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Perrucci E, Marcantonini M, Arena E, Fulcheri C, Reggioli V, Dipilato AC, Palumbo I, Saldi S, Falcinelli L, Ingrosso G, Bini V, Aristei C. Effect of internal port on dose distribution in post-mastectomy radiotherapy for breast cancer patients after expander breast reconstruction. Rep Pract Oncol Radiother 2023; 28:1-8. [PMID: 37122911 PMCID: PMC10132188 DOI: 10.5603/rpor.a2023.0014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 03/17/2023] [Indexed: 05/02/2023] Open
Abstract
Background In patients with expander-based reconstruction a few dosimetric analyses detected radiation therapy dose perturbation due to the internal port of an expander, potentially leading to toxicity or loss of local control. This study aimed at adding data on this field. Materials and methods A dosimetric analysis was conducted in 30 chest wall treatment planning without and with correction for port artifact. In plans with artifact correction density was overwritten as 1 g/cm3. Medium, minimum and maximum chest wall doses were compared in the two plans. Both plans, with and without correction, were compared on an anthropomorphic phantom with a tissue expander on the chest covered by a bolus simulating the skin. Ex vivo dosimetry was carried out on the phantom and in vivo dosimetry in three patients by using film strips during one treatment fraction. Estimated doses and measured film doses were compared. Results No significant differences emerged in the minimum, medium and maximum doses in the two plans, without and with correction for port artifacts. Ex vivo and in vivo analyses showed a good correspondence between detected and calculated doses without and with correction. Conclusions The port did not significantly affect dose distribution in patients who will receive post-mastectomy radiation therapy.
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Affiliation(s)
| | | | | | | | | | - Anna Concetta Dipilato
- Radiation Oncology Section, University of Perugia and Perugia General Hospital, Perugia, Italy
| | - Isabella Palumbo
- Radiation Oncology Section, University of Perugia and Perugia General Hospital, Perugia, Italy
| | - Simonetta Saldi
- Radiation Oncology Section, Perugia General Hospital, Perugia, Italy
| | | | - Gianluca Ingrosso
- Radiation Oncology Section, University of Perugia and Perugia General Hospital, Perugia, Italy
| | - Vittorio Bini
- Department of Medicine, Section of Internal Medicine and Endocrine and Metabolic Sciences, University of Perugia, Perugia, Italy
| | - Cynthia Aristei
- Radiation Oncology Section, University of Perugia and Perugia General Hospital, Perugia, Italy
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2
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Yehia ZA, Punglia RS, Wong J. Integration of Radiation and Reconstruction After Mastectomy. Semin Radiat Oncol 2022; 32:237-244. [DOI: 10.1016/j.semradonc.2022.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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3
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Hall J, Fried D, Marks LB, Gupta GP, Jones E, Elmore S, Pearlstein K, Downs-Canner S, Gallagher K, Spanheimer PM, Carr J, Ogunleye AA, Casey DL. Dosimetric and Clinical Factors Associated with Breast Reconstruction Complications in Patients Receiving Post-Mastectomy Radiation. Pract Radiat Oncol 2021; 12:e169-e176. [PMID: 34920164 DOI: 10.1016/j.prro.2021.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 11/01/2021] [Accepted: 11/12/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE/OBJECTIVE(S) Approximately 30% of women who receive post-mastectomy radiation therapy (PMRT) in the setting of breast reconstruction suffer from reconstruction complications. This study aims to assess clinical and dosimetric factors associated with the risk of reconstruction complications after PMRT, with the ultimate goal of identifying a dosimetric constraint that can be utilized clinically to limit this risk. MATERIALS/METHODS We retrospectively identified 41 patients who underwent modified radical (MRM) or total mastectomy followed by immediate or delayed reconstruction (autologous or implant-based) and radiation at a single institution from 2014-2020. Reconstruction complications were defined as flap or implant failure, necrosis, capsular contracture, cellulitis/infection, implant rupture, implant malposition, leakage/rupture, unplanned operation, and hematoma/seroma. Clinical and dosimetric variables associated with complications were assessed with univariate analyses. RESULTS 12 patients (29%) suffered reconstruction complications which led to flap or implant failure in 5 patients. Median time to complication following reconstruction was 8 months. 32% of patients with immediate and 20% with delayed reconstruction suffered a complication, respectively. There were no local failures. Smoking (p=0.02), use of bolus (p=0.03), and V107 > 11% (p=0.03) were associated with increased complication rates. The complication rates were 42% when V107 > 11% versus 12% when V107 < 11%; 58% in smokers versus 17% in nonsmokers; and 42% with bolus versus 7% without. CONCLUSION Plan heterogeneity appears to be associated with the risk of reconstruction complications. Pending further validation, V107 < 11% may serve as a reasonable guide to limit this risk. Further consideration should be given to the selective use of bolus in this setting and optimization of clinical factors such as smoking cessation.
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Affiliation(s)
- Jacob Hall
- Department of Radiation Oncology, University of North Carolina, Chapel Hill, NC
| | - David Fried
- Department of Radiation Oncology, University of North Carolina, Chapel Hill, NC
| | - Lawrence B Marks
- Department of Radiation Oncology, University of North Carolina, Chapel Hill, NC
| | - Gaorav P Gupta
- Department of Radiation Oncology, University of North Carolina, Chapel Hill, NC
| | - Ellen Jones
- Department of Radiation Oncology, University of North Carolina, Chapel Hill, NC
| | - Shekinah Elmore
- Department of Radiation Oncology, University of North Carolina, Chapel Hill, NC
| | - Kevin Pearlstein
- Department of Radiation Oncology, University of North Carolina, Chapel Hill, NC
| | - Stephanie Downs-Canner
- Division of Surgical Oncology, Department of Surgery, University of North Carolina, Chapel Hill, NC
| | - Kristalyn Gallagher
- Division of Surgical Oncology, Department of Surgery, University of North Carolina, Chapel Hill, NC
| | - Philip M Spanheimer
- Division of Surgical Oncology, Department of Surgery, University of North Carolina, Chapel Hill, NC
| | - Jennifer Carr
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC
| | - Adeyemi A Ogunleye
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC
| | - Dana L Casey
- Department of Radiation Oncology, University of North Carolina, Chapel Hill, NC.
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4
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Poppe MM, Khan AJ. In Reply to Dyer et al. Int J Radiat Oncol Biol Phys 2021; 109:301-302. [PMID: 33308699 DOI: 10.1016/j.ijrobp.2020.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 09/08/2020] [Indexed: 10/22/2022]
Affiliation(s)
- Matthew M Poppe
- Huntsman Cancer Hospital, University of Utah, Salt Lake City, Utah
| | - Atif J Khan
- Memorial Sloan Kettering Cancer Center, New York, New York
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5
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Crawford K, Endara M. Lipotransfer Strategies and Techniques to Achieve Successful Breast Reconstruction in the Radiated Breast. MEDICINA (KAUNAS, LITHUANIA) 2020; 56:E516. [PMID: 33019768 PMCID: PMC7599742 DOI: 10.3390/medicina56100516] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 09/21/2020] [Accepted: 09/22/2020] [Indexed: 12/24/2022]
Abstract
Radiation therapy is frequently a critical component of breast cancer care but carries with it side effects that are particularly damaging to reconstructive efforts. Autologous lipotransfer has the ability to improve radiated skin throughout the body due to the pluripotent stem cells and multiple growth factors transferred therein. The oncologic safety of lipotransfer to the breasts is demonstrated in the literature and is frequently considered an adjunctive procedure for improving the aesthetic outcomes of breast reconstruction. Using lipotransfer as an integral rather than adjunctive step in the reconstructive process for breast cancer patients requiring radiation results in improved complication rates equivalent to those of nonradiated breasts, expanding options in these otherwise complicated cases. Herein, we provide a detailed review of the cellular toxicity conferred by radiotherapy and describe at length our approach to autologous lipotransfer in radiated breasts.
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Affiliation(s)
- Kristina Crawford
- Resident Physician, Vanderbilt University Medical Center, Nashville, TN 37232, USA;
| | - Matthew Endara
- Plastic Surgeon, Maury Regional Medical Group, Columbia, TN 38401, USA
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6
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Arenas M, Selek U, Kaidar-Person O, Perrucci E, Montero Luis A, Boersma L, Coles C, Offersen B, Meattini I, Bölükbaşı Y, Leonardi MC, Pfeffer R, Cutuli B, Vidali C, Franco P, Kouloulias V, Masiello V, Rivera S, Bourgier C, Ciabattoni A, Lancellotta V, Trigo L, Valentini V, Poortmans P, Aristei C. The 2018 assisi think tank meeting on breast cancer: International expert panel white paper. Crit Rev Oncol Hematol 2020; 151:102967. [PMID: 32450277 DOI: 10.1016/j.critrevonc.2020.102967] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 03/27/2020] [Accepted: 04/15/2020] [Indexed: 01/13/2023] Open
Abstract
We report on the second Assisi Think Tank Meeting (ATTM) on breast cancer which was held under the auspices of the European Society for RadioTherapy & Oncology (ESTRO). In discussing in-depth current evidence and practice it was designed to identify grey areas in diverse forms of the disease. It aimed at addressing uncertainties and proposing future trials to improve patient care. Before the meeting, three key topics were selected: 1) primary systemic therapy, mastectomy, breast reconstruction and post-mastectomy radiation therapy, 2) therapeutic options in ductal carcinoma in situ, and 3) therapy de-escalation in early stage breast cancer. Clinical practice in these areas was investigated by means of an online questionnaire. The time lapse period between the survey and the meeting was used to review the literature and on-going clinical trials. At the ATTM both were discussed in depth and research protocols were proposed.
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Affiliation(s)
| | - Ugur Selek
- Radiation Oncology, Koc University School of Medicine, Istambul, Turkey
| | - Orit Kaidar-Person
- Radiation Oncology, Oncology Institute, Rambam Medical Center, Haifa, Israel
| | | | | | - Liesbeth Boersma
- Radiation Oncology (Maastro), GROW School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Charlotte Coles
- Radiation Oncology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | | | - Icro Meattini
- Radiation Oncology, Azienda Ospedaliero-Universitaria Careggi (AOUC), Florence, Italy
| | - Yasemin Bölükbaşı
- Radiation Oncology, Koc University School of Medicine, Istambul, Turkey
| | | | - Raphael Pfeffer
- Radiation Oncology, Assuta Medical Centres, Tel Aviv, Israel
| | - Bruno Cutuli
- Radiation Oncology, Institut du Cancer Courlancy, Reims, France
| | - Cristiana Vidali
- Radiation Oncology, Azienda Sanitaria Universitaria Integrata di Trieste (ASUITS), Trieste, Italy
| | - Pierfrancesco Franco
- Radiation Oncology, Department of Oncology, University of Turin School of Medicine, Turin, Italy
| | - Vassilis Kouloulias
- Radiation Oncology, National and Kapodistrian University of Athens, Medical School, Attikon University Hospital, Athens, Greece
| | - Valeria Masiello
- Radiation Oncology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Sofia Rivera
- Radiation Oncology, Institut Gustave Roussy, Villejuif, France
| | - Céline Bourgier
- Radiation Oncology, ICM-Val d'Aurelle, University Montpellier, Montpellier, France
| | | | - Valentina Lancellotta
- Radiation Oncology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Lurdes Trigo
- Radiation Oncology, Instituto Portugues de Oncologia Francisco Martins Porto E.P.E, Porto, Portugal
| | - Vincenzo Valentini
- Radiation Oncology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Philip Poortmans
- Radiation Oncology, Iridium Kankernetwerk, Wilrijk-Antwerp - University of Antwerp, Faculty of Medicine and Health Sciences, Wilrijk-Antwerp, Belgium
| | - Cynthia Aristei
- Radiation Oncology, University of Perugia and Perugia General Hospital, Perugia, Italy.
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7
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Successful Immediate Staged Breast Reconstruction with Intermediary Autologous Lipotransfer in Irradiated Patients. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 7:e2398. [PMID: 31942379 PMCID: PMC6908383 DOI: 10.1097/gox.0000000000002398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 06/24/2019] [Indexed: 11/26/2022]
Abstract
As indications for radiotherapy in mastectomized patients grow, the need for greater reconstructive options is critical. Preliminary research suggests an ameliorating impact of lipotransfer on irradiated patients with expander-to-implant reconstruction. Herein, we present our technique using lipotransfer during the expansion stage to facilitate implant placement.
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8
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Kaidar-Person O, Vrou Offersen B, Hol S, Arenas M, Aristei C, Bourgier C, Cardoso MJ, Chua B, Coles CE, Engberg Damsgaard T, Gabrys D, Jagsi R, Jimenez R, Kirby AM, Kirkove C, Kirova Y, Kouloulias V, Marinko T, Meattini I, Mjaaland I, Nader Marta G, Witt Nystrom P, Senkus E, Skyttä T, Tvedskov TF, Verhoeven K, Poortmans P. ESTRO ACROP consensus guideline for target volume delineation in the setting of postmastectomy radiation therapy after implant-based immediate reconstruction for early stage breast cancer. Radiother Oncol 2019; 137:159-166. [PMID: 31108277 DOI: 10.1016/j.radonc.2019.04.010] [Citation(s) in RCA: 77] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Accepted: 04/04/2019] [Indexed: 02/07/2023]
Abstract
Immediate breast reconstruction (IBR) rates after mastectomy are increasing. Postmastectomy radiation therapy (PMRT) contouring guidelines for target volumes in the setting of IBR are lacking. Therefore, many patients who have had IBR receive PMRT to target volumes similar to conventional simulator-based whole breast irradiation. The aim of this paper is to describe delineation guidelines for PMRT after implant-based IBR based on a thorough understanding of the surgical procedures, disease stage, patterns of recurrence and radiation techniques. They are based on a consensus endorsed by a global multidisciplinary group of breast cancer experts.
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Affiliation(s)
- Orit Kaidar-Person
- Oncology Institute, Radiation Oncology Unit, Rambam Medical Center, Haifa, Israel.
| | - Birgitte Vrou Offersen
- Department of Experimental Clinical Oncology, Danish Center for Particle Therapy, Department of Oncology, Aarhus University Hospital, Denmark
| | - Sandra Hol
- Department of Radiation Oncology, Institute Verbeeten, Tilburg, the Netherlands
| | - Meritxell Arenas
- Department of Radiation Oncology, Hospital Universitari Sant Joan de Reus, University Rovira i Virgili, Spain
| | - Cynthia Aristei
- Radiation Oncology Section, Department of Surgical and Biomedical Science, University of Perugia and Perugia General Hospital, Italy
| | - Celine Bourgier
- Department of Radiation Oncology, ICM - Val d'Aurelle, INSERM U1194, IRCM; Montpellier University, Montpellier, France
| | - Maria Joao Cardoso
- Breast Unit, Champalimaud Foundation, and Nova Medical School, Lisbon, Portugal
| | - Boon Chua
- Faculty of Medicine, The University of New South Wales, UNSW Sydney, NSW, Australia
| | | | | | - Dorota Gabrys
- Department of Radiation Oncology, Maria Sklodowska Curie Memorial Cancer Centre, Gliwice, Poland
| | - Reshma Jagsi
- Department of Radiation Oncology, University of Michigan, Ann Arbor, USA
| | - Rachel Jimenez
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, USA
| | - Anna M Kirby
- Department of Radiotherapy, Royal Marsden NHS Foundation Trust and Institute of Cancer Research, Sutton, UK
| | - Carine Kirkove
- Department of Radiation Oncology, University Hospital St-Luc, Brussels, Belgium
| | - Youlia Kirova
- Department of Radiation Oncology, Institut Curie, Paris, France
| | - Vassilis Kouloulias
- National and Kapodistrian University of Athens, Medical School, 2nd Dpt of Radiology, Radiotherapy Unit, Athens, Greece
| | - Tanja Marinko
- Department of Radiation Oncology, Institute of Oncology Ljubljana, Slovenia
| | - Icro Meattini
- Department of Biomedical, Experimental, and Clinical Sciences, University of Florence, Italy, Radiation Oncology Unit - Oncology Department, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Ingvil Mjaaland
- Department of Oncology & Radiotherapy, Stavanger University Hospital, Norway
| | - Gustavo Nader Marta
- Department of Radiation Oncology, Hospital Sírio-Libanês, São Paulo, Brazil; Department of Radiology and Oncology, Division of Radiation Oncology, Instituto do Câncer do Estado de São Paulo (ICESP), Faculdade de Medicina da Universidade de São Paulo, Brazil
| | - Petra Witt Nystrom
- The Skandion Clinic, Uppsala, Sweden and Danish Center for Particle Therapy, Aarhus, Denmark
| | - Elzbieta Senkus
- Department of Oncology & Radiotherapy, Medical University of Gdańsk, Poland
| | - Tanja Skyttä
- Department of Oncology, Tampere University Hospital, Finland
| | - Tove F Tvedskov
- Dept. of Breast Surgery, Herlev Hospital, Copenhagen, Denmark
| | - Karolien Verhoeven
- GROW School for Oncology and Developmental Biology, Department of Radiation Oncology, Maastricht University Medical Centre, Netherlands
| | - Philip Poortmans
- Department of Radiation Oncology, Institut Curie, and Paris Sciences & Lettres University, Paris, France
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9
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Strach MC, Prasanna T, Kirova YM, Alran S, O'Toole S, Beith JM, Poortmans P, McNeil CM, Carroll S. Optimise not compromise: The importance of a multidisciplinary breast cancer patient pathway in the era of oncoplastic and reconstructive surgery. Crit Rev Oncol Hematol 2018; 134:10-21. [PMID: 30771869 DOI: 10.1016/j.critrevonc.2018.11.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2018] [Revised: 08/25/2018] [Accepted: 11/23/2018] [Indexed: 12/18/2022] Open
Abstract
Modern breast cancer care is a complex multidisciplinary undertaking in which the integrated function of multiple constituent parts is critical, and where changes to one therapeutic component may profoundly influence the delivery and outcomes of another. Oncoplastic and reconstructive breast surgery has evolved in the era of longer survival rates for women with breast cancer and aims to enhance oncological and cosmetic outcomes. However, concurrently there has been an expansion in the indications for post-mastectomy radiation therapy (Abdulkarim et al., 2011; Early Breast Cancer Trialists' Collaborative Group (EBCTCG), 2014; Poortmans et al., 2015; Wang et al., 2011), the recognition of several biologically distinct breast cancer subtypes (Perou et al., 2000; Sørlie et al., 2001, 2003; Cheang et al., 2008, 2009; Sotiriou et al., 2003; Millar et al., 2011; Blows et al., 2010; Schnitt, 2010; Haque et al., 2012; Dai et al., 2015) and the development of recommendations for prophylactic surgery for high-risk women, including BRCA-mutation carriers (James et al., 2006; Domchek et al., 2010). Primary systemic therapy is increasingly utilised yet has varying efficacy depending on tumour biology (Cortazar et al., 2014). In this paper we review the evidence which informs the multidisciplinary team opinion in the era of oncoplastic and reconstructive breast surgery. We aim to describe an optimal multidisciplinary approach which balances competing risks of multimodal therapies to optimise oncological and cosmetic outcomes.
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Affiliation(s)
- Madeleine C Strach
- Department of Medical Oncology, Chris O'Brien Lifehouse, Camperdown, New South Wales, Australia; Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia.
| | - Thiru Prasanna
- Department of Medical Oncology, Chris O'Brien Lifehouse, Camperdown, New South Wales, Australia; Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Youlia M Kirova
- Department of Radiation Oncology, Institut Curie, Paris, France
| | - Severine Alran
- Department of Surgical Oncology, Groupe Hospitalier Paris St Joseph, France
| | - Sandra O'Toole
- Garvan Institute of Medical Research, Darlinghurst, New South Wales, Australia; Sydney Medical School, University of Sydney, New South Wales, Australia; Australian Clinical Labs, Bella Vista, New South Wales, Australia
| | - Jane M Beith
- Department of Medical Oncology, Chris O'Brien Lifehouse, Camperdown, New South Wales, Australia; Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia; Sydney Medical School, University of Sydney, New South Wales, Australia
| | | | - Catriona M McNeil
- Department of Medical Oncology, Chris O'Brien Lifehouse, Camperdown, New South Wales, Australia; Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia; Sydney Medical School, University of Sydney, New South Wales, Australia
| | - Susan Carroll
- Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia; Sydney Medical School, University of Sydney, New South Wales, Australia; Department of Radiation Oncology, Royal North Shore Hospital, St Leonards, New South Wales, Australia
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10
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Using Mesh to Reinforce the Abdominal Wall in Abdominal Free Flaps for Breast Reconstruction. Ann Plast Surg 2018; 80:S295-S298. [DOI: 10.1097/sap.0000000000001468] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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11
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Solin LJ. Interaction of Postmastectomy Radiation Treatment With Breast Reconstruction: Many Questions, Emerging Data. J Natl Cancer Inst 2017; 110:4157684. [DOI: 10.1093/jnci/djx177] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Accepted: 08/02/2017] [Indexed: 11/12/2022] Open
Affiliation(s)
- Lawrence J. Solin
- Department of Radiation Oncology, Albert Einstein Healthcare Network, Philadelphia, PA
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