society of Radiation Oncology Breast Cancer Study Group

Objective

To understand the clinical approach of radiation oncologists during the treatment of patients with breast reconstruction.

Materials and Methods

A questionnaire survey was emailed to 105 active members of the Turkish Radiation Oncology Society, the Breast Cancer Study Group. The factors associated with radiation oncologists and their current practice was identified.

Results

Fifty radiation oncologists (47.6%) responded, and most of the responders (83%) were physicians who treated >50 new breast cancer patients annually. The majority of the physicians worked in academic hospitals and had more than 15 years of work experience. The early reconstruction rate was noted to be low among patients with mastectomy (<10% of the mastectomy patients) (p<0.05). Early implant irradiation with temporary tissue expander was noted to be a more common procedure. The majority of the respondents (68%) preferred to irradiate an inflated implant (20% total, 80% partial). In addition, 22% of the physicians declared that they routinely used bolus and that 60% of them used it only for patients at a high risk of local recurrence factors.

Conclusion

It can thus be concluded that variations exist between experienced radiation oncologists and others. Hypofractionation is not yet commonly practiced for patients with reconstruction in Turkey. A concrete consensus can be helpful to create a homogeneity in treatment decisions and practical applications.

Evaluating the impact of axillary dissection on recurrence-free survival by extent of nodal disease in invasive lobular carcinoma of the breast

PURPOSE

Clinical trials have shown that axillary lymph node dissection (ALND) can be avoided for many breast cancer patients with limited nodal involvement. However, whether its omission is safe for those with invasive lobular carcinoma (ILC) is still questioned. We sought to evaluate the impact of ALND on recurrence-free survival (RFS) by extent of nodal disease in patients with ILC.

METHODS

We performed a retrospective, cross-sectional analysis of ILC patients treated between 1990 and 2019 at our institution. Patients underwent either breast conservation surgery (BCS) or mastectomy. We used univariate and multivariate statistics in Stata 14.2 to evaluate associations between extent of axillary surgery and time to recurrence stratified by nodal burden.

RESULTS

Of 520 cases, 387 (78.4%) were node negative, 74 (14.9%) had 1-2 positive nodes, and 59 (11.4%) had three or more positive nodes. Most patients (93.3%) had hormone receptor-positive disease, and 94.8% had low or intermediate-grade tumors. The rate of ALND significantly decreased over time (p < 0.002). Using a multivariate model, there was no significant difference in RFS estimates based on receipt of ALND (HR = 0.53, 95% CI 0.17-1.64, p = 0.27), which also held true for patients with 1-2 positive nodes using a test of interaction (HR = 0.91, 95% CI 0.12-6.76, p = 0.92).

CONCLUSIONS

These findings support the safety of omitting ALND in selected patients with ILC. Further studies of axillary management in ILC and imaging tools to predict nodal involvement and therapeutic response are warranted.

Second conservative treatment for second ipsilateral breast tumor event: A systematic review of the different re-irradiation techniques

AIM

To address the different partial breast re-irradiation techniques available in the context of second conservative treatment (SCT), as an alternative to salvage mastectomy, for 2nd ipsilateral breast tumor event (IBTE) and summarize their respective oncological and toxicity outcomes.

MATERIAL AND METHODS

A literature search was made based on MeSH/PubMed, including papers from 1995 to 2019. Each article was described according to the main irradiation technique, fractionation, oncological results and grade 3 toxicities related to the salvage conservative treatment.

RESULTS

Twenty-two articles were identified, reporting the outcomes of over 1 000 patients. MIB Brachytherapy was the most used re-irradiation technique in case of SCT, with a median 3rdIBTE-FS rate of 88% and summed up grade 3 toxicities of 6%. As for IORT, the average rate of 3rdIBTE-FS was about Finally, external beam partial re-irradiation was recently tested in this indication with encouraging results in terms of tolerance.

CONCLUSION

When presenting a 2ndIBTE, a SCT can safely be proposed to carefully selected and well-informed patients, as an alternative to salvage mastectomy. MIB appears to be the first intention and most robust choice. IORT, external beam radiotherapy and balloon brachytherapy are interesting alternatives but have only been tested in small series. Further investigations are required and their use should be limited to clinical trial only.

Single stage immediate breast reconstruction with acellular dermal matrix and implant: Defining the risks and outcomes of post-mastectomy radiotherapy

INTRODUCTION

The objective of this study is to evaluate outcomes and complications in patients with single-stage ADM-implant based immediate breast reconstruction with and without radiotherapy (RT), highlighting the effects of RT on the reconstruction.

MATERIALS AND METHODS

This prospective study recruited 91 consecutive patients who underwent skin-sparing, nipple-sparing or wise-pattern skin reduction mastectomy with direct-to-implant breast reconstruction with ADMs using sub-pectoral or pre-pectoral approach at the two breast units. Early and late complications like seroma, delayed wound healing, wound breakdown, infection, capsular contracture, implant loss and revision surgery were evaluated in the RT and non-RT groups.

RESULTS

In the total cohort of 91 patients, 29 received adjuvant RT and 62 did not need RT. In the RT group, 3-7% of them had early complications like seroma, wound infections and delayed healing. 20.7% had post-RT capsular contractures which either required revision surgery with autologous flap (6.9%) or capsulotomy with exchange of implant (6.9%). In the non-RT group, 7-9% cases had seroma & wound infections, 3.06% had delayed wound healing and 7.25% had capsular contracture. 13.04% required revision surgery due to infection, implant loss or failure to achieve expectations. The total loss of implants in the cohort was 7.14% (RT group 6.9% and non-RT group 7.25%). The need for PMRT could have been predicted pre-operatively in the RT group in 55.17% cases based on the extent of disease, multifocality, tumour grade and positive LN status on imaging.

CONCLUSION

ADM based reconstruction in patients anticipated to receive adjuvant RT is always debatable. Though there is no significant difference in the revision surgeries in our study of the 2 groups, the rate of capsular contracture as expected, was higher in the RT group. Hence, pre-operative discussion on the need for RT highlighting the risks and complications will help patients make a better-informed choice.

Preoperative breast volume evaluation of one-stage immediate breast reconstruction using three-dimensional surface imaging and a printed mold

BACKGROUND

Accurate assessment of breast volume is an essential component of preoperative planning in one-stage immediate breast reconstruction (IBR) for achieving breast symmetry and a satisfactory cosmetic outcome. In this study, we compared breast volume estimation using three-dimensional (3D) surface imaging with magnetic resonance imaging (MRI) to determine the accuracy of breast volume measurements. Further, a 3D printing mold for facilitating autologous breast reconstruction intraoperatively is described.

METHODS

Patients scheduled to therapeutic or prophylactic mastectomy with one-stage IBR, either by autologous tissue transfer or direct implant, from 2016 to 2019, were enrolled in this study. 3D surface image and MRI were performed to evaluate breast volume and shape. The results were validated by the water displacement volume of the mastectomy specimen. Finally, a 3D printing mold was designed for breast reconstruction with autologous tissue.

RESULTS

Nineteen women who were scheduled to have 20 mastectomies (18 unilateral and one bilateral) were included. There was a strong linear association between breast volume measured using the two different methods and water displacement of mastectomy specimens when a Pearson correlation was used (3D surface image: r = 0.925, p < 0.001; MRI: r = 0.915, p < 0.001). Bland-Altman plots demonstrated no proportional bias between the assessment methods. The coefficient of variation was 52.7% for 3D surface imaging and 59.9% for MRI. The volume of six breasts was evaluated by both measurements and the intraclass correlation coefficient was 0.689 for 3D surface image (p = 0.043) and 0.743 for MRI (p = 0.028).

CONCLUSION

Using 3D surface image to evaluate breast shape and volume is a quick, effective, and convenient method. The accuracy, reproducibility, and reliability of 3D surface imaging were comparable with MRI in our study. In addition, 3D-printed molds can achieve better symmetry and aesthetic outcomes in immediate autologous breast reconstructions.

Modeling AeroForm tissue expander for postmastectomy radiation therapy

The AeroForm chest wall tissue expander (TE) is a silicon shell containing a metallic CO₂ reservoir, placed surgically after mastectomy. The patient uses a remote control to release compressed CO₂ from the reservoir to inflate the expander. AeroForm poses challenges in a radiation therapy setting: The high density of the metallic reservoir causes imaging artifacts on the planning CT, which encumber structure definition and cause misrepresentation of density information, in turn affecting dose calculation. Additionally, convolution-based dose calculation algorithms may not be well-suited to calculate dose in and around high-density materials. In this study, a model of the AeroForm TE was created in Eclipse treatment planning system (TPS). The TPS model was validated by comparing measured to calculated transmission through the AeroForm. Transmission was measured with various geometries using radiochromic film. Dose was calculated with both Varian's Anisotropic Analytical Algorithm (AAA) and Acuros External Beam (AXB) algorithms. AAA and AXB were compared using dose profile and gamma analyses. While both algorithms modeled direct transmission well, AXB better modeled lateral scatter from the AeroForm TE. Clinical significance was evaluated using clinical data from four patients with AeroForm TEs. The AeroForm TPS model was applied, and RT plans were optimized using AAA, then re-calculated with AXB. Structures of clinical significance were defined and dose volume histogram analysis was performed. Compared to AXB, AAA overestimates dose in the AeroForm device. Changes in clinically significant regions were patient- and plan-specific. This study proposes a clinical procedure for modeling the AeroForm in a commercial TPS, and discusses the limitations of dose calculation in and around the device. An understanding of dose calculation accuracy in the vicinity of the AeroForm is critical for assessing individual plan quality, appropriateness of different planning techniques and dose calculation algorithms, and even the decision to use the AeroForm in a postmastectomy radiation therapy setting.