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Ward J, Ho K, Ike C, Wood SH, Thiruchelvam PTR, Khan AA, Leff DR. Pre-operative chemoradiotherapy followed by mastectomy and breast reconstruction-A systematic review of clinical, oncological, reconstructive and aesthetic outcomes. J Plast Reconstr Aesthet Surg 2024; 96:242-253. [PMID: 39106546 DOI: 10.1016/j.bjps.2024.07.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2024] [Revised: 06/05/2024] [Accepted: 07/08/2024] [Indexed: 08/09/2024]
Abstract
BACKGROUND Pre-operative radiotherapy (PRT) and pre-operative chemoradiotherapy (PCRT) prior to mastectomy and immediate breast reconstruction for locally advanced breast cancer have the potential to reduce radiation late-effects and expedite oncologic treatment. Recent feasibility work indicates that PCRT is safe and technically possible. Here, we present a systematic review of currently available data on clinical, oncological, reconstructive and aesthetic outcomes. METHODS A prospectively registered search of Medline (Ovid), EMBASE (Ovid), EMCARE (Ovid) and CINAHL (EBSCO) databases was performed in August 2023. Clinical, oncological, reconstructive and aesthetic outcomes were appraised with risk of bias (ROBINS-I) and methodological quality determined (STROBE checklist) for each study. RESULTS Twenty-two published articles (19 journal articles and 3 abstracts) were identified reporting the outcomes of 1258 patients with median follow-up between 19.0-212.4 months. Patients received neoadjuvant chemotherapy in 20 studies. Rates of locoregional recurrence and overall survival ranged between 0-21.7% and 82.0%-98.3% respectively. Rates of flap loss or necrosis ranged from 0-7.6%. Rates of revisional procedures ranged between 1.9-35.3%. Patient-reported outcomes were reported in 7 studies and were mostly 'good' or 'excellent'. CONCLUSION PRT and PCRT preceding mastectomy and breast reconstruction produce acceptable oncological outcomes with rates of surgical complication and reconstructive outcomes within normal limits, however, the majority of available studies are of low methodological quality and at high risk of bias. A pragmatic randomised trial comparing PRT versus PMRT in the setting of breast reconstruction is now urgently required to guide surgical practice.
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Affiliation(s)
- Joseph Ward
- Department of Plastic Surgery, Royal Marsden Hospital, The Royal Marsden Hospital NHS Foundation Trust, 203 Fulham Road, London SW3 6JJ, United Kingdom.
| | - Ken Ho
- Imperial College Healthcare NHS Trust, Department of Breast Surgery, Charing Cross Hospital, Fulham Palace Road, London W6 8RF, United Kingdom
| | - Chiugo Ike
- Department of Plastic Surgery, Royal Marsden Hospital, The Royal Marsden Hospital NHS Foundation Trust, 203 Fulham Road, London SW3 6JJ, United Kingdom
| | - Simon H Wood
- Imperial College Healthcare NHS Trust, Department of Plastic Surgery, Charing Cross Hospital, Fulham Palace Road, London W6 8RF, United Kingdom
| | - Paul Thomas Ryan Thiruchelvam
- Imperial College Healthcare NHS Trust, Department of Breast Surgery, Charing Cross Hospital, Fulham Palace Road, London W6 8RF, United Kingdom
| | - Aadil A Khan
- Department of Plastic Surgery, Royal Marsden Hospital, The Royal Marsden Hospital NHS Foundation Trust, 203 Fulham Road, London SW3 6JJ, United Kingdom
| | - Daniel Richard Leff
- Imperial College Healthcare NHS Trust, Department of Breast Surgery, Charing Cross Hospital, Fulham Palace Road, London W6 8RF, United Kingdom; Department of Surgery and Cancer, Imperial College London, United Kingdom
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Schaverien MV, Singh P, Smith BD, Qiao W, Akay CL, Bloom ES, Chavez-MacGregor M, Chu CK, Clemens MW, Colen JS, Ehlers RA, Hwang RF, Joyner MM, Largo RD, Mericli AF, Mitchell MP, Shuck JW, Tamirisa N, Tripathy D, Villa MT, Woodward WA, Zacharia R, Kuerer HM, Hoffman KE. Premastectomy Radiotherapy and Immediate Breast Reconstruction: A Randomized Clinical Trial. JAMA Netw Open 2024; 7:e245217. [PMID: 38578640 PMCID: PMC10998161 DOI: 10.1001/jamanetworkopen.2024.5217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Accepted: 02/08/2024] [Indexed: 04/06/2024] Open
Abstract
Importance Premastectomy radiotherapy (PreMRT) is a new treatment sequence to avoid the adverse effects of radiotherapy on the final breast reconstruction while achieving the benefits of immediate breast reconstruction (IMBR). Objective To evaluate outcomes among patients who received PreMRT and regional nodal irradiation (RNI) followed by mastectomy and IMBR. Design, Setting, and Participants This was a phase 2 single-center randomized clinical trial conducted between August 3, 2018, and August 2, 2022, evaluating the feasibility and safety of PreMRT and RNI (including internal mammary lymph nodes). Patients with cT0-T3, N0-N3b breast cancer and a recommendation for radiotherapy were eligible. Intervention This trial evaluated outcomes after PreMRT followed by mastectomy and IMBR. Patients were randomized to receive either hypofractionated (40.05 Gy/15 fractions) or conventionally fractionated (50 Gy/25 fractions) RNI. Main Outcome and Measures The primary outcome was reconstructive failure, defined as complete autologous flap loss. Demographic, treatment, and outcomes data were collected, and associations between multiple variables and outcomes were evaluated. Analysis was performed on an intent-to-treat basis. Results Fifty patients were enrolled. Among 49 evaluable patients, the median age was 48 years (range, 31-72 years), and 46 patients (94%) received neoadjuvant systemic therapy. Twenty-five patients received 50 Gy in 25 fractions to the breast and 45 Gy in 25 fractions to regional nodes, and 24 patients received 40.05 Gy in 15 fractions to the breast and 37.5 Gy in 15 fractions to regional nodes, including internal mammary lymph nodes. Forty-eight patients underwent mastectomy with IMBR, at a median of 23 days (IQR, 20-28.5 days) after radiotherapy. Forty-one patients had microvascular autologous flap reconstruction, 5 underwent latissimus dorsi pedicled flap reconstruction, and 2 had tissue expander placement. There were no complete autologous flap losses, and 1 patient underwent tissue expander explantation. Eight of 48 patients (17%) had mastectomy skin flap necrosis of the treated breast, of whom 1 underwent reoperation. During follow-up (median, 29.7 months [range, 10.1-65.2 months]), there were no locoregional recurrences or distant metastasis. Conclusions and Relevance This randomized clinical trial found PreMRT and RNI followed by mastectomy and microvascular autologous flap IMBR to be feasible and safe. Based on these results, a larger randomized clinical trial of hypofractionated vs conventionally fractionated PreMRT has been started (NCT05774678). Trial Registration ClinicalTrials.gov Identifier: NCT02912312.
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Affiliation(s)
- Mark V. Schaverien
- Division of Surgery, Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston
| | - Puneet Singh
- Division of Surgery, Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Benjamin D. Smith
- Division of Radiation Oncology, Department of Breast Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Wei Qiao
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston
| | - Catherine L. Akay
- Division of Surgery, Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Elizabeth S. Bloom
- Division of Radiation Oncology, Department of Breast Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Mariana Chavez-MacGregor
- Division of Cancer Medicine, Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Carrie K. Chu
- Division of Surgery, Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston
| | - Mark W. Clemens
- Division of Surgery, Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston
| | - Jessica S. Colen
- Division of Surgery, Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Richard A. Ehlers
- Division of Surgery, Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Rosa F. Hwang
- Division of Surgery, Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Melissa M. Joyner
- Division of Radiation Oncology, Department of Breast Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Rene D. Largo
- Division of Surgery, Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston
| | - Alexander F. Mericli
- Division of Surgery, Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston
| | - Melissa P. Mitchell
- Division of Radiation Oncology, Department of Breast Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - John W. Shuck
- Division of Surgery, Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston
| | - Nina Tamirisa
- Division of Surgery, Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Debasish Tripathy
- Division of Cancer Medicine, Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Mark T. Villa
- Division of Surgery, Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston
| | - Wendy A. Woodward
- Division of Surgery, Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Rensi Zacharia
- Division of Radiation Oncology, Department of Breast Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Henry M. Kuerer
- Division of Surgery, Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Karen E. Hoffman
- Division of Radiation Oncology, Department of Breast Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston
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Kong X, Song J, Gao P, Gao R, Zhang L, Fang Y, Wang Y, Gao J, Wang J. Revolutionizing the battle against locally advanced breast cancer: A comprehensive insight into neoadjuvant radiotherapy. Med Res Rev 2024; 44:606-631. [PMID: 37947371 DOI: 10.1002/med.21998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Revised: 08/11/2023] [Accepted: 10/29/2023] [Indexed: 11/12/2023]
Abstract
Breast cancer (BC) constitutes one of the most pervasive malignancies affecting the female population. Despite progressive improvements in diagnostic and therapeutic technologies, leading to an increased detection of early stage BCs, locally advanced breast cancer (LABC) persists as a significant clinical challenge. Owing to its poor overall survival (OS) rate, elevated recurrence rate, and high potential for distant metastasis, LABC prominently impacts the comprehensive efficacy of BC treatments. Radiotherapy, encompassing preoperative, intraoperative, and postoperative modalities, is acknowledged as an effective strategy for mitigating BC metastasis and enhancing survival rates among patients. Nevertheless, the domain of preoperative neoadjuvant radiotherapy (NART) remains conspicuously underexplored in clinical studies. Available research suggests that NART can induce tumor volume reduction, provoke fibrotic changes in tumor and adjacent normal tissues, thereby mitigating intraoperative cancer propagation and enhancing the quality of life for LABC patients. This manuscript seeks to provide a review of contemporary research pertaining to LABC and its preoperative radiotherapy.
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Affiliation(s)
- Xiangyi Kong
- Department of Breast Surgical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Department of Breast Surgical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital & Shenzhen Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shenzhen, China
| | - Jiarui Song
- Department of Breast Surgical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital & Shenzhen Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shenzhen, China
| | - Peng Gao
- Department of Breast Surgical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Department of Breast Surgery, Clinical Research Center for Breast, West China Hospital, Sichuan University, Chengdu, China
| | - Ran Gao
- Department of Breast Surgical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lin Zhang
- Suzhou Industrial Park Monash Research Institute of Science and Technology, Suzhou, China
- The School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Yi Fang
- Department of Breast Surgical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yipeng Wang
- Department of Breast Surgical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jidong Gao
- Department of Breast Surgical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Department of Breast Surgical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital & Shenzhen Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shenzhen, China
| | - Jing Wang
- Department of Breast Surgical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Godden AR, Micha A, O'Connell RL, Mohammed K, Kirby AM, Thiruchelvam PTR, Leff DR, MacNeill FA, Rusby JE. Pre-operative Radiotherapy And Deep Inferior Epigastric Artery Perforator (DIEP) flAp study (PRADA): Aesthetic outcome and patient satisfaction at one year. J Plast Reconstr Aesthet Surg 2023; 78:19-28. [PMID: 36764040 DOI: 10.1016/j.bjps.2022.11.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 10/03/2022] [Accepted: 11/17/2022] [Indexed: 01/21/2023]
Abstract
INTRODUCTION The optimal combination of radiotherapy and breast reconstruction has not yet been defined. Post-mastectomy radiotherapy (PMRT) has deleterious effects on breast reconstruction, leading to caution amongst surgeons. Pre-operative radiotherapy (PRT) is a growing area of interest, is demonstrated to be safe, and spares autologous flaps from radiotherapy. This study evaluates the aesthetic outcome of PRT and deep inferior epigastric artery perforator (DIEP) flap reconstruction within the Pre-operative Radiotherapy And Deep Inferior Epigastric artery Perforator (DIEP) flAp (PRADA) cohort. METHODS PRADA was an observational cohort study designed to evaluate the feasibility and safety of PRT for women undergoing neoadjuvant chemotherapy and DIEP reconstruction. Panel evaluation of 3D surface images (3D-SIs) and patient-reported outcome measures (BREAST-Q) for a subset of women in the study were compared with those of a DIEP-PMRT cohort who had undergone DIEP reconstruction and PMRT. RESULTS Seventeen out of 33 women from the PRADA study participated in this planned substudy. Twenty-eight women formed the DIEP-PMRT cohort (median follow-up 23 months). The median (inter-quartile range [IQR]) 'satisfaction with breasts' score at 12 months for the PRADA cohort was significantly better than the DIEP-PMRT cohort (77 [72-87] versus 64 [54-71], respectively), p=0.01). Median [IQR] panel evaluation (5-point scale) was also significantly better for the PRADA cohort than for the DIEP-PMRT cohort (4.3 [3.9-4.6] versus 3.6 [2.8-4] p=0.003). CONCLUSIONS Aesthetic outcome for the PRADA cohort was reported to be 'good' or 'excellent' in 93% of cases using a bespoke panel assessment with robust methodology. Patient satisfaction at one year is encouraging and superior to DIEP-PMRT at 23 months. Switching surgery-radiotherapy sequencing leads to similar breast aesthetic outcomes and warrants further large-scale, multi-centre evaluation in a randomised trial.
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Affiliation(s)
- Amy R Godden
- The Royal Marsden NHS Foundation Trust, United Kingdom; Institute of Cancer Research, United Kingdom
| | | | - Rachel L O'Connell
- The Royal Marsden NHS Foundation Trust, United Kingdom; Institute of Cancer Research, United Kingdom
| | | | - Anna M Kirby
- The Royal Marsden NHS Foundation Trust, United Kingdom; Institute of Cancer Research, United Kingdom
| | | | - Daniel R Leff
- Imperial College Healthcare NHS Trust, London, United Kingdom
| | | | - Jennifer E Rusby
- The Royal Marsden NHS Foundation Trust, United Kingdom; Institute of Cancer Research, United Kingdom.
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Pathologic Complete Response and Oncologic Outcomes in Locally Advanced Breast Cancers Treated With Neoadjuvant Radiation Therapy: An Australian Perspective. Pract Radiat Oncol 2023:S1879-8500(22)00389-7. [PMID: 36599393 DOI: 10.1016/j.prro.2022.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 11/24/2022] [Accepted: 12/05/2022] [Indexed: 01/02/2023]
Abstract
PURPOSE To assess the degree of pathologic complete response (pCR), postoperative surgical complication rates, and oncological outcomes in women with locally advanced breast cancer or high-risk breast cancers treated with neoadjuvant radiation therapy (NART). METHODS AND MATERIALS This retrospective, multi-institutional review involved 138 clinically staged patients with 140 breast cancers treated with NART between January 2014 and February 2021. Treatments involved sequential neoadjuvant chemotherapy and NART, followed by mastectomy with or without axillary surgery and immediate autologous breast reconstruction. Descriptive statistics were used to assess patient and disease features, treatment regimens, pathologic response, and factors affecting postoperative complications. Kaplan-Meier curves were performed to assess locoregional recurrence-free, distant metastasis-free, and overall survival outcomes. RESULTS Median age was 47 years (interquartile range, 42-52). The median follow-up was 35.2 months (interquartile range, 17.1-46.5). pCR was achieved in 36.4% (as defined by Chevallier classification) or 42.1% (as defined by Miller-Payne scores) of patients. Greater pCR rates were achieved for HER2+ (73.8%-85.7%) and triple-negative phenotypes (47.6%-57.1%). There were 21 grade 3 surgical complications including 10 grade 3B breast events and 8 grade 3B donor-site events, where surgical reintervention was required. At 3-years' follow-up, the locoregional recurrence-free survival was 98.1%, distant metastasis-free survival was 83.6%, and overall survival was 95.3%%. CONCLUSIONS NART is feasible to facilitate a single-stage mastectomy and immediate autologous breast reconstruction. This study demonstrated comparable rates of postoperative complication to standard of care, and high rates of pCR, which translates to high rates of locoregional control, distant metastasis-free survival, and overall survival.
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Preoperative Radio(Chemo)Therapy in Breast Cancer: Time to Switch the Perspective? Curr Oncol 2022; 29:9767-9787. [PMID: 36547182 PMCID: PMC9777182 DOI: 10.3390/curroncol29120768] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 12/02/2022] [Accepted: 12/05/2022] [Indexed: 12/14/2022] Open
Abstract
AIM Radiation therapy represents, together with surgery and systemic treatment, the triad on which the current management of patients with breast cancer is based, achieving high control and survival rates. In recent years we have witnessed a (r)evolution in the conception of breast cancer treatment. The classic scheme of surgery followed by systemic treatment and radiotherapy is being subverted and it is becoming more and more frequent to propose the primary administration of systemic treatment before surgery, seeking to maximize its effect and favoring not only the performance of more conservative surgeries but also, in selected cases, increasing the rates of disease-free survival and overall survival. Radiotherapy is also evolving toward a change in perspective: considering preoperative primary administration of radiotherapy may be useful in selected groups. Advances in radiobiological knowledge, together with technological improvements that are constantly being incorporated into clinical practice, support the administration of increasingly reliable, precise, and effective radiotherapy, as well as its safe combination with antitumor drugs or immunotherapy in the primary preoperative context. In this paper, we present a narrative review of the usefulness of preoperative radiotherapy for breast cancer patients and the possibilities for its combination with other therapies.
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Clement Z, Egbeare D, Kollias J, Gill G, Whitfield R, Bingham J, Bochner M. Safety and efficacy of immediate autologous breast reconstruction after mastectomy in patients undergoing neoadjuvant chemoradiotherapy for locally advanced breast cancer. Breast Dis 2022; 41:267-272. [PMID: 35599461 DOI: 10.3233/bd-210062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE Immediate autologous breast reconstruction (IABR) offers fewer surgeries with better psychosocial, quality of life and aesthetic outcomes. In high-risk patients or those with locally advanced breast cancer (LABC), adjuvant postmastectomy radiotherapy decreases local recurrence and improves survival. However, it has negative effects on the reconstructed flap. Reversing the treatment protocol using neoadjuvant radiotherapy may minimise the negative effects on the reconstructed breast in women requesting IABR. We assessed the safety and efficacy of women who underwent mastectomy and IABR post-neoadjuvant chemoradiotherapy (NACRT) for LABC. METHODOLOGY A cohort study using a retrospective and prospective analysis was performed on women with LABC who underwent mastectomy and IABR post-NACRT between 1998 and 2018. All reconstructions were performed by oncoplastic breast surgeons from a single unit. Outcome measures analysed included surgical complications, flap failure, loco-regional recurrence, overall and disease-free survival. This study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). This study was approved by the institutional review board. RESULTS A total of 28 women with a median age of 50 (33-64) were included. 25% underwent TRAM flap and 75% underwent LD flap reconstruction. The median period of follow-up was 61 months. Post-NACRT, 35.7% achieved complete pathological response (PCR). 3/28 (10.7%) had early complications (2 implant and 1 donor site infection). 7% underwent revision surgery. There was no flap loss. 1/28 (3.5%) had loco-regional recurrence, 3.2% had distant metastasis, and 2.5% had breast cancer related mortality. CONCLUSION In women with LABC, NACRT followed by mastectomy and IABR is safe and may not compromise oncological and cosmetic outcomes. If offers the benefits of immediate breast reconstruction and avoids delaying adjuvant therapy.
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Affiliation(s)
- Zackariah Clement
- Department of Breast and Endocrine Surgery, Royal Adelaide Hospital, South Australia, Australia.,Department of Breast and Endocrine Surgery, The Tweed Hospital, New South Wales, Australia
| | - Donna Egbeare
- Department of Breast and Endocrine Surgery, Royal Adelaide Hospital, South Australia, Australia
| | - Jim Kollias
- Department of Breast and Endocrine Surgery, Royal Adelaide Hospital, South Australia, Australia
| | - Grantley Gill
- Department of Breast and Endocrine Surgery, Royal Adelaide Hospital, South Australia, Australia
| | - Robert Whitfield
- Department of Breast and Endocrine Surgery, Royal Adelaide Hospital, South Australia, Australia
| | - Janne Bingham
- Department of Breast and Endocrine Surgery, Royal Adelaide Hospital, South Australia, Australia
| | - Melissa Bochner
- Department of Breast and Endocrine Surgery, Royal Adelaide Hospital, South Australia, Australia
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Thiruchelvam PTR, Leff DR, Godden AR, Cleator S, Wood SH, Kirby AM, Jallali N, Somaiah N, Hunter JE, Henry FP, Micha A, O'Connell RL, Mohammed K, Patani N, Tan MLH, Gujral D, Ross G, James SE, Khan AA, Rusby JE, Hadjiminas DJ, MacNeill FA. Primary radiotherapy and deep inferior epigastric perforator flap reconstruction for patients with breast cancer (PRADA): a multicentre, prospective, non-randomised, feasibility study. Lancet Oncol 2022; 23:682-690. [PMID: 35397804 PMCID: PMC9630150 DOI: 10.1016/s1470-2045(22)00145-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Revised: 02/01/2022] [Accepted: 02/28/2022] [Indexed: 12/20/2022]
Abstract
BACKGROUND Radiotherapy before mastectomy and autologous free-flap breast reconstruction can avoid adverse radiation effects on healthy donor tissues and delays to adjuvant radiotherapy. However, evidence for this treatment sequence is sparse. We aimed to explore the feasibility of preoperative radiotherapy followed by skin-sparing mastectomy and deep inferior epigastric perforator (DIEP) flap reconstruction in patients with breast cancer requiring mastectomy. METHODS We conducted a prospective, non-randomised, feasibility study at two National Health Service trusts in the UK. Eligible patients were women aged older than 18 years with a laboratory diagnosis of primary breast cancer requiring mastectomy and post-mastectomy radiotherapy, who were suitable for DIEP flap reconstruction. Preoperative radiotherapy started 3-4 weeks after neoadjuvant chemotherapy and was delivered to the breast, plus regional nodes as required, at 40 Gy in 15 fractions (over 3 weeks) or 42·72 Gy in 16 fractions (over 3·2 weeks). Adverse skin radiation toxicity was assessed preoperatively using the Radiation Therapy Oncology Group toxicity grading system. Skin-sparing mastectomy and DIEP flap reconstruction were planned for 2-6 weeks after completion of preoperative radiotherapy. The primary endpoint was the proportion of open breast wounds greater than 1 cm width requiring a dressing at 4 weeks after surgery, assessed in all participants. This study is registered with ClinicalTrials.gov, NCT02771938, and is closed to recruitment. FINDINGS Between Jan 25, 2016, and Dec 11, 2017, 33 patients were enrolled. At 4 weeks after surgery, four (12·1%, 95% CI 3·4-28·2) of 33 patients had an open breast wound greater than 1 cm. One (3%) patient had confluent moist desquamation (grade 3). There were no serious treatment-related adverse events and no treatment-related deaths. INTERPRETATION Preoperative radiotherapy followed by skin-sparing mastectomy and immediate DIEP flap reconstruction is feasible and technically safe, with rates of breast open wounds similar to those reported with post-mastectomy radiotherapy. A randomised trial comparing preoperative radiotherapy with post-mastectomy radiotherapy is required to precisely determine and compare surgical, oncological, and breast reconstruction outcomes, including quality of life. FUNDING Cancer Research UK, National Institute for Health Research.
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Affiliation(s)
| | - Daniel R Leff
- Department of Breast Surgery, Imperial College Healthcare NHS Trust, London, UK; BioSurgery and Surgical Technology, Department of Surgery, Imperial College London, London, UK
| | - Amy R Godden
- Department of Breast Surgery, Royal Marsden NHS Foundation Trust, London, UK
| | - Susan Cleator
- Department of Clinical Oncology, Imperial College Healthcare NHS Trust, London, UK
| | - Simon H Wood
- Department of Plastic and Reconstructive Surgery, Imperial College Healthcare NHS Trust, London, UK
| | | | - Navid Jallali
- Department of Plastic and Reconstructive Surgery, Imperial College Healthcare NHS Trust, London, UK
| | | | - Judith E Hunter
- Department of Plastic and Reconstructive Surgery, Imperial College Healthcare NHS Trust, London, UK
| | - Francis P Henry
- Department of Plastic and Reconstructive Surgery, Imperial College Healthcare NHS Trust, London, UK
| | - Aikaterini Micha
- Department of Breast Surgery, Royal Marsden NHS Foundation Trust, London, UK
| | - Rachel L O'Connell
- Department of Breast Surgery, Royal Marsden NHS Foundation Trust, London, UK
| | | | - Neill Patani
- Department of Breast Surgery, University College London Hospitals NHS Trust, London, UK
| | - Melissa L H Tan
- Department of Breast Surgery, Birmingham City Hospital, Birmingham, UK
| | - Dorothy Gujral
- Department of Clinical Oncology, Imperial College Healthcare NHS Trust, London, UK
| | | | - Stuart E James
- Department of Plastic and Reconstructive Surgery, Royal Marsden NHS Foundation Trust, London, UK
| | - Aadil A Khan
- Department of Plastic and Reconstructive Surgery, Royal Marsden NHS Foundation Trust, London, UK
| | - Jennifer E Rusby
- Department of Breast Surgery, Royal Marsden NHS Foundation Trust, London, UK; The Institute of Cancer Research, London, UK
| | | | - Fiona A MacNeill
- Department of Breast Surgery, Royal Marsden NHS Foundation Trust, London, UK
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Maire M, Debled M, Petit A, Fournier M, Macgrogan G, Quenel-Thueux N, Charitansky H, Mathoulin-Pelissier S, Bonnefoi H, Tunon de Lara C. Neoadjuvant chemotherapy and radiotherapy for locally advanced breast cancer: Safety and efficacy of reverse sequence compared to standard technique? Eur J Surg Oncol 2022; 48:1699-1705. [PMID: 35523623 DOI: 10.1016/j.ejso.2022.04.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 03/23/2022] [Accepted: 04/25/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The reverse sequence of neoadjuvant chemotherapy, preoperative radiotherapy, mastectomy then immediate breast reconstruction is currently proposed for selected patients with locally advanced breast cancer. Few studies have compared it to the standard sequence of neoadjuvant chemotherapy, mastectomy and radiotherapy with or without differed reconstruction. Our study compares overall (OS) and recurrence-free (RFS) survivals of breast cancer patients treated with reverse sequence compared to the standard technique. METHODS In this retrospective, single center study at a Comprehensive Cancer Center in France, patients were included if: female, age <65y, had received neoadjuvant chemotherapy, mastectomy and radiotherapy, and were M0. Outcomes for patients treated by reverse sequence (RS) are compared to those for patients treated by standard sequence (ST). Data was collected from medical records. RESULTS From January 2009 to April 2018, 222 eligible patients were treated, 46 by RS and 176 by ST. Mean follow-up was 61.7 months. Five-year OS and RFS did not differ between groups. 5-yr OS: 88.4% 95%CI [74.1-95.0] for RS and 81.5% 95%CI [74.0-87.0] for ST (P = 0.4412); 5-yr RFS: 78.3% 95%CI [61.9-88.3] for RS and 70.1% 95%CI [62.2-76.7] for ST (P = 0.3003). Overall treatment time was significantly shorter in the RS group, and the rate of severe surgical complications did not differ between groups. CONCLUSIONS For locally advanced breast cancer patients with an indication for radiation therapy the reverse sequence offers similar safety and efficacy results as the standard treatment while allowing immediate breast reconstruction. However, careful patient selection is necessary, particularly with regard to preoperative lymph node invasion.
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Affiliation(s)
- Mathilde Maire
- Univ. Bordeaux, 146 Rue Léo Saignat, 33000, Bordeaux, France; Department of Surgery Institut Bergonié, 229 Cours de L'Argonne, 33076, Bordeaux, France
| | - Marc Debled
- Department of Oncology, Institut Bergonié, 229 Cours de L'Argonne, 33076, Bordeaux, France
| | - Adeline Petit
- Department of Radiotherapy, Institut Bergonié, 229 Cours de L'Argonne, 33076, Bordeaux, France
| | - Marion Fournier
- Department of Surgery Institut Bergonié, 229 Cours de L'Argonne, 33076, Bordeaux, France
| | - Gaëtan Macgrogan
- Department of Pathology, Institut Bergonié, 229 Cours de L'Argonne, 33076, Bordeaux, France
| | - Nathalie Quenel-Thueux
- Department of Oncology, Institut Bergonié, 229 Cours de L'Argonne, 33076, Bordeaux, France
| | - Hélène Charitansky
- Department of Surgery Institut Bergonié, 229 Cours de L'Argonne, 33076, Bordeaux, France
| | - Simone Mathoulin-Pelissier
- Univ. Bordeaux, 146 Rue Léo Saignat, 33000, Bordeaux, France; Department of Biostatistics, Institut Bergonié, 229 Cours de L'Argonne, 33076, Bordeaux, France
| | - Hervé Bonnefoi
- Univ. Bordeaux, 146 Rue Léo Saignat, 33000, Bordeaux, France; Department of Oncology, Institut Bergonié, 229 Cours de L'Argonne, 33076, Bordeaux, France
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Metz G, Snook K, Sood S, Baron-Hay S, Spillane A, Lamoury G, Carroll S. Breast Radiotherapy after Oncoplastic Surgery—A Multidisciplinary Approach. Cancers (Basel) 2022; 14:cancers14071685. [PMID: 35406457 PMCID: PMC8996843 DOI: 10.3390/cancers14071685] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 03/02/2022] [Accepted: 03/21/2022] [Indexed: 11/16/2022] Open
Abstract
Simple Summary This article aims to review and summarize the current evidence for the role of oncoplastic breast surgery and the implications this may have on other therapies, such as radiotherapy and chemotherapy. Abstract Oncoplastic breast surgery encompasses a range of techniques used to provide equitable oncological outcomes compared with standard breast surgery while, simultaneously, prioritizing aesthetic outcomes. While the outcomes of oncoplastic breast surgery are promising, it can add an extra complexity to the treatment paradigm of breast cancer and impact on decision-making surrounding adjuvant therapies, like chemotherapy and radiotherapy. As such, early discussions at the multidisciplinary team meeting with surgeons, medical oncologists, and radiation oncologists present, should be encouraged to facilitate best patient care.
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Affiliation(s)
- Gabrielle Metz
- Northern Sydney Cancer Centre, Royal North Shore Hospital, Sydney, NSW 2065, Australia; (S.S.); (S.B.-H.); (G.L.); (S.C.)
- Correspondence:
| | - Kylie Snook
- Sydney Medical School, University of Sydney, Sydney, NSW 2006, Australia; (K.S.); (A.S.)
- Breast and Surgical Oncology, The Poche Centre, Sydney, NSW 2060, Australia
- The Mater Hospital, Sydney, NSW 2060, Australia
| | - Samriti Sood
- Northern Sydney Cancer Centre, Royal North Shore Hospital, Sydney, NSW 2065, Australia; (S.S.); (S.B.-H.); (G.L.); (S.C.)
- Sydney Medical School, University of Sydney, Sydney, NSW 2006, Australia; (K.S.); (A.S.)
- Breast and Surgical Oncology, The Poche Centre, Sydney, NSW 2060, Australia
- The Mater Hospital, Sydney, NSW 2060, Australia
- Breast and Melanoma Surgery Unit, Royal North Shore Hospital, Sydney, NSW 2065, Australia
| | - Sally Baron-Hay
- Northern Sydney Cancer Centre, Royal North Shore Hospital, Sydney, NSW 2065, Australia; (S.S.); (S.B.-H.); (G.L.); (S.C.)
| | - Andrew Spillane
- Sydney Medical School, University of Sydney, Sydney, NSW 2006, Australia; (K.S.); (A.S.)
- Breast and Surgical Oncology, The Poche Centre, Sydney, NSW 2060, Australia
- The Mater Hospital, Sydney, NSW 2060, Australia
- Breast and Melanoma Surgery Unit, Royal North Shore Hospital, Sydney, NSW 2065, Australia
| | - Gillian Lamoury
- Northern Sydney Cancer Centre, Royal North Shore Hospital, Sydney, NSW 2065, Australia; (S.S.); (S.B.-H.); (G.L.); (S.C.)
- Sydney Medical School, University of Sydney, Sydney, NSW 2006, Australia; (K.S.); (A.S.)
- The Mater Hospital, Sydney, NSW 2060, Australia
| | - Susan Carroll
- Northern Sydney Cancer Centre, Royal North Shore Hospital, Sydney, NSW 2065, Australia; (S.S.); (S.B.-H.); (G.L.); (S.C.)
- Sydney Medical School, University of Sydney, Sydney, NSW 2006, Australia; (K.S.); (A.S.)
- The Mater Hospital, Sydney, NSW 2060, Australia
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Ahmed M, Jozsa F, Douek M. A systematic review of neo-adjuvant radiotherapy in the treatment of breast cancer. Ecancermedicalscience 2021; 15:1175. [PMID: 33680089 PMCID: PMC7929768 DOI: 10.3332/ecancer.2021.1175] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Indexed: 11/14/2022] Open
Abstract
Introduction The use of neo-adjuvant radiotherapy (NRT) has been proven effective at improving cancer related outcome measures, including overall-survival (OS) in the management of solid cancers. However, its utilisation in breast cancer has not been explored to the extent of neo-adjuvant chemotherapy (NAC). The evidence for the application of NRT in breast cancer is evaluated. Methods PubMed, Embase and the Cochrane Library databases were searched systematically in August 2020 for studies that addressed the role of NRT in the treatment of breast cancer. Studies were deemed eligible if they reported on objective outcome measurements of OS, disease free-survival (DFS) or pathological complete response (pCR) and attained a satisfactory quality assessment. Findings A total of 23 studies reported upon 3,766 patients who had received NRT of which 3,233 also received NAC concurrently (neo-adjuvant chemo-radiotherapy (NCRT)). The pCR values ranged from 14% to 42%, 5-year DFS 61.4% to 81% and 5-year OS 71.6% to 84.2%. Complications were confined to radiation dermatitis with no cases of implant loss reported during breast reconstruction. The application of NRCT alone showed no significant difference in OS or DFS compared to NCRT followed by surgery. Interpretation Numbers of patients receiving exclusively NRT is small. However, NCRT is oncologically safe with a low side-effect profile including preceding breast reconstruction. Potential benefits include precise cancer volume targeting, chemosensitisation, elimination of delays in adjuvant therapies and alternatives to chemotherapy in oestrogen receptor positive patients. These factors warrant further exploration within randomised controlled-trials.
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Affiliation(s)
- Muneer Ahmed
- Division of Surgery and interventional Science, University College London, Royal Free Hospital, 9th Floor (East), 2QG, 10 Pond St, London NW3 2PS, UK
| | - Felix Jozsa
- Division of Surgery and interventional Science, University College London, Royal Free Hospital, 9th Floor (East), 2QG, 10 Pond St, London NW3 2PS, UK
| | - Michael Douek
- Nuffield Department of Surgical Sciences, University of Oxford, Botnar Research Centre, Windmill Road, Oxford OX3 7LD, UK
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Breast Reconstruction in Obese Patients: The Fat Grafted Latissimus versus Abdominal Free Tissue Transfer. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e2668. [PMID: 32537332 PMCID: PMC7253236 DOI: 10.1097/gox.0000000000002668] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 11/22/2019] [Indexed: 11/26/2022]
Abstract
Immediate fat grafting to the pedicled myocutaneous latissimus dorsi (LD) flap has recently gained in popularity as a means to supplement volume for breast reconstruction. The aim of this study is to compare complication rates of the immediately fat-grafted LD to free tissue transfer in the obese population.
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Houvenaeghel G, Cohen M, Ribeiro SR, Barrou J, Heinemann M, Frayret C, Lambaudie E, Bannier M. Robotic Nipple-Sparing Mastectomy and Immediate Breast Reconstruction With Robotic Latissimus Dorsi Flap Harvest: Technique and Results. Surg Innov 2020; 27:481-491. [PMID: 32418492 DOI: 10.1177/1553350620917916] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction. Only few cases of robotic latissimus dorsi flap reconstruction (RLDFR) have been reported in indication of reconstruction for breast cancer (BC). We report our experience of combined robotic nipple-sparing mastectomy (R-NSM) and RLDFR, and analyze technique, indications, and reproducibility. Methods. All patients with R-NSM and RLDFR from November 2016 to August 2, 2018, were analyzed, and technics have been described. Complication rate with Clavien-Dindo grading and postoperative hospitalization length (days) are reported. Results. Thirty-five R-NSM with RLDFR were performed in 22 cases for primitive BC and 13 for local recurrence. In 12 patients, another surgical procedure was performed during the same time (axillary lymph node dissection or contralateral breast surgery). R-NSM was realized through a short axillar incision, with inside-only installation for 12 patients (34.3%): 18 nonautologous and 17 autologous RLDFR associated with implant in 9 patients. In logistic regression, mastectomy weight >330 g was significantly associated with the use of implant (odds ratio [OR] = 17, P = .015), and significant factor of the time of anesthesia ≥380 minutes was 2 installations (OR = 10.4, P = .049). The median duration of hospitalization stay was 4 days. Complications rates were 51.4% (18/35; 9 grade-1, 2 grade-2, and 7 grade-3). In logistic regression, associated other surgical procedure was predictive of grade-3 complications (OR = 6.87, P = .053). Conclusion. We confirmed the reproducibility and safety of R-NSM and RLDFR with a decreased complication rate. NSM was performed in 42.8% of our patients after previous radiotherapy. We observed an increase of grade-3 complications when R-NSM and RLDFR was combined to another surgical procedure.
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Affiliation(s)
- Gilles Houvenaeghel
- Paoli Calmettes Institute and CRCM, CNRS, INSERM, Aix Marseille Université, Marseille, Provence-Alpes-Côte d'Azu, France
| | - Monique Cohen
- Paoli Calmettes Institute and CRCM, CNRS, INSERM, Aix Marseille Université, Marseille, Provence-Alpes-Côte d'Azu, France
| | - Sandrine Rua Ribeiro
- Paoli Calmettes Institute and CRCM, CNRS, INSERM, Aix Marseille Université, Marseille, Provence-Alpes-Côte d'Azu, France
| | - Julien Barrou
- Paoli Calmettes Institute and CRCM, CNRS, INSERM, Aix Marseille Université, Marseille, Provence-Alpes-Côte d'Azu, France
| | - Mellie Heinemann
- Paoli Calmettes Institute and CRCM, CNRS, INSERM, Aix Marseille Université, Marseille, Provence-Alpes-Côte d'Azu, France
| | - Christine Frayret
- Paoli Calmettes Institute and CRCM, CNRS, INSERM, Aix Marseille Université, Marseille, Provence-Alpes-Côte d'Azu, France
| | - Eric Lambaudie
- Paoli Calmettes Institute and CRCM, CNRS, INSERM, Aix Marseille Université, Marseille, Provence-Alpes-Côte d'Azu, France
| | - Marie Bannier
- Paoli Calmettes Institute and CRCM, CNRS, INSERM, Aix Marseille Université, Marseille, Provence-Alpes-Côte d'Azu, France
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Khajuria A, Charles WN, Prokopenko M, Beswick A, Pusic AL, Mosahebi A, Dodwell DJ, Winters ZE. Immediate and delayed autologous abdominal microvascular flap breast reconstruction in patients receiving adjuvant, neoadjuvant or no radiotherapy: a meta-analysis of clinical and quality-of-life outcomes. BJS Open 2020; 4:182-196. [PMID: 32207573 PMCID: PMC7093792 DOI: 10.1002/bjs5.50245] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2019] [Accepted: 11/11/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Effects of postmastectomy radiotherapy (PMRT) on autologous breast reconstruction (BRR) are controversial regarding surgical complications, cosmetic appearance and quality of life (QOL). This systematic review evaluated these outcomes after abdominal free flap reconstruction in patients undergoing postoperative adjuvant radiotherapy (PMRT), preoperative radiotherapy (neoadjuvant radiotherapy) and no radiotherapy, aiming to establish evidence-based optimal timings for radiotherapy and BRR to guide contemporary management. METHODS The study was registered on PROSPERO (CRD42017077945). Embase, MEDLINE, Google Scholar, CENTRAL, Science Citation Index and ClinicalTrials.gov were searched (January 2000 to August 2018). Study quality and risk of bias were assessed using GRADE and Cochrane's ROBINS-I respectively. RESULTS Some 12 studies were identified, involving 1756 patients (350 PMRT, 683 no radiotherapy and 723 neoadjuvant radiotherapy), with a mean follow-up of 27·1 (range 12·0-54·0) months for those having PMRT, 16·8 (1·0-50·3) months for neoadjuvant radiotherapy, and 18·3 (1·0-48·7) months for no radiotherapy. Three prospective and nine retrospective cohorts were included. There were no randomized studies. Five comparative radiotherapy studies evaluated PMRT and four assessed neoadjuvant radiotherapy. Studies were of low quality, with moderate to serious risk of bias. Severe complications were similar between the groups: PMRT versus no radiotherapy (92 versus 141 patients respectively; odds ratio (OR) 2·35, 95 per cent c.i. 0·63 to 8·81, P = 0·200); neoadjuvant radiotherapy versus no radiotherapy (180 versus 392 patients; OR 1·24, 0·76 to 2·04, P = 0·390); and combined PMRT plus neoadjuvant radiotherapy versus no radiotherapy (272 versus 453 patients; OR 1·38, 0·83 to 2·32, P = 0·220). QOL and cosmetic studies used inconsistent methodologies. CONCLUSION Evidence is conflicting and study quality was poor, limiting recommendations for the timing of autologous BRR and radiotherapy. The impact of PMRT and neoadjuvant radiotherapy appeared to be similar.
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Affiliation(s)
- A. Khajuria
- Kellogg College, Nuffield Department of SurgeryUniversity of OxfordOxfordUK
- Department of Surgery and CancerImperial College LondonLondonUK
| | - W. N. Charles
- Department of Surgery and CancerImperial College LondonLondonUK
| | - M. Prokopenko
- Department of Plastic SurgeryRoyal Free HospitalLondonUK
| | - A. Beswick
- School of Clinical SciencesUniversity of BristolBristolUK
| | - A. L. Pusic
- Patient‐Reported Outcomes, Value and Experience Centre, Brigham and Women's HospitalHarvard Medical SchoolBostonMassachusettsUSA
| | - A. Mosahebi
- Department of Plastic SurgeryRoyal Free HospitalLondonUK
| | - D. J. Dodwell
- Nuffield Department of Population HealthUniversity of OxfordOxfordUK
| | - Z. E. Winters
- Surgical Intervention Trials Unit, Division of Surgery and Interventional ScienceUniversity College LondonLondonUK
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Yoon WS, Rim CH, Yang DS, Lee JA, Son GS, Chang YW, Woo SU, Kim DW, Dhong ES. Long-term outcomes of immediate autologous breast reconstruction after definite adjuvant therapy in intermediate and locally advanced breast cancer. ANNALS OF TRANSLATIONAL MEDICINE 2020; 7:743. [PMID: 32042759 DOI: 10.21037/atm.2019.11.129] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Background To analyze oncologic outcomes and reconstruction quality in locally advanced stage breast cancer after performing immediate autologous breast reconstruction (IABR). Methods From 2007 to 2014, data of patients aged ≤70 years old with stage II-III breast cancer who received total mastectomy (TM) were extracted from medical records. Exclusion criteria were: previous contralateral breast cancer, follow-up loss before adjuvant therapy completion, and artificial reconstruction. Patients were divided into two groups: (I) TM alone, and (II) TM + IABR. Overall survival (OS) and loco-regional recurrence free survival (LRRFS) were calculated. Times of minor revision, abnormal image findings in breast, and change of breast height were observed. Results Sixty-one of 188 patients received IABR after TM. Stage IIIB-C was the most important prognostic factor for OS (P<0.001) and LRRFS (P<0.001). For stage II, five-year TM and TM + IABR OS rates were 96.8% and 100% (P=0.324), respectively. For stage IIIB-C, five-year TM and TM + IABR OS rates were 57.6% and 62.5% (P=0.544), respectively. For stage II, five-year TM and TM + IABR LRRFS were 98.1% and 95.7% (P=0.998), respectively. For stage IIIB-C, five-year TM and TM + IABR LRRFS were 70.8% and 62.5% (P=0.378), respectively. Two major complications were observed after IABR. Minor revisions, abnormal image findings, and change of breast height were common without showing significant relation with adjuvant radiotherapy or tumor stage. Conclusions IABR showed feasible oncologic outcomes in 5-year follow-up. Adjuvant radiotherapy had little effect on quality of reconstruction. However, IABR in advanced stage should be cautiously applied considering expected survival and minor problems after IABR.
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Affiliation(s)
- Won Sup Yoon
- Department of Radiation Oncology, Ansan Hospital, Korea University Medical Center, Ansan, Republic of Korea
| | - Chai Hong Rim
- Department of Radiation Oncology, Ansan Hospital, Korea University Medical Center, Ansan, Republic of Korea
| | - Dae Sik Yang
- Department of Radiation Oncology, Guro Hospital, Korea University Medical Center, Seoul, Republic of Korea
| | - Jung Ae Lee
- Department of Radiation Oncology, Guro Hospital, Korea University Medical Center, Seoul, Republic of Korea
| | - Gil Soo Son
- Department of Surgery, Ansan Hospital, Korea University Medical Center, Ansan, Republic of Korea
| | - Young Woo Chang
- Department of Surgery, Ansan Hospital, Korea University Medical Center, Ansan, Republic of Korea
| | - Sang Uk Woo
- Department of Surgery, Guro Hospital, Korea University Medical Center, Seoul, Republic of Korea
| | - Deok-Woo Kim
- Department of Plastic Surgery, Ansan Hospital, Korea University Medical Center, Ansan, Republic of Korea
| | - Eun-Sang Dhong
- Department of Plastic Surgery, Guro Hospital, Korea University Medical Center, Ansan, Republic of Korea
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Houvenaeghel G, Bannier M, Rua S, Barrou J, Heinemann M, Knight S, Lambaudie E, Cohen M. Robotic breast and reconstructive surgery: 100 procedures in 2-years for 80 patients. Surg Oncol 2019; 31:38-45. [DOI: 10.1016/j.suronc.2019.09.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 08/05/2019] [Accepted: 09/09/2019] [Indexed: 11/24/2022]
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Singh P, Kuerer HM. Preoperative Radiotherapy Trials to Facilitate Immediate Breast Reconstruction after Mastectomy. CURRENT BREAST CANCER REPORTS 2019. [DOI: 10.1007/s12609-019-00328-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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18
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Houvenaeghel G, Bannier M, Rua S, Barrou J, Heinemann M, Lambaudie E, Cohen M. Skin sparing mastectomy and robotic latissimus dorsi-flap reconstruction through a single incision. World J Surg Oncol 2019; 17:176. [PMID: 31677640 PMCID: PMC6825710 DOI: 10.1186/s12957-019-1711-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Accepted: 09/12/2019] [Indexed: 11/21/2022] Open
Abstract
Background Robotic latissimus dorsi-flap reconstruction (RLDFR) after skin-sparing mastectomy (SSM) for breast cancer (BC) has been performed through a single nipple incision. We report results of SSM with RLDFR, mainly with analysis of feasibility, morbidity, indications, and technique standardization. Methods We determined characteristics of patients, previous treatment of BC, and type of reconstruction. Surgical technique, duration of surgery, and complication rate were reported according to three successive periods: P1–3. Results Forty RLDFR, with breast implant for 16 patients, with previous breast radiotherapy in 30% had been performed. In logistic regression, factors significantly associated with duration of surgery ≥ 300 min were P2 (OR 0.024, p = 0.004) and P3 (OR 0.012, p = 0.004) versus P1. The median mastectomy weight was 330 g and 460 g for BMI < and ≥ 23.5 (p = 0.025). Length of hospitalization was 4 days. Total complication rate was 20% (8/40): seven breast complications (four re-operations) and one RLDF complication with re-operation. Periods were significantly predictive of complications (p = 0.045). Conclusion SSM with RLDFR is feasible, safe, and reproducible. We reported a decrease of duration of surgery, length of post-operative hospitalization, and complication rate.
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Affiliation(s)
- Gilles Houvenaeghel
- Department of Surgical Oncology, Paoli Calmettes Institute and CRCM, CNRS, INSERM, Aix Marseille Université, 232 Bd de Sainte Marguerite, 13009, Marseille, France.
| | - Marie Bannier
- Department of Surgical Oncology, Paoli Calmettes Institute, Marseille, France
| | - Sandrine Rua
- Department of Surgical Oncology, Paoli Calmettes Institute, Marseille, France
| | - Julien Barrou
- Department of Surgical Oncology, Paoli Calmettes Institute, Marseille, France
| | - Mellie Heinemann
- Department of Surgical Oncology, Paoli Calmettes Institute and CRCM, CNRS, INSERM, Aix Marseille Université, 232 Bd de Sainte Marguerite, 13009, Marseille, France
| | - Eric Lambaudie
- Department of Surgical Oncology, Paoli Calmettes Institute and CRCM, CNRS, INSERM, Aix Marseille Université, 232 Bd de Sainte Marguerite, 13009, Marseille, France
| | - Monique Cohen
- Department of Surgical Oncology, Paoli Calmettes Institute, Marseille, France
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Long-Term Follow-up of Immediate Latissimus Dorsi Flap Reconstruction After Neoadjuvant Chemotherapy and Radiotherapy for Invasive Breast Cancer. Clin Breast Cancer 2019; 19:e540-e546. [DOI: 10.1016/j.clbc.2019.03.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Revised: 03/27/2019] [Accepted: 03/31/2019] [Indexed: 11/21/2022]
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Singh P, Hoffman K, Schaverien MV, Krause KJ, Butler C, Smith BD, Kuerer HM. Neoadjuvant Radiotherapy to Facilitate Immediate Breast Reconstruction: A Systematic Review and Current Clinical Trials. Ann Surg Oncol 2019; 26:3312-3320. [PMID: 31342362 DOI: 10.1245/s10434-019-07538-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Indexed: 01/04/2023]
Abstract
BACKGROUND Postmastectomy radiotherapy currently is used for locally advanced breast cancers that carry a high risk of locoregional failure. However, radiotherapy can have deleterious effects on immediate breast reconstruction (IBR). Neoadjuvant radiotherapy (NART) to facilitate postmastectomy IBR is an emerging new therapeutic sequence. A systematic review was undertaken to evaluate the current evidence on the feasibility and safety of this sequence. METHODS A comprehensive search of MEDLINE, EMBASE, Cochrane Library, Web of Science, and ClinicalTrials.gov from inception to 2018 was conducted, resulting in 592 records. The review included 18 retrospective and prospective studies of NART and IBR. RESULTS The majority of the studies used whole-breast radiotherapy with 50 Gy, conventionally fractionated, and waited 6-8 weeks before surgery. The IBR methods were varied, with both implant and autologous reconstructions. No intraoperative complications occurred, and the postoperative complication rates ranged from 3 to 36%. The partial and total flap loss rates were very low. Studies reporting cosmetic outcomes rated the majority of cases as good or excellent. The pathologic complete response rates ranged from 17 to 55%, and the locoregional recurrence rates were low (≤ 10%), with a short follow-up period. The current MD Anderson Cancer Center prospective clinical trial is described. CONCLUSIONS The initial results of NART and IBR demonstrate the safety of this treatment both technically and oncologically. Longer follow-up evaluation of these studies and larger prospective controlled clinical trials are needed to establish this new therapeutic sequence as a standard of care.
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Affiliation(s)
- Puneet Singh
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Karen Hoffman
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Mark V Schaverien
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kate J Krause
- Research Medical Library, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Charles Butler
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Benjamin D Smith
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Henry M Kuerer
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Nava MB, Benson JR, Audretsch W, Blondeel P, Catanuto G, Clemens MW, Cordeiro PG, De Vita R, Hammond DC, Jassem J, Lozza L, Orecchia R, Pusic AL, Rancati A, Rezai M, Scaperrotta G, Spano A, Winters ZE, Rocco N. International multidisciplinary expert panel consensus on breast reconstruction and radiotherapy. Br J Surg 2019; 106:1327-1340. [PMID: 31318456 DOI: 10.1002/bjs.11256] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Revised: 12/11/2018] [Accepted: 05/06/2019] [Indexed: 11/06/2022]
Abstract
BACKGROUND Conflicting evidence challenges clinical decision-making when breast reconstruction is considered in the context of radiotherapy. Current literature was evaluated and key statements on topical issues were generated and discussed by an expert panel at the International Oncoplastic Breast Surgery Meeting in Milan 2017. METHODS Studies on radiotherapy and breast reconstruction (1985 to September 2017) were screened using MEDLINE, Embase and CENTRAL. The literature review yielded 30 controversial key questions. A set of key statements was derived and the highest levels of clinical evidence (LoE) for each of these were summarized. Nineteen panellists convened for dedicated discussions at the International Oncoplastic Breast Surgery Meeting to express agreement, disagreement or abstention for the generated key statements. RESULTS The literature review identified 1522 peer-reviewed publications. A list of 22 key statements was produced, with the highest LoE recorded for each statement. These ranged from II to IV, with most statements (11 of 22, 50 per cent) supported by LoE III. There was full consensus for nine (41 per cent) of the 22 key statements, and more than 75 per cent agreement was reached for half (11 of 22). CONCLUSION Poor evidence exists on which to base patient-informed consent. Low-quality studies are conflicting with wide-ranging treatment options, precluding expert consensus regarding optimal type and timing of breast reconstruction in the context of radiotherapy. There is a need for high-quality evidence from prospective registries and randomized trials in this field.
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Affiliation(s)
- M B Nava
- Department of Plastic Surgery, University of Milan, Milan, Italy
| | - J R Benson
- Cambridge Breast Unit, Addenbrooke's Hospital, Cambridge, UK.,School of Medicine, Anglia Ruskin University, Cambridge and Chelmsford, UK
| | - W Audretsch
- Department of Senology and Breast Surgery, Heinrich Heine University, Dusseldorf, Germany
| | - P Blondeel
- Department of Plastic Surgery, University Hospital Ghent, Ghent, Belgium
| | - G Catanuto
- Multidisciplinary Breast Unit, Azienda Ospedaliera Cannizzaro, Catania, Italy
| | - M W Clemens
- Plastic and Reconstructive Surgery Unit, MD Anderson Cancer Center, Houston, Texas
| | - P G Cordeiro
- Department of Plastic and Reconstructive Surgery, Weill Cornell Medicine and.,Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, USA
| | - R De Vita
- Department of Plastic Surgery, National Cancer Institute 'Regina Elena', Rome, Italy
| | - D C Hammond
- Partners in Plastic Surgery of West Michigan, Grand Rapids, Michigan, USA
| | - J Jassem
- Department of Oncology and Radiotherapy, Medical University of Gdansk, Gdansk, Poland
| | - L Lozza
- Radiotherapy Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - R Orecchia
- Department of Radiotherapy, European Institute of Oncology, Milan, Italy
| | - A L Pusic
- Division of Plastic and Reconstructive Surgery, Brigham and Women's Hospital, Harvard University, Boston, Massachusetts, USA
| | - A Rancati
- Oncoplastic Surgery, Instituto Henry Moore, University of Buenos Aires, Buenos Aires, Argentina
| | - M Rezai
- European Breast Centre, Dusseldorf, Germany
| | - G Scaperrotta
- Radiology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - A Spano
- Plastic Surgery Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Z E Winters
- Division of Surgery and Interventional Science, Faculty of Medical Sciences, University College London, London, UK
| | - N Rocco
- Department of Clinical Medicine and Surgery, University of Naples 'Federico II', Naples, Italy
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22
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Preoperative radiotherapy: A paradigm shift in the treatment of breast cancer? A review of literature. Crit Rev Oncol Hematol 2019; 141:102-111. [PMID: 31272045 DOI: 10.1016/j.critrevonc.2019.06.003] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Revised: 05/12/2019] [Accepted: 06/03/2019] [Indexed: 12/31/2022] Open
Abstract
The standard of care for early-stage breast cancer (BC) consists of breast-conserving surgery followed by postoperative irradiation. Recently, the concept of changing the usual sequence of treatment components in BC RT has been investigated. Potential advantages of preoperative RT in BC include a possible tumor downstaging with improved surgical cosmetic outcomes, accurate tumor site identification and better target volume delineation. Furthermore, preoperative RT could serve as a tool for treatment stratification for de-escalation of treatments in the event of pathological complete response. The present literature review analyzed the available clinical data regarding the potential impact of preoperative RT. Overall, available clinical evidence of preoperative RT in BC remains limited, deriving mostly from retrospective case series. Nevertheless, the experiences prove the feasibility of the preoperative RT approach and confirm the efficacy in almost all analyzed studies, including experiences using higher prescription RT doses or RT in combination with systemic therapy.
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23
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Durry A, Baratte A, Mathelin C, Bruant-Rodier C, Bodin F. [Postoperative course after immediate breast reconstruction: Comparison between five surgical techniques]. ANN CHIR PLAST ESTH 2019; 64:165-177. [PMID: 30611562 DOI: 10.1016/j.anplas.2018.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Accepted: 12/05/2018] [Indexed: 10/27/2022]
Abstract
INTRODUCTION This study analyzes postoperative course of different immediate breast reconstruction techniques: deep inferior epigastric perforator flap (DIEP), gracilis, latissimus dorsi flap, expander implants and definitive implants. METHODS All women operated on IBR between 2012 and 2017 in the CHU Strasbourg were included in this retrospective study. The main data collected were healing time, complications, surgical revisions and failure rates. These data were compared between the five IBR techniques to find a significant difference. Two groups were distinguished according to the surgical techniques: free flaps and implants. Data of those groups were compared too. RESULTS One hundred and ninety three patients have had a breast surgical treatment between 2012 and 2017. Among them, 44 had a bilateral IBR (23%). Early and unserious complications, were less frequent in the implants group than in the free flaps group: 8.6% vs. 33.3% (P<0.01) for unilateral reconstructions and 10.9% vs. 38.9% (P<0.01) for bilateral reconstructions. No surgical failures were found in the free flaps group versus 6.2% for definitive implants and 3.6% for expander implants. Healing time was longer for the free flaps group than for the prothesis group: 5.6 weeks vs. 4.2weeks, (P<0.01). CONCLUSION IBR with free flaps is associated with a higher risk for early and unserious complications as healing disorders, which extend the dressings time. However the failure rate is not higher with free flaps.
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Affiliation(s)
- A Durry
- Service de chirurgie plastique, hôpital civil Strasbourg, 1, place de l'Hôpital, 67091 Strasbourg, France.
| | - A Baratte
- Service de chirurgie plastique, hôpital civil Strasbourg, 1, place de l'Hôpital, 67091 Strasbourg, France
| | - C Mathelin
- Service de sénologie, hôpital Hautepierre, 1, avenue Molière, 67200 Strasbourg, France
| | - C Bruant-Rodier
- Service de chirurgie plastique, hôpital civil Strasbourg, 1, place de l'Hôpital, 67091 Strasbourg, France
| | - F Bodin
- Service de chirurgie plastique, hôpital civil Strasbourg, 1, place de l'Hôpital, 67091 Strasbourg, France
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24
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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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25
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Skin-sparing mastectomy with immediate nipple reconstruction during autologous latissimus dorsi breast reconstruction: A review of patient satisfaction. Arch Plast Surg 2018; 45:534-541. [PMID: 30466233 PMCID: PMC6258984 DOI: 10.5999/aps.2017.01725] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2017] [Accepted: 10/02/2018] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Nipple-areolar complex (NAC) reconstruction following curative mastectomy is traditionally performed as a second-stage procedure several months after initial breast reconstruction. The recent literature has documented the increasing popularity of immediate nipple reconstruction carried out simultaneously during autologous reconstruction. The aim of this study was to evaluate the surgical outcomes and patient satisfaction with immediate breast and nipple reconstruction performed in a single stage after skin-sparing mastectomy. METHODS All patients who underwent a skin-sparing mastectomy with immediate latissimus dorsi flap breast and NAC reconstruction as a single-stage procedure from 2007 to 2015 were included. Patient demographics, oncologic details, and surgical outcomes were recorded. The BREAST-Q questionnaire was administered to patients to assess the impact and effectiveness of this reconstructive strategy. RESULTS During the study period, 34 breast and NAC reconstructions in 29 patients were performed at Cork University Hospital. The majority of our patient cohort were non-smokers (93.1%) and did not receive adjuvant radiotherapy. Postoperative complications were infrequent, with no cases of partial necrosis or complete loss of the nipple. The response rate to the BREAST-Q was 62% (n=18). Patients reported high levels of satisfaction with the reconstructed breast (62±4), nipple reconstruction (61±4.8), overall outcome (74.3±5), and psychosocial well-being (77.7±3.2). CONCLUSIONS Skin-sparing mastectomy with immediate nipple reconstruction during autologous latissimus dorsi reconstruction was demonstrated to be a safe and aesthetically reliable procedure in our cohort, yielding high levels of psychological and physical well-being. A single-stage procedure promotes psychosocial well-being involving issues that are intrinsically linked with breast cancer surgery.
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26
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Recent Advances and Future Directions in Postmastectomy Breast Reconstruction. Clin Breast Cancer 2018; 18:e571-e585. [DOI: 10.1016/j.clbc.2018.02.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Revised: 02/08/2018] [Accepted: 02/10/2018] [Indexed: 11/20/2022]
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27
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Neoadjuvant chemoradiation and breast reconstruction: the potential for improved outcomes in the treatment of breast cancer. Ir J Med Sci 2018; 188:75-83. [DOI: 10.1007/s11845-018-1846-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Accepted: 06/08/2018] [Indexed: 01/08/2023]
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28
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Pazos M, Schönecker S, Reitz D, Rogowski P, Niyazi M, Alongi F, Matuschek C, Braun M, Harbeck N, Belka C, Corradini S. Recent Developments in Radiation Oncology: An Overview of Individualised Treatment Strategies in Breast Cancer. Breast Care (Basel) 2018; 13:285-291. [PMID: 30319331 DOI: 10.1159/000488189] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Radiation therapy (RT) for breast cancer has dramatically changed over the past years, leading to individualized risk-adapted treatment strategies. Historically, the choice of RT regimen was limited to conventional fractionation protocols using standard tangential fields. Nowadays, technological and technical improvements in modern RT have added a variety of other RT modalities, different fractionation schedules, and individualised treatment volumes to the portfolio of breast RT. This review aims to give a short overview on the main topics which have recently found their way into clinical practice: hypofractionated treatment protocols, accelerated partial breast irradiation (APBI) for low-risk patients, deep inspiration breath hold (DIBH) for maximal heart protection, extent of regional nodal irradiation for high-risk patients, and the implementation of new radiation techniques such as intensity modulated RT (IMRT) and volumetric modulated RT (VMAT).
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Affiliation(s)
- Montserrat Pazos
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Stephan Schönecker
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Daniel Reitz
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Paul Rogowski
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Maximilian Niyazi
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Filippo Alongi
- Department of Radiation Oncology, Sacro Cuore Don Calbria Negrar, Verona, Italy.,University of Brescia, Brescia, Italy
| | - Christiane Matuschek
- Department of Radiation Oncology, Heinrich Heine University, Düsseldorf, Germany
| | - Michael Braun
- Department of Gynecology and Obstetrics, Red Cross Hospital, Munich, Germany
| | - Nadia Harbeck
- Breast Center, Department of Gynecology and Obstetrics, University Hospital, LMU Munich, Munich, Germany
| | - Claus Belka
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Stefanie Corradini
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
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29
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Sharp E. Avelle NPWT system: frequently asked questions. J Wound Care 2018; 27:S24-S25. [PMID: 29509087 DOI: 10.12968/jowc.2018.27.sup3.s24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Emma Sharp
- Limb Reconstruction Clinical Nurse Specialist, NHS Greater Glasgow and Clyde, UK
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30
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Charitansky H. Case study 3: breast reconstruction. J Wound Care 2018; 27:S22-S24. [PMID: 29509090 DOI: 10.12968/jowc.2018.27.sup3.s22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Hélène Charitansky
- Gynaecological Surgeon, Specialist in Senology, Institut Bergonié, Bordeaux, France
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31
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Cassidy MR, Zabor EC, Stempel M, Mehrara B, Gemignani ML. Does response to neo-adjuvant chemotherapy impact breast reconstruction? Breast J 2018; 24:567-573. [PMID: 29316048 DOI: 10.1111/tbj.12977] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Accepted: 07/06/2017] [Indexed: 02/06/2023]
Abstract
Neo-adjuvant chemotherapy (NAC) is administered in breast cancer treatment for downstaging of disease. Here, we determined the impact of response to NAC on breast reconstruction uptake. A prospective NAC and mastectomy database with or without reconstruction were reviewed with IRB approval. Univariable analyses were conducted using Kruskal-Wallis or Fisher's exact tests. Multivariable logistic regression was used to adjust for potential confounders. We identified 271 patients with unilateral breast cancer receiving NAC and either unilateral or bilateral mastectomy from 9/2013 to 5/2016. Seventy patients (25.8%) had a pCR to NAC. One hundred and seventy-five patients (64.6%) had immediate reconstruction (IR), and 96 had no IR. On univariable analysis, younger age (P < .001), lower T-stage at presentation (P < .001), bilateral versus unilateral mastectomy (P<.001) and HR-negative tumor subtype (P = .006) were significantly associated with higher IR rates. On multivariable analysis, pCR (P = .792) and tumor subtype (P = 0.061) were not significantly associated with IR; T-stage was significantly associated with IR (P < .001), such that patients with T4 tumors at presentation had lower odds of IR (OR 0.10, 95% CI 0.02-0.50), even when accounting for response to NAC. One hundred and seventy-three patients (63.8%) received adjuvant radiation therapy; this was associated with lower IR frequency (P = .048) but was not associated with reconstruction type (tissue expander versus autologous, P = 1.0) among 175 patients who had IR. In patients who have mastectomy after NAC, IR is influenced by age, T-stage at presentation, and choice of bilateral mastectomy, but not by response to NAC. A subset of patients who are young, with earlier T-stage and pCR, is more likely to proceed with bilateral mastectomy.
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Affiliation(s)
- Michael R Cassidy
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Emily C Zabor
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Michelle Stempel
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Babak Mehrara
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Mary L Gemignani
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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32
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Pathological complete response in invasive breast cancer treated by skin sparing mastectomy and immediate reconstruction following neoadjuvant chemotherapy and radiation therapy: Comparison between immunohistochemical subtypes. Breast 2017; 32:37-43. [DOI: 10.1016/j.breast.2016.12.014] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Revised: 12/04/2016] [Accepted: 12/19/2016] [Indexed: 11/19/2022] Open
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33
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Postmastectomy Breast Reconstruction Combined With Contralateral Breast Augmentation for Taiwanese Women With Small Breasts. Ann Plast Surg 2017; 78:S102-S107. [DOI: 10.1097/sap.0000000000001014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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34
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Neoadjuvant radiotherapy followed by mastectomy and immediate breast reconstruction : An alternative treatment option for locally advanced breast cancer. Strahlenther Onkol 2017; 193:324-331. [PMID: 28124093 DOI: 10.1007/s00066-017-1100-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Accepted: 01/06/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND The optimal sequence of mastectomy with immediate breast reconstruction (IBR) and radiotherapy (RT) for the treatment of locally advanced breast cancer (LABC) is still under debate. Increased rates of postoperative complications are described following postmastectomy RT. Neoadjuvant RT aims to improve the aesthetic results and simplify the reconstructive pathway. PATIENTS A total of 22 patients diagnosed with LABC and treated with neoadjuvant RT followed by mastectomy and IBR between 04/2012 and 03/2015 were retrospectively analyzed. RT consisted of external beam RT to the breast and the regional lymphatics, if indicated. Both implant-based and autologous tissue-transfer reconstruction techniques were used. RESULTS At the time of RT, 10 patients had no prior surgery and 12 patients had previously undergone breast-conserving surgery (BCS) with positive resection margins without the possibility to perform a second BCS. Additional neoadjuvant chemotherapy was administered in 18 patients prior to RT. A complete pathological response was achieved in 55.0% of patients. The 2‑year overall survival rate was 89.3%, the 2‑year disease-free-survival 79.8% and the local-recurrence-free survival was 95.2%. The cosmetic result was excellent or good in 66% of the patients treated with upfront mastectomy and 37% of the patients who had previously undergone BCS. Among patients who received implant-based IBR, 4 patients developed serious wound-healing problems with implant loss. The most satisfactory results were achieved with autologous tissue reconstruction. CONCLUSION A sequential neoadjuvant chemo-/radiotherapy to allow IBR following mastectomy in selected cases of LABC seems feasible and can be safely attempted. Careful patient selection, close monitoring, and continuous patient support is mandatory to ensure compliance in this treatment strategy.
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35
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Ren ZH, Gong ZJ, Wu HJ. Unit resection of buccal squamous cell carcinoma: Description of a new surgical technique. Oncotarget 2016; 8:52420-52431. [PMID: 28881740 PMCID: PMC5581039 DOI: 10.18632/oncotarget.14191] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2016] [Accepted: 11/20/2016] [Indexed: 12/18/2022] Open
Abstract
This study characterized the infiltration of primary tumors along the muscles, fascia and spaces of the maxillofacial region in buccal squamous cell carcinoma (BSCC) and suggested a new surgical strategy that is suitable for most stages. Based on the anatomic characteristics and infiltration of the primary tumor a new surgical approach - unit resection buccal surgery (URBS) - was developed. We evaluated this new surgical strategy, across a cohort of 127 BSCCs: 60 cases treated with URBS and 67 cases treated with conventional surgery. Notably there was no statistical difference in the clinicopathological variables between the two groups. After initial treatment with curative intent, the patients were regularly followed-up with clinical examination and imaging. URBS proved suitable for almost all stages of BSCC, and was particularly advantageous for advanced stages of BSCC. At 2 years post-treatment, the rates of overall survival were 83.3% in the URBS group and 60.1% in the conventional surgery group, respectively (hazard ratio 0.38; 95% CI 0.20 to 0.75; P=0.005). Similarly, the rates of disease-free survival were 76.6% and 51.9% in the URBS group and the conventional surgery group, respectively (hazard ratio 0.42; 95% CI 0.23 to 0.75; P=0.003). The principles of URBS are suitable for almost all stages of BSCC, especially advanced stages. URBS may improve the prognosis of BSCC patients.
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Affiliation(s)
- Zhen-Hu Ren
- Department of Oral and Maxillofacial surgery, Second Xiangya hospital of Central South University, Changsha, Hunan, 410011, China.,Department of Oral Maxillofacial-Head and Neck Oncology, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200011, China
| | - Zhao-Jian Gong
- Department of Oral and Maxillofacial surgery, Second Xiangya hospital of Central South University, Changsha, Hunan, 410011, China
| | - Han-Jiang Wu
- Department of Oral and Maxillofacial surgery, Second Xiangya hospital of Central South University, Changsha, Hunan, 410011, China
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36
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Szloch J, Marczyk E, Kołodziej-Rzepa M, Komorowski AL. Impact of different type of cancer treatment on the effectiveness of breast reconstruction. Gland Surg 2016; 5:444-9. [PMID: 27562472 DOI: 10.21037/gs.2016.05.06] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
For women undergoing mastectomy as part of their breast cancer treatment, breast reconstruction is an important part of therapy. However, neoadjuvant, adjuvant treatments as well as other patient-related factors can compromise the results of breast reconstruction techniques. In this article we have reviewed current approaches to the management of complications and risks that neoadjuvant and adjuvant therapies pose on breast reconstruction after mastectomy for breast cancer. Non-treatment related factors influencing reconstruction techniques were reviewed as well.
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Affiliation(s)
- Joanna Szloch
- Department of Surgical Oncology, Maria Skłodowska-Curie Memorial Institute of Oncology, Cancer Centre, Krakow, Poland
| | - Elżbieta Marczyk
- Department of Surgical Oncology, Maria Skłodowska-Curie Memorial Institute of Oncology, Cancer Centre, Krakow, Poland
| | - Marta Kołodziej-Rzepa
- Department of Surgical Oncology, Maria Skłodowska-Curie Memorial Institute of Oncology, Cancer Centre, Krakow, Poland
| | - Andrzej L Komorowski
- Department of Surgical Oncology, Maria Skłodowska-Curie Memorial Institute of Oncology, Cancer Centre, Krakow, Poland
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37
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Nestle-Krämling C, Bölke E, Budach W, Andree C. Erratum to: Breast reconstruction after neoadjuvant radio chemotherapy: review and personal technique IDEAL concept. Eur J Med Res 2016; 21:30. [PMID: 27417214 PMCID: PMC4946236 DOI: 10.1186/s40001-016-0223-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Accepted: 06/29/2016] [Indexed: 11/10/2022] Open
Affiliation(s)
- Carolin Nestle-Krämling
- Department of Senology, Sana Kliniken Düsseldorf-Gerresheim, Graeulinger Straße 120, 40625, Düsseldorf, Germany
| | - Edwin Bölke
- Department of Radiation Oncology, Heinrich Heine University, Moorenstrasse 5, 40225, Düsseldorf, Germany.
| | - Wilfried Budach
- Department of Radiation Oncology, Heinrich Heine University, Moorenstrasse 5, 40225, Düsseldorf, Germany
| | - Christoph Andree
- Department of Plastic and Reconstructive Surgery, Sana Kliniken Düsseldorf-Gerresheim, Graeulinger Straße 120, 40625, Düsseldorf, Germany
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Ataseven B, von Minckwitz G. The Impact of Neoadjuvant Treatment on Surgical Options and Outcomes. Ann Surg Oncol 2016; 23:3093-9. [DOI: 10.1245/s10434-016-5364-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Indexed: 11/18/2022]
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Nestle-Krämling C, Bölke E, Budach W, Andree C. Breast reconstruction after neoadjuvant radio chemotherapy: review and personal technique IDEAL concept REV-EJMR-D-15-00268. Eur J Med Res 2016; 21:24. [PMID: 27287332 PMCID: PMC4902933 DOI: 10.1186/s40001-016-0219-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Accepted: 05/26/2016] [Indexed: 12/31/2022] Open
Abstract
Neoadjuvant radio chemotherapy and immediate reconstruction for breast cancer are still under debate. But there are recent abstracts and articles which show that neoadjuvant radio chemotherapy is feasible and could improve the clinical outcome of breast cancer patients. The aim of this review is to present the authors’ techniques and approaches with regard to neoadjuvant radiation of breast cancer patients. It seems that the concept of immediate implant delayed autologous breast reconstruction could be a safe procedure that is at least equivalent to primary autologous reconstruction.
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Affiliation(s)
- Carolin Nestle-Krämling
- Department of Senology, Sana Kliniken Düsseldorf-Gerresheim, Graeulinger Straße 120, 40625, Düsseldorf, Germany
| | - Edwin Bölke
- Department of Radiation Oncology, Heinrich Heine University, Moorenstrasse 5, 40225, Düsseldorf, Germany.
| | - Wilfried Budach
- Department of Radiation Oncology, Heinrich Heine University, Moorenstrasse 5, 40225, Düsseldorf, Germany
| | - Christoph Andree
- Department of Plastic and Reconstructive Surgery, Sana Kliniken Düsseldorf-Gerresheim, Graeulinger Straße 120, 40625, Düsseldorf, Germany
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