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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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Zhao J, Xiao C. Oncologic Safety of One-Stage Implant-Based Breast Reconstruction in Breast Cancer Patients With Positive Sentinel Lymph Nodes: A Single-Center Retrospective Study Using Propensity Score Matching. Clin Breast Cancer 2024; 24:e1-e8. [PMID: 37775348 DOI: 10.1016/j.clbc.2023.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 09/08/2023] [Indexed: 10/01/2023]
Abstract
OBJECTIVE The purpose of this study is to evaluate the oncologic safety of one-stage implant-based breast reconstruction (OIBR) following mastectomy in breast cancer patients with positive sentinel lymph nodes (SLNs). METHODS We collected clinical and pathological data from breast cancer patients with positive SLNs who underwent OIBR or not after mastectomy between January 2015 and December 2018. A total of 194 patients were included, with 130 patients undergoing mastectomy alone (MA) and 64 patients receiving OIBR after mastectomy. The clinical and pathological features, as well as the postoperative oncologic outcomes, of the 2 groups were retrospectively analyzed. Propensity score matching (PSM) was employed to mitigate the effects of data bias and confounding factors. RESULTS The median follow-up time was 66 months for the OIBR group and 64 months for the MA group after PSM. The majority of reconstructive surgeries use an approach of prosthetic implantation (52.0%). This is followed by prosthetic implantation combined with a latissimus dorsi (LD) flap (32.0%), and acellular dermal matrix (ADM)-assisted implant placement (16.0%). During the follow-up period, a local recurrence was observed in 1 case, regional recurrence in 3 cases, and distant metastasis leading to death in 3 cases among the OIBR group patients. No significant difference was found between the OIBR and MA groups in disease-free survival (DFS) (P = .66), distant metastasis-free survival (DMFS) (P = .91), locoregional recurrence-free survival (LRRFS) (P = .44), and overall survival (OS) (P = .57). CONCLUSION OIBR is a safe option for breast cancer patients with positive SLNs and does not negatively impact cancer recurrence or overall survival.
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Affiliation(s)
- Jingjing Zhao
- The First Department of Breast Cancer, Tianjin Medical University, Cancer Institute and Hospital, National Clinical Research Center for Cancer, Tianjin, China
| | - Chunhua Xiao
- The First Department of Breast Cancer, Tianjin Medical University, Cancer Institute and Hospital, National Clinical Research Center for Cancer, Tianjin, China.
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Banys-Paluchowski M, Brus L, Krawczyk N, Kopperschmidt SV, Gasparri ML, Bündgen N, Rody A, Hanker L, Hemptenmacher F, Paluchowski P. Latissimus dorsi flap for breast reconstruction: a large single-institution evaluation of surgical outcome and complications. Arch Gynecol Obstet 2024; 309:269-280. [PMID: 37584773 PMCID: PMC10770241 DOI: 10.1007/s00404-023-07186-3] [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: 06/16/2023] [Accepted: 08/02/2023] [Indexed: 08/17/2023]
Abstract
PURPOSE The use of autologous tissues is considered gold standard for patients undergoing breast reconstruction and is the preferred method in the post-radiation setting. Although the latissimus dorsi flap (LDF) has been replaced by abdominal flaps as technique of choice, it remains a valuable option in several specific clinical situations and its use has been regaining popularity in recent years. In this work, we present an 18-year retrospective analysis of a single-institution single-surgeon experience with LDF-based reconstruction with focus on early complications and reconstructive failures. METHODS Hospital records of all patients undergoing breast surgery for any reason in the Certified Breast Cancer Center, Regio Klinikum Pinneberg, Germany between April, 1st 2005 and October, 31st 2022 were reviewed. 142 consecutive LDF-based reconstructive procedures were identified. Detailed information was gathered on patient characteristics, treatment-related factors, and complications. RESULTS One hundred forty patients (139 female, 1 male) received 142 LDF-based surgeries. The flap was used mainly for immediate breast reconstruction with or without implant (83% of patients), followed by defect coverage after removal of a large tumor (7%), implant-to-flap conversion with or without placement of a new implant (6%), and delayed post-mastectomy reconstruction (4%). The use of LDF decreased between 2005 and 2020 (2005: 17, 2006: 13, 2007: 14, 2008: 16, 2009: 5, 2010: 9, 2011: 8, 2012: 3, 2013: 10, 2014: 8, 2015: 8, 2016: 7, 2017: 7, 2018: 4, 2019: 4, 2020: 2, 2021: 6, 2022: 4). Surgery was performed for invasive breast cancer in 78%, ductal carcinoma in situ in 20% and other reasons such as genetic mutation in 1% of patients. Ipsilateral radiation therapy was received by 12% of patients prior to LDF surgery and by 37% after the surgery. 25% of patients were smokers. The median duration of surgery, including all procedures conducted simultaneously such as e.g., mastectomy, axillary surgery, or implant placement, was 117 min (range 56-205). Patients stayed in the hospital for a median of 7 days (range 2-23 days). The most common complication was seroma (26%), followed by wound dehiscence (8%), surgical site infection (7%), partial skin and/or nipple necrosis of any size (7%) and hematoma requiring surgical evacuation (2%). 19% of all patients required seroma aspiration or drainage, mostly at the donor site and performed under ultrasound guidance in the ambulatory setting. Flap loss due to necrosis occurred in 2% of patients. CONCLUSIONS Latissimus dorsi flap is a well-established surgical technique commonly used for immediate breast reconstruction as well as defect coverage in locally advanced breast cancer. To the best of our knowledge, this is one of the largest single-surgeon analyses of early complications in patients receiving LDF. As expected, seroma was the most common complication observed in nearly one third of patients and requiring a therapeutic intervention in every fifth patient. Serious adverse events occurred rarely, and flap loss rate was very low.
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Affiliation(s)
- Maggie Banys-Paluchowski
- Department of Obstetrics and Gynecology, University Hospital of Schleswig Holstein, Campus Lübeck, Lübeck, Germany.
| | - Laura Brus
- Department of Gynecology and Obstetrics and Breast Cancer Center, Regio Klinikum Pinneberg, Pinneberg, Germany
| | - Natalia Krawczyk
- Department of Gynecology and Obstetrics, University of Düsseldorf, Düsseldorf, Germany
| | | | - Maria Luisa Gasparri
- Department of Gynecology and Obstetrics, Ospedale Regionale di Lugano EOC, Lugano, Switzerland
- Faculty of Biomedical Sciences, Università Della Svizzera Italiana, Lugano, Switzerland
| | - Nana Bündgen
- Department of Obstetrics and Gynecology, University Hospital of Schleswig Holstein, Campus Lübeck, Lübeck, Germany
| | - Achim Rody
- Department of Obstetrics and Gynecology, University Hospital of Schleswig Holstein, Campus Lübeck, Lübeck, Germany
| | - Lars Hanker
- Department of Obstetrics and Gynecology, University Hospital of Schleswig Holstein, Campus Lübeck, Lübeck, Germany
| | - Franziska Hemptenmacher
- Department of Obstetrics and Gynecology, University Hospital of Schleswig Holstein, Campus Lübeck, Lübeck, Germany
| | - Peter Paluchowski
- Department of Gynecology and Obstetrics and Breast Cancer Center, Regio Klinikum Pinneberg, Pinneberg, Germany
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Mota BS, Bevilacqua JLB, Barrett J, Ricci MD, Munhoz AM, Filassi JR, Baracat EC, Riera R. Skin-sparing mastectomy for the treatment of breast cancer. Cochrane Database Syst Rev 2023; 3:CD010993. [PMID: 36972145 PMCID: PMC10042433 DOI: 10.1002/14651858.cd010993.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
Abstract
BACKGROUND Skin-sparing mastectomy (SSM) is a surgical technique that aims to maximize skin preservation, facilitate breast reconstruction, and improve cosmetic outcomes. Despite its use in clinical practice, the benefits and harms related to SSM are not well established. OBJECTIVES To assess the effectiveness and safety of skin-sparing mastectomy for the treatment of breast cancer. SEARCH METHODS We searched Cochrane Breast Cancer's Specialized Register, CENTRAL, MEDLINE, Embase, LILACS, the World Health Organization's International Clinical Trials Registry Platform (WHO ICTRP), and ClinicalTrials.gov on 9 August 2019. SELECTION CRITERIA Randomized controlled trials (RCTs), quasi-randomized or non-randomized studies (cohort and case-control) comparing SSM to conventional mastectomy for treating ductal carcinoma in situ (DCIS) or invasive breast cancer. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. The primary outcome was overall survival. Secondary outcomes were local recurrence free-survival, adverse events (including overall complications, breast reconstruction loss, skin necrosis, infection and hemorrhage), cosmetic results, and quality of life. We performed a descriptive analysis and meta-analysis of the data. MAIN RESULTS We found no RCTs or quasi-RCTs. We included two prospective cohort studies and twelve retrospective cohort studies. These studies included 12,211 participants involving 12,283 surgeries (3183 SSM and 9100 conventional mastectomies). It was not possible to perform a meta-analysis for overall survival and local recurrence free-survival due to clinical heterogeneity across studies and a lack of data to calculate hazard ratios (HR). Based on one study, the evidence suggests that SSM may not reduce overall survival for participants with DCIS tumors (HR 0.41, 95% CI 0.17 to 1.02; P = 0.06; 399 participants; very low-certainty evidence) or for participants with invasive carcinoma (HR 0.81, 95% CI 0.48 to 1.38; P = 0.44; 907 participants; very low-certainty evidence). For local recurrence-free survival, meta-analysis was not possible, due to high risk of bias in nine of the ten studies that measured this outcome. Informal visual examination of effect sizes from nine studies suggested the size of the HR may be similar between groups. Based on one study that adjusted for confounders, SSM may not reduce local recurrence-free survival (HR 0.82, 95% CI 0.47 to 1.42; P = 0.48; 5690 participants; very low-certainty evidence). The effect of SSM on overall complications is unclear (RR 1.55, 95% CI 0.97 to 2.46; P = 0.07, I2 = 88%; 4 studies, 677 participants; very low-certainty evidence). Skin-sparing mastectomy may not reduce the risk of breast reconstruction loss (RR 1.79, 95% CI 0.31 to 10.35; P = 0.52; 3 studies, 475 participants; very low-certainty evidence), skin necrosis (RR 1.15, 95% CI 0.62 to 2.12; P = 0.22, I2 = 33%; 4 studies, 677 participants; very low-certainty evidence), local infection (RR 2.04, 95% CI 0.03 to 142.71; P = 0.74, I2 = 88%; 2 studies, 371 participants; very low-certainty evidence), nor hemorrhage (RR 1.23, 95% CI 0.47 to 3.27; P = 0.67, I2 = 0%; 4 studies, 677 participants; very low-certainty evidence). We downgraded the certainty of the evidence due to the risk of bias, imprecision, and inconsistency among the studies. There were no data available on the following outcomes: systemic surgical complications, local complications, explantation of implant/expander, hematoma, seroma, rehospitalization, skin necrosis with revisional surgery, and capsular contracture of the implant. It was not possible to perform a meta-analysis for cosmetic and quality of life outcomes due to a lack of data. One study performed an evaluation of aesthetic outcome after SSM: 77.7% of participants with immediate breast reconstruction had an overall aesthetic result of excellent or good versus 87% of participants with delayed breast reconstruction. AUTHORS' CONCLUSIONS Based on very low-certainty evidence from observational studies, it was not possible to draw definitive conclusions on the effectiveness and safety of SSM for breast cancer treatment. The decision for this technique of breast surgery for treatment of DCIS or invasive breast cancer must be individualized and shared between the physician and the patient while considering the potential risks and benefits of available surgical options.
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Affiliation(s)
- Bruna S Mota
- Department of Obstetrics and Gynecology, Instituto do Câncer do Estado de São Paulo (ICESP/FMUSP), São Paulo, Brazil
| | | | - Jessica Barrett
- Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Strangeways Research Laboratory, Cambridge, UK
| | - Marcos Desidério Ricci
- Department of Obstetrics and Gynecology, Instituto do Câncer do Estado de São Paulo (ICESP/FMUSP), São Paulo, Brazil
| | - Alexandre M Munhoz
- Plastic Surgery, Instituto do Câncer do Estado de São Paulo - ICESP, São Paulo, Brazil
| | - José Roberto Filassi
- Department of Obstetrics and Gynecology, Instituto do Câncer do Estado de São Paulo (ICESP/FMUSP), São Paulo, Brazil
| | - Edmund Chada Baracat
- Department of Obstetrics and Gynecology, Instituto do Câncer do Estado de São Paulo (ICESP/FMUSP), São Paulo, Brazil
| | - Rachel Riera
- Cochrane Affiliate Rio de Janeiro, Cochrane, Petrópolis, Brazil
- Center of Health Technology Asessment, Hospital Sírio-Libanês, São Paulo, Brazil
- Núcleo de Ensino e Pesquisa em Saúde Baseada em Evidências e Avaliação Tecnológica em Saúde (NEP-Sbeats), Universidade Federal de São Paulo, São Paulo, Brazil
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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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Association between Immediate Breast Reconstruction and the Development of Breast Cancer-Related Lymphedema. Plast Reconstr Surg 2023; 151:214e-222e. [PMID: 36696309 DOI: 10.1097/prs.0000000000009831] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND With the increasing number of patients undergoing immediate breast reconstruction after mastectomy, the impact of immediate breast reconstruction on the risk of breast cancer-related lymphedema has become an emerging area of interest. This study aimed to identify the association between immediate breast reconstruction and postoperative lymphedema. METHODS A retrospective cohort study was conducted from 2006 to 2016 with 5900 consecutive patients who underwent mastectomy for primary breast cancer with or without immediate breast reconstruction. After excluding patients with synchronous contralateral breast cancer, lymphedema before mastectomy, history of procedures performed in the axillary region, and follow-up data of less than 1 year, the cumulative incidence of lymphedema after immediate breast reconstruction and after no reconstruction was calculated and compared using multivariate Cox regression analysis. RESULTS Overall, 5497 patients (mean age, 51.7 years) were included, and 630 developed lymphedema. The 5-year cumulative incidence rate of lymphedema was significantly reduced in patients who underwent immediate breast reconstruction versus control patients (9.6% versus 12.2%; P = 0.02). In the multivariate analysis, immediate breast reconstruction status (hazard ratio, 0.75; 95% confidence interval, 0.56 to 0.99; P = 0.042) was an independent predictor for lymphedema. Similar significant associations were observed in the subgroup analyses of patients with a body mass index less than 30 kg/m2 (P = 0.024), in those with fewer than 10 dissected lymph nodes (P = 0.042), or in those with adjuvant radiotherapy (P = 0.048). CONCLUSIONS Immediate breast reconstruction was associated with a reduced risk of lymphedema. These results may be used for predicting the development of lymphedema following breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, II.
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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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9
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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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10
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Nakagawa T, Oda G, Mori H, Uemura N, Onishi I, Sagawa N, Fujioka T, Mori M, Kubota K, Ishikawa T, Okamoto K, Uetake H. Prognosis of Subcutaneous Mastectomy for Special Types of Breast Cancer. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58010112. [PMID: 35056420 PMCID: PMC8780999 DOI: 10.3390/medicina58010112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 01/05/2022] [Accepted: 01/06/2022] [Indexed: 11/16/2022]
Abstract
Background and objectives: In the treatment of the special type of breast cancer (STBC), the choice of chemotherapeutic agents is often based on the characteristic features of the histological type. On the other hand, the surgical strategy is usually determined by the tumor size and presence of lymph node metastasis, and the indication for immediate reconstruction is rarely discussed based on the histological type. The prognoses of STBC and invasive ductal carcinoma of the breast (IDC) patients who underwent subcutaneous mastectomy (SCM) with immediate reconstruction at our institution were compared. Materials and Methods: A total of 254 patients with SCM with immediate reconstruction from 1998 to 2018 were included; their tumor diameter or induration was less than 25 mm, and it was not in close proximity to the skin. Preoperative chemotherapy and non-invasive cancer cases were excluded. Results: The number of patients was 166 for skin-sparing mastectomy (SSM) and 88 for nipple-sparing mastectomy (NSM). The reconstructive techniques were deep inferior epigastric artery perforator flap (DIEP) reconstruction in 43 cases, latissimus dorsi flap reconstruction (LDflap) in 63 cases, tissue expander (TE) in 117 cases, and transverse rectus abdominis myocutaneous flap/vertical rectus abdominis myocutaneous flap (TRAM/VRAM) reconstruction in 31 cases. The histological types of breast cancer were 211 IDC and 43 STBC; 17 were mucinous carcinoma (MUC), 17 were invasive lobular carcinoma (ILC), 6 were apocrine carcinoma, 1 was tubular carcinoma, and 2 were invasive micropapillary carcinoma. There was no difference in local recurrence or disease-free survival (LRFS, DFS) between IDC and STBC, and overall survival (OS) was significantly longer in STBC. OS was better in the STBC group because SCM with immediate reconstruction was performed for STBC, which is a histological type with a relatively good prognosis. Highly malignant histological types, such as squamous cell carcinoma or metaplastic carcinoma, were totally absent in this study. Conclusions: The indications for SCM with immediate reconstruction for relatively common STBCs such as MUC and ILC can be the same as for IDC.
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Affiliation(s)
- Tsuyoshi Nakagawa
- Department of Breast Surgery, Tokyo Medical and Dental University, Tokyo 1138519, Japan; (G.O.); (N.S.)
- Correspondence: ; Tel.: +81-3-5803-5261
| | - Goshi Oda
- Department of Breast Surgery, Tokyo Medical and Dental University, Tokyo 1138519, Japan; (G.O.); (N.S.)
| | - Hiroki Mori
- Department of Plastic Surgery, Tokyo Medical and Dental University, Tokyo 1138519, Japan; (H.M.); (N.U.)
| | - Noriko Uemura
- Department of Plastic Surgery, Tokyo Medical and Dental University, Tokyo 1138519, Japan; (H.M.); (N.U.)
| | - Iichiro Onishi
- Department of Pathology, Tokyo Medical and Dental University, Tokyo 1138519, Japan;
| | - Noriko Sagawa
- Department of Breast Surgery, Tokyo Medical and Dental University, Tokyo 1138519, Japan; (G.O.); (N.S.)
| | - Tomoyuki Fujioka
- Department of Radiology, Tokyo Medical and Dental University, Tokyo 1138519, Japan; (T.F.); (M.M.); (K.K.)
| | - Mio Mori
- Department of Radiology, Tokyo Medical and Dental University, Tokyo 1138519, Japan; (T.F.); (M.M.); (K.K.)
| | - Kazunori Kubota
- Department of Radiology, Tokyo Medical and Dental University, Tokyo 1138519, Japan; (T.F.); (M.M.); (K.K.)
| | - Toshiaki Ishikawa
- Department of Specialized Surgeries, Graduated School, Tokyo Medical and Dental University, Tokyo 1138519, Japan; (T.I.); (K.O.); (H.U.)
| | - Kentaro Okamoto
- Department of Specialized Surgeries, Graduated School, Tokyo Medical and Dental University, Tokyo 1138519, Japan; (T.I.); (K.O.); (H.U.)
| | - Hiroyuki Uetake
- Department of Specialized Surgeries, Graduated School, Tokyo Medical and Dental University, Tokyo 1138519, Japan; (T.I.); (K.O.); (H.U.)
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11
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Goel A, Agarwal VK, Nayak V, Yogsrivas R, Gulia A. Surgical Management of Locoregional Recurrence in Breast Cancer. Indian J Surg Oncol 2021; 12:616-623. [PMID: 34658592 DOI: 10.1007/s13193-021-01342-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 04/29/2021] [Indexed: 11/27/2022] Open
Abstract
Locoregional recurrences from breast cancer represent a heterogeneous group of disease that poses a therapeutic challenge and needs a multidisciplinary team management. The incidence of local recurrence after breast conservation surgery ranges from 10 to 22% and 5-15% after mastectomy at 10-year follow-up. Management of locoregional recurrence depends on tumor biology, stage at presentation, and prior local and systemic therapy. With improvements in diagnostic, pathological, and surgical techniques, radiation and systemic therapy approach, outcomes in these patients have improved. In this review, we discuss the risk factors, prognostic factors, surgical and reconstruction options, re-irradiation, and role of systemic therapy to define a reasonable treatment approach without compromising oncologic safety and achieve good cosmetic and survival outcomes.
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Affiliation(s)
- Ashish Goel
- Department of Surgical and Radiation Oncolgy, Jaypee Hospital, Noida, India
| | | | - Vikash Nayak
- Department of Surgical and Radiation Oncolgy, Jaypee Hospital, Noida, India
| | - Rekha Yogsrivas
- Department of Surgical and Radiation Oncolgy, Jaypee Hospital, Noida, India
| | - Abhishek Gulia
- Department of Surgical and Radiation Oncolgy, Jaypee Hospital, Noida, India
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12
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Taqi K, Pao JS, Chen L, Ma C, Zhang M, McKevitt E, Bazzarelli A, Dingee C, Warburton R. Immediate breast reconstruction in locally advanced breast cancer: is it safe? Breast Cancer Res Treat 2021; 190:175-182. [PMID: 34467443 DOI: 10.1007/s10549-021-06366-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Accepted: 08/09/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE Immediate breast reconstruction (IBR) following mastectomy remains controversial for locally advanced breast cancer over concerns regarding recurrence and complications which may delay adjuvant therapies. This study aimed to compare the oncologic outcomes and surgical safety of IBR following mastectomy with mastectomy alone (MA) for locally advanced breast cancer. METHODS All patients treated at the Providence Breast Center between 2012 and 2017 for biopsy-proven locally advanced breast cancer, AJCC (8th edition) clinical stages (IIB-IIIC), were included. Primary outcomes were overall survival (OS), disease-specific survival (DSS), and disease-free survival (DFS). Secondary outcomes included recurrence rate, adjuvant therapy use, and reoperation. RESULTS 267 patients (112 IBR, 155 MA) were included. On average, IBR patients were younger (48.82 years vs 61.42 years, P < 0.001). Median study follow-up was 50.7 months. OS was higher among IBR patients (86.6% vs 73.5%, P < 0.05). However, no significant differences were found in DSS (87.5% vs 84.5%, P = 0.34), DFS (79.5% vs 78.7%, P = 0.55), local recurrence (0% vs 1.9%, P = 0.194), adjuvant therapy use (95.5% vs 91.6%, P = 0.155), or reoperation (1.8% vs 1.3%, P = 0.559). CONCLUSION IBR is a safe option for patients with locally advanced breast cancer and does not negatively impact survival, cancer recurrence rates, and use of adjuvant therapy.
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Affiliation(s)
- Kadhim Taqi
- Department of Surgery, Division of General Surgery, University of British Columbia Faculty of Medicine, Vancouver, BC, Canada
| | - Jin-Si Pao
- Division of General Surgery, Department of Surgery, Providence Health Care Breast Centre, Providence Breast Centre & University of British Columbia, Mount Saint Joseph Hospital, 3rd Floor, 3080 Prince Edward Street, Vancouver, BC, V5T 3N4, Canada
- Department of Surgery, Division of General Surgery, University of British Columbia Faculty of Medicine, Vancouver, BC, Canada
| | - Leo Chen
- Department of Surgery, Division of General Surgery, University of British Columbia Faculty of Medicine, Vancouver, BC, Canada
| | - Crystal Ma
- Division of General Surgery, Department of Surgery, Providence Health Care Breast Centre, Providence Breast Centre & University of British Columbia, Mount Saint Joseph Hospital, 3rd Floor, 3080 Prince Edward Street, Vancouver, BC, V5T 3N4, Canada
| | - Mabel Zhang
- Division of General Surgery, Department of Surgery, Providence Health Care Breast Centre, Providence Breast Centre & University of British Columbia, Mount Saint Joseph Hospital, 3rd Floor, 3080 Prince Edward Street, Vancouver, BC, V5T 3N4, Canada
| | - Elaine McKevitt
- Division of General Surgery, Department of Surgery, Providence Health Care Breast Centre, Providence Breast Centre & University of British Columbia, Mount Saint Joseph Hospital, 3rd Floor, 3080 Prince Edward Street, Vancouver, BC, V5T 3N4, Canada
- Department of Surgery, Division of General Surgery, University of British Columbia Faculty of Medicine, Vancouver, BC, Canada
| | - Amy Bazzarelli
- Division of General Surgery, Department of Surgery, Providence Health Care Breast Centre, Providence Breast Centre & University of British Columbia, Mount Saint Joseph Hospital, 3rd Floor, 3080 Prince Edward Street, Vancouver, BC, V5T 3N4, Canada
- Department of Surgery, Division of General Surgery, University of British Columbia Faculty of Medicine, Vancouver, BC, Canada
| | - Carol Dingee
- Division of General Surgery, Department of Surgery, Providence Health Care Breast Centre, Providence Breast Centre & University of British Columbia, Mount Saint Joseph Hospital, 3rd Floor, 3080 Prince Edward Street, Vancouver, BC, V5T 3N4, Canada
- Department of Surgery, Division of General Surgery, University of British Columbia Faculty of Medicine, Vancouver, BC, Canada
| | - Rebecca Warburton
- Division of General Surgery, Department of Surgery, Providence Health Care Breast Centre, Providence Breast Centre & University of British Columbia, Mount Saint Joseph Hospital, 3rd Floor, 3080 Prince Edward Street, Vancouver, BC, V5T 3N4, Canada.
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13
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Garibotto NL. The Benefits and Pitfalls of Using an Autologous Dermal Flap in Immediate Implant-Based Reconstruction. Cureus 2021; 13:e14144. [PMID: 33927946 PMCID: PMC8075570 DOI: 10.7759/cureus.14144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
One of the challenges of implant breast reconstruction post-subcutaneous mastectomy is coverage of the inferior pole of the implant to provide a barrier between the implant and skin. Numerous biological and synthetic meshes are available on the market for this purpose; however, they are often very costly and carry all the risks of using a foreign body. In patients with large ptotic breast, the skin of the inferior mastectomy flap can be used instead. A number of techniques and variations have been developed over the last 40 years driven by the increasing cost of healthcare and acceptance of breast reconstruction as vital part of breast cancer care and survivorship. This review outline the benefits and pitfalls of using an autologous dermal flap in breast construction and the variations in published use.
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14
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Saheb-Al-Zamani M, Cordeiro E, O'Neill AC, Hofer SO, Cil TD, Zhong T. Early Postoperative Complications From National Surgical Quality Improvement Program: A Closer Examination of Timing and Technique of Breast Reconstruction. Ann Plast Surg 2021; 86:S159-S164. [PMID: 33208650 PMCID: PMC7969155 DOI: 10.1097/sap.0000000000002590] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 09/13/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Despite the recent surge in rates of immediate breast reconstruction, there is a paucity of large multicenter studies to compare differences in morbidity after immediate versus delayed breast reconstruction. This study used the National Surgical Quality Improvement Program (NSQIP) to study the association between timing of breast reconstruction and complication rates, stratified by reconstructive modality. STUDY DESIGN The NSQIP database was used to identify breast reconstructions from 2005 to 2012. Rates of major complications were compared by timing within each reconstructive modality (implant vs autologous). Cohort differences in baseline characteristics and variables associated with increased complication rates were identified in bivariate analyses. A multivariable model was created to compare the association between the timing of reconstruction and major complications. RESULTS Of 24,506 postmastectomy reconstructions, 85.8% were immediate, 14.2% were delayed, 84% were implant, and 16% were autologous reconstructions. Overall, 10.0% of patients suffered a major complication. After stratification, only implant reconstructions showed a statistically higher complication rate with immediate (8.8%) reconstruction compared with delayed (5.3%) (odds ratio, 1.7, P < 0.01). There was no significant difference in complication rates between autologous immediate (18.4%) or delayed (19.0%) reconstructions. After controlling for baseline cohort differences and other risk factors, immediate reconstruction remained as an independent significant predictor of major complications in implant reconstructions (odds ratio, 1.8, P < 0.01). CONCLUSIONS Immediate rather than delayed breast reconstruction is associated with a significantly higher rate of major complications in implant reconstruction but not in autologous reconstruction. It is important to include these findings in the routine preoperative surgeon-patient discussion of reconstructive options.
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Affiliation(s)
| | | | - Anne C. O'Neill
- From the Division of Plastic and Reconstructive Surgery, University of Toronto, Toronto
| | - Stefan O.P. Hofer
- From the Division of Plastic and Reconstructive Surgery, University of Toronto, Toronto
| | - Tulin D. Cil
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Toni Zhong
- From the Division of Plastic and Reconstructive Surgery, University of Toronto, Toronto
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15
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Rattay T, Seibold P, Aguado-Barrera ME, Altabas M, Azria D, Barnett GC, Bultijnck R, Chang-Claude J, Choudhury A, Coles CE, Dunning AM, Elliott RM, Farcy Jacquet MP, Gutiérrez-Enríquez S, Johnson K, Müller A, Post G, Rancati T, Reyes V, Rosenstein BS, De Ruysscher D, de Santis MC, Sperk E, Stobart H, Symonds RP, Taboada-Valladares B, Vega A, Veldeman L, Webb AJ, West CM, Valdagni R, Talbot CJ. External Validation of a Predictive Model for Acute Skin Radiation Toxicity in the REQUITE Breast Cohort. Front Oncol 2020; 10:575909. [PMID: 33216838 PMCID: PMC7664984 DOI: 10.3389/fonc.2020.575909] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 09/15/2020] [Indexed: 12/25/2022] Open
Abstract
Background: Acute skin toxicity is a common and usually transient side-effect of breast radiotherapy although, if sufficiently severe, it can affect breast cosmesis, aftercare costs and the patient's quality-of-life. The aim of this study was to develop predictive models for acute skin toxicity using published risk factors and externally validate the models in patients recruited into the prospective multi-center REQUITE (validating pREdictive models and biomarkers of radiotherapy toxicity to reduce side-effects and improve QUalITy of lifE in cancer survivors) study. Methods: Patient and treatment-related risk factors significantly associated with acute breast radiation toxicity on multivariate analysis were identified in the literature. These predictors were used to develop risk models for acute erythema and acute desquamation (skin loss) in three Radiogenomics Consortium cohorts of patients treated by breast-conserving surgery and whole breast external beam radiotherapy (n = 2,031). The models were externally validated in the REQUITE breast cancer cohort (n = 2,057). Results: The final risk model for acute erythema included BMI, breast size, hypo-fractionation, boost, tamoxifen use and smoking status. This model was validated in REQUITE with moderate discrimination (AUC 0.65), calibration and agreement between predicted and observed toxicity (Brier score 0.17). The risk model for acute desquamation, excluding the predictor tamoxifen use, failed to validate in the REQUITE cohort. Conclusions: While most published prediction research in the field has focused on model development, this study reports successful external validation of a predictive model using clinical risk factors for acute erythema following radiotherapy after breast-conserving surgery. This model retained discriminatory power but will benefit from further re-calibration. A similar model to predict acute desquamation failed to validate in the REQUITE cohort. Future improvements and more accurate predictions are expected through the addition of genetic markers and application of other modeling and machine learning techniques.
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Affiliation(s)
- Tim Rattay
- Cancer Research Centre, University of Leicester, Leicester, United Kingdom
| | - Petra Seibold
- Division of Cancer Epidemiology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Miguel E Aguado-Barrera
- Fundación Pública Galega Medicina Xenómica, Santiago de Compostela, Spain.,Instituto de Investigación Sanitaria de Santiago de Compostela, Santiago de Compostela, Spain
| | - Manuel Altabas
- Radiation Oncology Department, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - David Azria
- Fédération Universitaire d'Oncologie Radiothérapie d'Occitanie Méditérranée, Département d'Oncologie Radiothérapie, ICM Montpellier, INSERM U1194 IRCM, University of Montpellier, Montpellier, France
| | - Gillian C Barnett
- Department of Oncology, University of Cambridge, Cambridge, United Kingdom
| | - Renée Bultijnck
- Department of Human Structure and Repair, Ghent University, Ghent, Belgium.,Department of Radiation Oncology, Ghent University Hospital, Ghent, Belgium
| | - Jenny Chang-Claude
- Division of Cancer Epidemiology, German Cancer Research Center (DKFZ), Heidelberg, Germany.,University Cancer Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ananya Choudhury
- Translational Radiobiology Group, Division of Cancer Sciences, University of Manchester, Manchester Academic Health Science Centre, The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Charlotte E Coles
- Department of Oncology, University of Cambridge, Cambridge, United Kingdom
| | - Alison M Dunning
- Centre for Cancer Genetic Epidemiology, Department of Oncology, Strangeways Research Laboratory, University of Cambridge, Cambridge, United Kingdom
| | - Rebecca M Elliott
- Translational Radiobiology Group, Division of Cancer Sciences, University of Manchester, Manchester Academic Health Science Centre, The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Marie-Pierre Farcy Jacquet
- Fédération Universitaire d'Oncologie Radiothérapie d'Occitanie Méditérranée, Département d'Oncologie Radiothérapie, CHU Carémeau, Nîmes, France
| | - Sara Gutiérrez-Enríquez
- Hereditary Cancer Genetics Group, Vall d'Hebron Institute of Oncology (VHIO), Vall d'Hebron Hospital Campus, Barcelona, Spain
| | - Kerstie Johnson
- Cancer Research Centre, University of Leicester, Leicester, United Kingdom
| | - Anusha Müller
- Division of Cancer Epidemiology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Giselle Post
- Department of Human Structure and Repair, Ghent University, Ghent, Belgium
| | - Tiziana Rancati
- Prostate Cancer Program, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Victoria Reyes
- Radiation Oncology Department, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Barry S Rosenstein
- Department of Radiation Oncology, Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Dirk De Ruysscher
- MAASTRO Clinic, GROW School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, Netherlands.,Department of Radiation Oncology, University Hospitals Leuven/KU Leuven, Leuven, Belgium
| | - Maria C de Santis
- Department of Radiation Oncology 1, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Elena Sperk
- Department of Radiation Oncology, Universitätsklinikum Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Hilary Stobart
- Independent Cancer Patients' Voice, London, United Kingdom
| | - R Paul Symonds
- Cancer Research Centre, University of Leicester, Leicester, United Kingdom
| | - Begoña Taboada-Valladares
- Instituto de Investigación Sanitaria de Santiago de Compostela, Santiago de Compostela, Spain.,Department of Radiation Oncology, Complexo Hospitalario Universitario de Santiago, Servizo Galego de Saúde (SERGAS), Santiago de Compostela, Spain
| | - Ana Vega
- Fundación Pública Galega Medicina Xenómica, Santiago de Compostela, Spain.,Instituto de Investigación Sanitaria de Santiago de Compostela, Santiago de Compostela, Spain
| | - Liv Veldeman
- Department of Human Structure and Repair, Ghent University, Ghent, Belgium.,Department of Radiation Oncology, Ghent University Hospital, Ghent, Belgium
| | - Adam J Webb
- Department of Genetics and Genome Biology, University of Leicester, Leicester, United Kingdom
| | - Catharine M West
- Translational Radiobiology Group, Division of Cancer Sciences, University of Manchester, Manchester Academic Health Science Centre, The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Riccardo Valdagni
- Hereditary Cancer Genetics Group, Vall d'Hebron Institute of Oncology (VHIO), Vall d'Hebron Hospital Campus, Barcelona, Spain.,Department of Radiation Oncology 1, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy.,Department of Hematology and Hemato-Oncology, Università degli Studi di Milano, Milan, Italy
| | - Christopher J Talbot
- Department of Genetics and Genome Biology, University of Leicester, Leicester, United Kingdom
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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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17
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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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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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20
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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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21
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Effect of Drain Placement on Infection, Seroma, and Return to Operating Room in Expander-Based Breast Reconstruction. Ann Plast Surg 2017; 79:536-540. [DOI: 10.1097/sap.0000000000001174] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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22
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Olsen MA, Nickel KB, Fox IK, Margenthaler JA, Wallace AE, Fraser VJ. Comparison of Wound Complications After Immediate, Delayed, and Secondary Breast Reconstruction Procedures. JAMA Surg 2017; 152:e172338. [PMID: 28724125 DOI: 10.1001/jamasurg.2017.2338] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Few data are available concerning surgical site infection (SSI) and noninfectious wound complications (NIWCs) after delayed (DR) and secondary reconstruction (SR) compared with immediate reconstruction (IR) procedures in the breast. Objective To compare the incidence of SSI and NIWCs after implant and autologous IR, DR, and SR breast procedures after mastectomy. Design, Setting, and Participants This retrospective cohort study included women aged 18 to 64 years undergoing mastectomy from January 1, 2004, through December 31, 2011. Data were abstracted from a commercial insurer claims database in 12 states and analyzed from January 1, 2015, through February 7, 2017. Exposures Reconstruction within 7 days of mastectomy was considered immediate. Reconstruction more than 7 days after mastectomy was considered delayed if the mastectomy did not include IR or secondary if the mastectomy included IR. Main Outcomes and Measures International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes for SSI and NIWCs. Results Mastectomy was performed in 17 293 women (mean [SD] age, 50.4 [8.5] years); 61.4% of women had IR or DR. Among patients undergoing implant reconstruction, the incidence of SSI was 8.9% (685 of 7655 women) for IR, 5.7% (21 of 369) for DR, and 3.2% (167 of 5150) for SR. Similar results were found for NIWCs. In contrast, the incidence of SSI was similar after autologous IR (9.8% [177 of 1799]), DR (13.9% [19 of 137]), and SR (11.6% [11 of 95]) procedures. Compared with women without an SSI after implant IR, women with an SSI after implant IR were significantly more likely to have another SSI (47 of 412 [11.4%] vs 131 of 4791 [2.7%]) and an NIWC (24 of 412 [5.8%] vs 120 of 4791 [2.5%]) after SR. The incidence of SSI (24 of 379 [6.3%] vs 152 of 5286 [2.9%]) and NIWC (22 of 379 [5.8%] vs 129 of 5286 [2.4%]) after implant SR was higher in women who had received adjuvant radiotherapy. Wound complications after IR were associated with significantly more breast surgical procedures (mean of 1.92 procedures [range, 0-9] after implant IR and 1.11 [range, 0-6] after autologous IR) compared with women who did not have a complication (mean of 1.37 procedures [range, 0-8] after implant IR and 0.87 [range, 0-6] after autologous IR). Conclusions and Relevance The incidence of SSI and NIWCs was slightly higher for implant IR compared with delayed or secondary implant reconstruction. Women who had an SSI or NIWC after implant IR had a higher risk for subsequent complications after SR and more breast operations. The risk for complications should be carefully balanced with the psychosocial and technical benefits of IR. Select high-risk patients may benefit from consideration of delayed rather than immediate implant reconstruction to decrease breast complications after mastectomy.
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Affiliation(s)
- Margaret A Olsen
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, St Louis, Missouri.,Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Katelin B Nickel
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, St Louis, Missouri
| | - Ida K Fox
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Julie A Margenthaler
- Division of General Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | | | - Victoria J Fraser
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, St Louis, Missouri
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The Effect of the Timing of Radiotherapy on Clinical and Patient-Reported Outcomes After Latissimus Dorsi Breast Reconstruction: A 10-Year Study. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2017; 5:e1348. [PMID: 28740767 PMCID: PMC5505828 DOI: 10.1097/gox.0000000000001348] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Accepted: 04/07/2017] [Indexed: 11/26/2022]
Abstract
Background: Breast reconstruction (BR) is considered to be adversely affected by radiotherapy (RT), particularly when an implant is used. The aim of this study was to compare clinical and patient-reported outcomes after expander-assisted latissimus dorsi breast reconstruction depending on the timing of RT. Methods: Patients undergoing BR over a 10-year period (follow-up mean, 56 [14–134] months) were divided into 3 groups. Group 1, RT after mastectomy and BR, Group 2, RT before mastectomy and BR, and Group 3, RT after mastectomy but before BR. The primary endpoints were early and late surgical interventions. Validated questionnaires were circulated to all study patients and matched controls. Results: Three hundred thirteen patients underwent 389 BRs. One hundred eighteen patients received RT, of which 65 had undergone expander-assisted latissimus dorsi breast reconstruction. Both use and timing of RT influenced clinical outcomes. Overall, use of RT resulted in a 3-fold increase in complications (P = 0.003). Postreconstruction RT resulted in more than double the number of complications compared with prereconstruction RT (P = 0.008) and delaying BR until after mastectomy and RT reduced complications to levels observed in control patients (P = nonsignificant). Complications were halved in patients undergoing autologous LD reconstruction (P = 0.0001). Patient-reported outcomes were similar for emotional well-being, satisfaction, and shoulder symptoms, although a nonsignificant increase in chronic breast symptoms was reported by the RT group. Conclusion: The timing and type of LD reconstruction chosen by patients receiving RT has a significant impact on the risk of subsequent complications and unplanned interventions but has little impact on longer term patient well-being or satisfaction.
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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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25
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The 2016 Assisi Think Tank Meeting on breast cancer: white paper. Breast Cancer Res Treat 2016; 160:211-221. [DOI: 10.1007/s10549-016-3998-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Accepted: 09/21/2016] [Indexed: 10/20/2022]
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Abstract
SURGICAL DE-ESCALATION FOR INVASIVE BREAST CANCER TREATMENT A surgical therapeutic de-escalation is going to continue but necessarily has to design in a progressive careful way and especially arranged with the other practitioners and therapeutic methods. These strategies concern as well the surgery of the breast as that of the axillary basin.
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Affiliation(s)
- Gilles Houvenaeghel
- Institut Paoli Calmettes & CRCM, 232, Bd de Sainte Marguerite, 13009 Marseille: Université Aix-Marseille, Faculté de Médecine Timone, 27 Boulevard Jean Moulin, 13005 Marseille..
| | - Monique Cohen
- Institut Paoli Calmettes & CRCM, 232, Bd de Sainte Marguerite, 13009 Marseille: Université Aix-Marseille, Faculté de Médecine Timone, 27 Boulevard Jean Moulin, 13005 Marseille
| | - Marie Bannier
- Institut Paoli Calmettes & CRCM, 232, Bd de Sainte Marguerite, 13009 Marseille: Université Aix-Marseille, Faculté de Médecine Timone, 27 Boulevard Jean Moulin, 13005 Marseille
| | - Camille Jauffret
- Institut Paoli Calmettes & CRCM, 232, Bd de Sainte Marguerite, 13009 Marseille: Université Aix-Marseille, Faculté de Médecine Timone, 27 Boulevard Jean Moulin, 13005 Marseille
| | - Max Buttarelli
- Institut Paoli Calmettes & CRCM, 232, Bd de Sainte Marguerite, 13009 Marseille: Université Aix-Marseille, Faculté de Médecine Timone, 27 Boulevard Jean Moulin, 13005 Marseille
| | - Eric Lambaudie
- Institut Paoli Calmettes & CRCM, 232, Bd de Sainte Marguerite, 13009 Marseille: Université Aix-Marseille, Faculté de Médecine Timone, 27 Boulevard Jean Moulin, 13005 Marseille
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Evaluation of mastectomy with immediate autologous latissimus dorsi breast reconstruction following neoadjuvant chemotherapy and radiation therapy: A single institution study of 111 cases of invasive breast carcinoma. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2016; 42:949-55. [DOI: 10.1016/j.ejso.2016.03.024] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Revised: 03/07/2016] [Accepted: 03/22/2016] [Indexed: 11/22/2022]
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A Systematic Meta-analysis of Prosthetic-Based Breast Reconstruction in Irradiated Fields With or Without Autologous Muscle Flap Coverage. Ann Plast Surg 2016; 77:129-34. [DOI: 10.1097/sap.0000000000000288] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Immediate Implant Reconstruction Is Associated With a Reduced Risk of Lymphedema Compared to Mastectomy Alone: A Prospective Cohort Study. Ann Surg 2016; 263:399-405. [PMID: 25607768 DOI: 10.1097/sla.0000000000001128] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
OBJECTIVE We sought to determine the risk of lymphedema associated with immediate breast reconstruction compared to mastectomy alone. BACKGROUND Immediate breast reconstruction is increasingly performed at the time of mastectomy. Few studies have examined whether breast reconstruction impacts development of lymphedema. METHODS A total of 616 patients with breast cancer who underwent 891 mastectomies between 2005 and 2013 were prospectively screened for lymphedema at our institution, with 22.2 months' median follow-up. Mastectomies were categorized as immediate implant, immediate autologous, or no reconstruction. Arm measurements were performed preoperatively and during postoperative follow-up using a Perometer. Lymphedema was defined as 10% or more arm volume increase compared to preoperative. Kaplan-Meier and Cox regression analyses were performed to determine lymphedema rates and risk factors. RESULTS Of 891 mastectomies, 65% (580/891) had immediate implant, 11% (101/891) immediate autologous, and 24% (210/891) no reconstruction. The two-year cumulative incidence of lymphedema was as follows: 4.08% [95% confidence interval (CI): 2.59-6.41%] implant, 9.89% (95% CI: 4.98-19.1%) autologous, and 26.7% (95% CI: 20.4-34.4%) no reconstruction. By multivariate analysis, immediate implant [hazards ratio (HR): 0.352, P < 0.0001] but not autologous (HR: 0.706, P = 0.2151) reconstruction was associated with a significantly reduced risk of lymphedema compared to no reconstruction. Axillary lymph node dissection (P < 0.0001), higher body mass index (P < 0.0001), and greater number of nodes dissected (P = 0.0324) were associated with increased lymphedema risk. CONCLUSIONS This prospective study suggests that in patients for whom implant-based reconstruction is available, immediate implant reconstruction does not increase the risk of lymphedema compared to mastectomy alone.
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Quinn TT, Miller GS, Rostek M, Cabalag MS, Rozen WM, Hunter-Smith DJ. Prosthetic breast reconstruction: indications and update. Gland Surg 2016; 5:174-86. [PMID: 27047785 DOI: 10.3978/j.issn.2227-684x.2015.07.01] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND Despite 82% of patients reporting psychosocial improvement following breast reconstruction, only 33% patients choose to undergo surgery. Implant reconstruction outnumbers autologous reconstruction in many centres. METHODS A systematic review of the literature was undertaken. Inclusion required: (I) Meta-analyses or review articles; (II) adult patients aged 18 years or over undergoing alloplastic breast reconstruction; (III) studies including outcome measures; (IV) case series with more than 10 patients; (V) English language; and (VI) publication after 1(st) January, 2000. RESULTS After full text review, analysis and data extraction was conducted for a total of 63 articles. Definitive reconstruction with an implant can be immediate or delayed. Older patients have similar or even lower complication rates to younger patients. Complications include capsular contracture, hematoma and infection. Obesity, smoking, large breasts, diabetes and higher grade tumors are associated with increased risk of wound problems and reconstructive failure. Silicone implant patients have higher capsular contracture rates but have higher physical and psychosocial function. There were no associations made between silicone implants and cancer or systemic disease. There were no differences in outcomes or complications between round and shaped implants. Textured implants have a lower risk of capsular contracture than smooth implants. Smooth implants are more likely to be displaced as well as having higher rates of infection. Immediate breast reconstruction (IBR) gives the best aesthetic outcome if radiotherapy is not required but has a higher rate of capsular contracture and implant failure. Delayed-immediate reconstruction patients can achieve similar aesthetic results to IBR whilst preserving the breast skin if radiotherapy is required. Delayed breast reconstruction (DBR) patients have fewer complications than IBR patients. CONCLUSIONS Implant reconstruction is a safe and popular mode of post-mastectomy reconstruction. Evidence exists for the settings in which complications are more likely, and we can now more reliably predict outcomes of reconstruction on an individual basis and assess patient suitability.
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Affiliation(s)
- Tam T Quinn
- 1 Department of Plastic and Reconstructive Surgery, Frankston Hospital, Peninsula Health, Frankston, Victoria 3199, Australia ; 2 Monash University Plastic Surgery Group (Peninsula Clinical School), Peninsula Health, Frankston, Victoria 3199, Australia ; 3 Department of Surgery, School of Medicine and Dentistry, James Cook University Clinical School, Townsville Hospital, Townsville, Queensland 4814, Australia
| | - George S Miller
- 1 Department of Plastic and Reconstructive Surgery, Frankston Hospital, Peninsula Health, Frankston, Victoria 3199, Australia ; 2 Monash University Plastic Surgery Group (Peninsula Clinical School), Peninsula Health, Frankston, Victoria 3199, Australia ; 3 Department of Surgery, School of Medicine and Dentistry, James Cook University Clinical School, Townsville Hospital, Townsville, Queensland 4814, Australia
| | - Marie Rostek
- 1 Department of Plastic and Reconstructive Surgery, Frankston Hospital, Peninsula Health, Frankston, Victoria 3199, Australia ; 2 Monash University Plastic Surgery Group (Peninsula Clinical School), Peninsula Health, Frankston, Victoria 3199, Australia ; 3 Department of Surgery, School of Medicine and Dentistry, James Cook University Clinical School, Townsville Hospital, Townsville, Queensland 4814, Australia
| | - Miguel S Cabalag
- 1 Department of Plastic and Reconstructive Surgery, Frankston Hospital, Peninsula Health, Frankston, Victoria 3199, Australia ; 2 Monash University Plastic Surgery Group (Peninsula Clinical School), Peninsula Health, Frankston, Victoria 3199, Australia ; 3 Department of Surgery, School of Medicine and Dentistry, James Cook University Clinical School, Townsville Hospital, Townsville, Queensland 4814, Australia
| | - Warren M Rozen
- 1 Department of Plastic and Reconstructive Surgery, Frankston Hospital, Peninsula Health, Frankston, Victoria 3199, Australia ; 2 Monash University Plastic Surgery Group (Peninsula Clinical School), Peninsula Health, Frankston, Victoria 3199, Australia ; 3 Department of Surgery, School of Medicine and Dentistry, James Cook University Clinical School, Townsville Hospital, Townsville, Queensland 4814, Australia
| | - David J Hunter-Smith
- 1 Department of Plastic and Reconstructive Surgery, Frankston Hospital, Peninsula Health, Frankston, Victoria 3199, Australia ; 2 Monash University Plastic Surgery Group (Peninsula Clinical School), Peninsula Health, Frankston, Victoria 3199, Australia ; 3 Department of Surgery, School of Medicine and Dentistry, James Cook University Clinical School, Townsville Hospital, Townsville, Queensland 4814, Australia
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Zinzindohoué C, Bertrand P, Michel A, Monrigal E, Miramand B, Sterckers N, Faure C, Charitansky H, Gutowski M, Cohen M, Houvenaeghel G, Trentini F, Raro P, Daures JP, Lacombe S. A Prospective Study on Skin-Sparing Mastectomy for Immediate Breast Reconstruction with Latissimus Dorsi Flap After Neoadjuvant Chemotherapy and Radiotherapy in Invasive Breast Carcinoma. Ann Surg Oncol 2016; 23:2350-6. [PMID: 26957504 DOI: 10.1245/s10434-016-5146-y] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Indexed: 11/18/2022]
Abstract
BACKGROUND Skin-sparing mastectomy (SSM) with immediate breast reconstruction (IBR) is increasingly used in invasive breast cancer. However, adjuvant chemotherapy (CT) and radiotherapy (RT) can increase the rate of local complications. OBJECTIVE The aim of this study was to assess the morbidity of SSM-IBR after neoadjuvant CT and RT. METHODS A French prospective pilot study of women aged 18-75 years with invasive breast cancer requiring mastectomy after CT and RT. Reconstruction was performed using autologous latissimus dorsi flap with or without prosthesis. The primary endpoint was the skin necrosis rate within 6 months, while secondary endpoints included pathological complete response rate (pCR) and global morbidity. RESULTS Among 94 patients included in this study, 83 were analyzed (mean age 45.2 ± 9.5 years, T1 23.6 %, T2 55.6 %, T3 18.1 %). All but one patient received anthracyclines and taxanes, and all patients received RT (49.3 ± 5.2 Gy) before SSM-IBR. Prostheses were used for IBR in 32 patients (mean volume 256 ± 73 mm(3)). Five patients had necrosis (≤2 cm(2), 2-10 cm(2) and >10 cm(2), in three, one, and one cases, respectively), and they all recovered without revision surgery. Among 50 patients who underwent upfront mastectomy, 36 % achieved pCR. CONCLUSIONS SSM-IBR performed after CT and RT is safe, with an acceptable local morbidity rate. Long-term data are needed to evaluate recurrence rates.
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Affiliation(s)
| | - Pierre Bertrand
- Montpellier Institut du Sein, Clinique Clémentville, Montpellier, France
| | - Aude Michel
- Montpellier Institut du Sein, Clinique Clémentville, Montpellier, France.,Epsylon EA 4556 Laboratory "Dynamics of Human Abilities & Health Behaviors", University Paul Valéry Montpellier 3, Montpellier, France
| | - Emilie Monrigal
- Montpellier Institut du Sein, Clinique Clémentville, Montpellier, France
| | | | | | | | | | - Marian Gutowski
- Institut Du Cancer De Montpellier (ICM), Montpellier, France
| | | | | | - Frederic Trentini
- Montpellier Institut du Sein, Clinique Saint Roch, Montpellier, France
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Jinno H, Inokuchi M, Ito T, Kitamura K, Kutomi G, Sakai T, Kijima Y, Wada N, Ito Y, Mukai H. The Japanese Breast Cancer Society clinical practice guideline for surgical treatment of breast cancer, 2015 edition. Breast Cancer 2016; 23:367-77. [PMID: 26921084 DOI: 10.1007/s12282-016-0671-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Accepted: 01/23/2016] [Indexed: 11/28/2022]
Affiliation(s)
- Hiromitsu Jinno
- Department of Surgery, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi, Tokyo, 1738606, Japan.
| | - Masafumi Inokuchi
- Department of Breast Oncology, Kanazawa University Hospital, Ishikawa, Japan
| | - Toshikazu Ito
- Department of Surgery, Rinku General Medical Center, Osaka, Japan
| | - Kaoru Kitamura
- Department of Breast Surgery, Nagumo Clinic Fukuoka, Fukuoka, Japan
| | - Goro Kutomi
- Department of Surgery, Surgical Oncology and Science, Sapporo Medical University Hospital Hokkaido, Sapporo, Japan
| | - Takehiko Sakai
- Breast Oncology Center, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Yuko Kijima
- Department of Digestive Surgery, Breast and Thyroid Surgery, Kagoshima University School of Medicine, Kagoshima, Japan
| | - Noriaki Wada
- Department of General and Breast Surgery, Tokyo Dental College Ichikawa General Hospital, Chiba, Japan
| | - Yoshinori Ito
- Department of Breast Medical Oncology, The Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Hirofumi Mukai
- Department of General and Breast Surgery, Tokyo Dental College Ichikawa General Hospital, Chiba, Japan
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Mastectomy Weight and Tissue Expander Volume Predict Necrosis and Increased Costs Associated with Breast Reconstruction. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2015; 3:e450. [PMID: 26301139 PMCID: PMC4527624 DOI: 10.1097/gox.0000000000000408] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2014] [Accepted: 05/04/2015] [Indexed: 12/26/2022]
Abstract
Introduction: Impaired vascular perfusion in tissue expander (TE) breast reconstruction leads to mastectomy skin necrosis. We investigated factors and costs associated with skin necrosis in postmastectomy breast reconstruction. Methods: Retrospective review of 169 women with immediate TE placement following mastectomy between May 1, 2009 and May 31, 2013 was performed. Patient demographics, comorbidities, intraoperative, and postoperative outcomes were collected. Logistic regression analysis on individual variables was performed to determine the effects of tissue expander fill volume and mastectomy specimen weight on skin necrosis. Billing data was obtained to determine the financial burden associated with necrosis. Results: This study included 253 breast reconstructions with immediate TE placement from 169 women. Skin necrosis occurred in 20 flaps for 15 patients (8.9%). Patients with hypertension had 8 times higher odds of skin necrosis [odd ratio (OR), 8.10, P < 0.001]. Patients with TE intraoperative fill volumes >300 cm3 had 10 times higher odds of skin necrosis (OR, 10.66, P =0.010). Volumes >400 cm3 had 15 times higher odds of skin necrosis (OR, 15.56, P = 0.002). Mastectomy specimen weight was correlated with skin necrosis. Specimens >500 g had 10 times higher odds of necrosis and specimens >1000 g had 18 times higher odds of necrosis (OR, 10.03 and OR, 18.43; P =0.003 and P <0.001, respectively). Mastectomy skin necrosis was associated with a 50% increased inpatient charge. Conclusion: Mastectomy flap necrosis is associated with HTN, larger TE volumes and mastectomy specimen weights, resulting in increased inpatient charges. Conservative TE volumes should be considered for patients with hypertension and larger mastectomy specimens.
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Lee M, Reinertsen E, McClure E, Liu S, Kruper L, Tanna N, Brian Boyd J, Granzow JW. Surgeon motivations behind the timing of breast reconstruction in patients requiring postmastectomy radiation therapy. J Plast Reconstr Aesthet Surg 2015; 68:1536-42. [PMID: 26277336 DOI: 10.1016/j.bjps.2015.06.026] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Accepted: 06/21/2015] [Indexed: 11/19/2022]
Abstract
OBJECTIVES Although postmastectomy radiation therapy (PMRT) has been shown to reduce breast cancer burden and improve survival, PMRT may negatively influence outcomes after reconstruction. The goal of this study was to compare current opinions of plastic and reconstructive surgeons (PRS) and surgical oncologists (SO) regarding the optimal timing of breast reconstruction for patients requiring PMRT. METHODS Members of the American Society of Plastic Surgeons (ASPS), the American Society of Breast Surgeons (ASBS), and the Society of Surgical Oncology (SSO) were asked to participate in an anonymous web-based survey. Responses were solicited in accordance to the Dillman method, and they were analyzed using standard descriptive statistics. RESULTS A total of 330 members of the ASPS and 348 members of the ASBS and SSO participated in our survey. PRS and SO differed in patient-payor mix (p < 0.01) and practice setting (p < 0.01), but they did not differ by urban versus rural setting (p = 0.65) or geographic location (p = 0.30). Although PRS favored immediate reconstruction versus SO, overall timing did not significantly differ between the two specialists (p = 0.14). The primary rationale behind delayed breast reconstruction differed significantly between PRS and SO (p < 0.01), with more PRS believing that the reconstructive outcome is significantly and adversely affected by radiation. Both PRS and SO cited "patient-driven desire to have immediate reconstruction" (p = 0.86) as the primary motivation for immediate reconstruction. CONCLUSIONS Although the optimal timing of reconstruction is controversial between PRS and SO, our study suggests that the timing of reconstruction in PMRT patients is ultimately driven by patient preferences and the desire of PRS to optimize aesthetic outcomes.
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Affiliation(s)
- Ming Lee
- Emory University School of Medicine, Atlanta, GA, USA
| | - Erik Reinertsen
- Emory University School of Medicine, Atlanta, GA, USA; Department of Biomedical Engineering, Georgia Institute of Technology, Atlanta, GA, USA
| | - Evan McClure
- Emory University School of Medicine, Atlanta, GA, USA; Goizueta Business School, Emory University, Atlanta, GA, USA
| | - Shuling Liu
- Department of Biostatistics, Rollins School of Public Health at Emory University, Atlanta, GA, USA
| | - Laura Kruper
- Division of Surgical Oncology, City of Hope Cancer Center, Los Angeles, CA, USA
| | - Neil Tanna
- Division of Plastic and Reconstructive Surgery, North Shore - LIJ Health System, New York, NY, USA
| | - J Brian Boyd
- Harbor-UCLA Medical Center and the UCLA David Geffen School of Medicine, Los Angeles, CA, USA
| | - Jay W Granzow
- Harbor-UCLA Medical Center and the UCLA David Geffen School of Medicine, Los Angeles, CA, USA.
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Caterson SA, Carty MJ, Helliwell LA, Hergrueter CA, Pribaz JJ, Sinha I. Evolving options for breast reconstruction. Curr Probl Surg 2015; 52:192-224. [DOI: 10.1067/j.cpsurg.2015.04.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2015] [Accepted: 04/08/2015] [Indexed: 01/11/2023]
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Maass SWMC, Bagher S, Hofer SOP, Baxter NN, Zhong T. Systematic Review: Aesthetic Assessment of Breast Reconstruction Outcomes by Healthcare Professionals. Ann Surg Oncol 2015; 22:4305-16. [PMID: 25691279 DOI: 10.1245/s10434-015-4434-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2014] [Indexed: 11/18/2022]
Abstract
BACKGROUND Achieving an aesthetic outcome following postmastectomy breast reconstruction is both an important goal for the patient and plastic surgeon. However, there is currently an absence of a widely accepted, standardized, and validated professional aesthetic assessment scale following postmastectomy breast reconstruction. METHODS A systematic review was performed to identify all articles that provided professional assessment of the aesthetic outcome following postmastectomy, implant- or autologous tissue-based breast reconstruction. A modified version of the Scientific Advisory Committee's Medical Outcomes Trust (MOT) criteria was used to evaluate all professional aesthetic assessment scales identified by our systematic review. The criteria included conceptual framework formation, reliability, validity, responsiveness, interpretability, burden, and correlation with patient-reported outcomes. RESULTS A total of 120 articles were identified: 52 described autologous breast reconstruction, 37 implant-based reconstruction, and 29 both. Of the 12 different professional aesthetic assessment scales that exist in the literature, the most commonly used scale was the four-point professional aesthetic assessment scale. The highest score on the modified MOT criteria was assigned to the ten-point professional aesthetic assessment scale. However, this scale has limited clinical usefulness due to its poor responsiveness to change, lack of interpretability, and wide range of intra- and inter-rater agreements (Veiga et al. in Ann Plast Surg 48(5):515-520, 2002). CONCLUSIONS A "gold standard" professional aesthetic assessment scale needs to be developed to enhance the comparability of breast reconstruction results across techniques, surgeons, and studies to aid with the selection of procedures that produce the best aesthetic results from both the perspectives of the surgeon and patients.
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Affiliation(s)
- Saskia W M C Maass
- Division of Plastic & Reconstructive Surgery, Department of Surgery and Surgical Oncology, University Health Network, Toronto, ON, Canada.,Division of Plastic & Reconstructive Surgery, University of Toronto, Toronto, ON, Canada
| | - Shaghayegh Bagher
- Division of Plastic & Reconstructive Surgery, Department of Surgery and Surgical Oncology, University Health Network, Toronto, ON, Canada.,Division of Plastic & Reconstructive Surgery, University of Toronto, Toronto, ON, Canada
| | - Stefan O P Hofer
- Division of Plastic & Reconstructive Surgery, Department of Surgery and Surgical Oncology, University Health Network, Toronto, ON, Canada.,Division of Plastic & Reconstructive Surgery, University of Toronto, Toronto, ON, Canada.,Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Nancy N Baxter
- Departments of Surgery and Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada.,The Keenan Research Centre, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada.,Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Toni Zhong
- Division of Plastic & Reconstructive Surgery, Department of Surgery and Surgical Oncology, University Health Network, Toronto, ON, Canada. .,Division of Plastic & Reconstructive Surgery, University of Toronto, Toronto, ON, Canada. .,Department of Surgery, University of Toronto, Toronto, ON, Canada.
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Komoike Y, Inokuchi M, Itoh T, Kitamura K, Kutomi G, Sakai T, Jinno H, Wada N, Ohsumi S, Mukai H. Japan Breast Cancer Society clinical practice guideline for surgical treatment of breast cancer. Breast Cancer 2014; 22:37-48. [PMID: 25091115 DOI: 10.1007/s12282-014-0558-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2014] [Accepted: 07/16/2014] [Indexed: 10/24/2022]
Affiliation(s)
- Yoshifumi Komoike
- Section of Breast and Endocrine Surgery, Department of Surgery, Kinki University Faculty of Medicine, 377-2 Onohigashi, Osakasayama, Osaka, 589-8511, Japan,
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Walsh SM, Lowery AJ, Prichard RS, McDermott EW, Evoy D, Geraghty J. Postmastectomy radiotherapy: indications and implications. Surgeon 2014; 12:310-5. [PMID: 25037652 DOI: 10.1016/j.surge.2014.04.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2013] [Revised: 04/14/2014] [Accepted: 04/16/2014] [Indexed: 11/16/2022]
Abstract
BACKGROUND Although breast conservation surgery, when combined with radiotherapy, has been shown to provide excellent locoregional control for breast cancer, approximately one third of women with breast cancer require mastectomy. Many of these women are offered immediate reconstruction. Postmastectomy radiotherapy (PMRT) is indicated in some cases, but is associated with side-effects, including its impact on the reconstructed breast. OBJECTIVE To review the pertinent issues surrounding PMRT, including patient selection for radiotherapy and the effect of radiotherapy on reconstructive decisions. METHODS A literature review was performed using the Medline database. CONCLUSIONS PMRT is indicated in patients who are deemed to have a high risk of loco-regional recurrence. Although PMRT is strongly recommended for patients with four or more positive lymphnodes, other indications for PMRT remain controversial. Immediate reconstruction post mastectomy has been shown to have favorable outcomes. However, PMRT may increase the need for revision surgery post immediate reconstruction. There are few randomized trials looking at these key issues, and the evidence is largely derived from observational retrospective studies. Patients should be carefully counseled before a decision is made to proceed with immediate reconstruction, where there is a high chance that PMRT may be indicated.
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Affiliation(s)
- S M Walsh
- Department of Breast Surgery, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - A J Lowery
- Department of Breast Surgery, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - R S Prichard
- Department of Breast Surgery, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - E W McDermott
- Department of Breast Surgery, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - D Evoy
- Department of Breast Surgery, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - J Geraghty
- Department of Breast Surgery, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland.
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Shea-Budgell M, Quan ML, Mehling B, Temple-Oberle C. Breast reconstruction following prophylactic or therapeutic mastectomy for breast cancer: Recommendations from an evidence-based provincial guideline. Plast Surg (Oakv) 2014. [DOI: 10.1177/229255031402200204] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Affiliation(s)
| | - May Lynn Quan
- Division of Surgical Oncology, University of Calgary, Calgary; Calgary, Alberta
| | - Blair Mehling
- Division of Plastic Surgery, University of Alberta, Edmonton; Calgary, Alberta
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Incidence of Surgical-Site Infection Is Not Affected by Method of Immediate Breast Reconstruction. Plast Reconstr Surg 2013; 132:20e-29e. [DOI: 10.1097/prs.0b013e318290f87e] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Krumboeck A, Giovanoli P, Plock JA. Fat grafting and stem cell enhanced fat grafting to the breast under oncological aspects--recommendations for patient selection. Breast 2013; 22:579-84. [PMID: 23769661 DOI: 10.1016/j.breast.2013.05.006] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2012] [Accepted: 05/05/2013] [Indexed: 11/29/2022] Open
Abstract
Reconstructive and aesthetic fat grafting has been introduced to the breast level over the last years. The safety of such procedures has so far not been completely clarified. The concept has now been refined to stem cell enhanced fat grafting. However beside the promise of using adult stem cells in terms of tissue rejuvenation and augmentation, scar treatment and reconstruction, the variance of adipose stem cell function--including angiogenetic, antiapoptotic, immunomodulatory, chemotactic and anti-scarring potential--raises new scepsis about oncological safety. Herein we reviewed experimental and clinical data on fat grafting and stem cell enhanced fat grafting addressing surgical promise and oncological concerns. Based on these data we suggest clinical criteria for patient selection undergoing fat grafting for aesthetic or reconstructive reasons based on their individual breast cancer risk.
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Affiliation(s)
- Anna Krumboeck
- Division of Plastic and Hand Surgery, University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland
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Brennan M, Spillane A. Uptake and predictors of post-mastectomy reconstruction in women with breast malignancy – Systematic review. Eur J Surg Oncol 2013; 39:527-41. [DOI: 10.1016/j.ejso.2013.02.021] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2012] [Revised: 02/13/2013] [Accepted: 02/20/2013] [Indexed: 01/20/2023] Open
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Lumbar herniation following extended autologous latissimus dorsi breast reconstruction. BMC Surg 2013; 13:16. [PMID: 23721459 PMCID: PMC3671191 DOI: 10.1186/1471-2482-13-16] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2012] [Accepted: 05/21/2013] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Reconstructive breast surgery is now recognized to be an important part of the treatment for breast cancer. Surgical reconstruction options consist of implants, autologous tissue transfer or a combination of the two. The latissimus dorsi flap is a pedicled musculocutaneous flap and is an established method of autologous breast reconstruction.Lumbar hernias are an unusual type of hernia, the majority occurring after surgery or trauma in this area. The reported incidence of a lumbar hernia subsequent to a latissimus dorsi reconstruction is very low. CASE PRESENTATION We present the unusual case of lumbar herniation after an extended autologous latissimus dorsi flap for breast reconstruction following a mastectomy. The lumbar hernia was confirmed on CT scanning and the patient underwent an open mesh repair of the hernia through the previous latissimus dorsi scar. CONCLUSION Lumbar hernias are a rare complication that can occur following latissimus dorsi breast reconstruction. It should be considered in all patients presenting with persistent pain or swelling in the lumbar region.
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Current status of autologous tissue-based breast reconstruction in patients receiving postmastectomy radiation therapy. Plast Reconstr Surg 2012; 130:282-292. [PMID: 22842406 DOI: 10.1097/prs.0b013e3182589be1] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND The threshold for patients with breast cancer to receive radiation therapy continues to be lowered. The author reviewed the literature to determine the clinical impact that the increasing use of radiation therapy has had on the management of patients with breast cancer who desire autologous tissue-based breast reconstruction. METHODS The MEDLINE database was searched for articles on breast reconstruction and radiation therapy published between January of 2008 and June of 2011. Abstracts of those articles were reviewed to identify articles that addressed the most pressing radiation-related issues facing reconstructive breast surgeons performing autologous tissue-based reconstruction. This subgroup of articles was reviewed in detail. RESULTS Two-hundred eighty-five articles were identified. Seventeen articles were reviewed in detail. Nine articles provided level III evidence, mostly from retrospective comparative studies. Five articles provided level I (n=2) or II (n=3) evidence from high-quality, multicenter or single-center, randomized, controlled trials or prospective cohort studies. Three articles provided level IV evidence from case series and were included in the review because they offered a novel approach or perspective. Since the author's last review of the literature in 2009, there have been changes in the practice patterns in the approach to autologous breast reconstruction in patients who undergo radiation therapy. CONCLUSION With the increasing use of radiation therapy in patients with breast cancer, future studies should seek to provide more meaningful data (level I and II evidence) to help guide clinical decision-making. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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Abstract
INTRODUCTION Surgical site infections (SSI) are a source of significant postoperative morbidity and cost. Although immediate breast reconstruction after mastectomy has become routine, the data regarding the incidence of SSI in immediate breast reconstruction is highly variable and series dependent. METHODS Using the National Surgical Quality Improvement Program database, all female patients undergoing mastectomy, with or without immediate reconstruction, from 2005 to 2009 were identified. Only "clean" procedures were included. The primary outcome was incidence of SSI within 30 days of operation. Stepwise logistic regression analysis was used to identify risk factors associated with SSI. RESULTS A total of 48,393 mastectomies were performed during the study period, of which 9315 (19.2%) had immediate breast reconstruction. The incidence of SSI was 3.5% (330/9315) (95% CI [confidence interval]: 3.2%-4%) in patients undergoing mastectomy with reconstruction and 2.5% (966/39,078) (95% CI: 2.3%-2.6%) in patients undergoing mastectomy without reconstruction (P < 0.001). Independent risk factors for SSI include increased preoperative body mass index (BMI), heavy alcohol use, ASA (American Society of Anesthesiologists) score greater than 2, flap failure, and operative time of 6 hours or longer. CONCLUSIONS Immediate breast reconstruction is associated with a statistically significant increase in risk of SSI in patients undergoing mastectomy (3.5% vs 2.5%). However, this difference was not considered to be clinically significant. In this large series, increased BMI, alcohol use, ASA class greater than 2, flap failure, and prolonged operative time were associated with increased risk of SSI.
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Rykała J, Szychta P, Kruk-Jeromin J. Delayed two-stage breast reconstruction with implants: The authors' recent experience. THE CANADIAN JOURNAL OF PLASTIC SURGERY = JOURNAL CANADIEN DE CHIRURGIE PLASTIQUE 2012; 19:88-92. [PMID: 22942657 DOI: 10.1177/229255031101900306] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Presently, breast cancer detection is delayed in Poland and, thus, the only other option for patients is amputation and breast reconstruction (immediate or delayed). Reconstructive methods are based on using the patient's own tissue (pedicled or free myocutaneous flaps) or implants (a tissue expander, which is later exchanged for a prosthesis or an expandable implant). OBJECTIVE To evaluate the aesthetic results of a delayed two-stage breast reconstruction with the use of implants (expander and prosthesis) in patients who have previously undergone cancer-related mastectomy. METHODS From 2006 to 2009, 54 patients (34 to 65 years of age) underwent reconstruction at least one year after their mastectomy and adjuvant chemotherapy; three women also received x-ray therapy. All women underwent a two-stage treatment with a tissue expander, which was later exchanged for a prosthesis. RESULTS Outcomes of the surgery (evaluated by the physician and the patient at least six months after all stages of reconstruction) were found to be very good in 42 patients and good in 12 patients. After amputation and x-ray therapy in two cases, a fistula developed, which necessitated implant removal. CONCLUSIONS After amputation, breast reconstruction with implants (expander and prosthesis) provides good aesthetic results. The method is mildly burdening to the patient and does not cause severe scarring. Symmetrization of the second breast is often recommended; however, the cost is not covered by the national health system. In principle, earlier x-ray therapy disqualifies the application of implants. Dividing reconstruction into two stages (expander and prosthesis) allows for possible correction of prosthesis placement.
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Affiliation(s)
- Jan Rykała
- Plastic, Reconstructive and Aesthetic Surgery Department, Medical University of Lodz, Poland
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Oh E, Chim H, Soltanian HT. The effects of neoadjuvant and adjuvant chemotherapy on the surgical outcomes of breast reconstruction. J Plast Reconstr Aesthet Surg 2012; 65:e267-80. [PMID: 22633392 DOI: 10.1016/j.bjps.2012.04.053] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2011] [Revised: 03/24/2012] [Accepted: 04/30/2012] [Indexed: 12/26/2022]
Abstract
Breast reconstruction following mastectomy has become, in many centers the standard of care. An increasingly encountered trend is the use of neoadjuvant chemotherapy to downstage high stage tumors and to decrease tumor burden prior to definitive oncologic surgery. These agents clearly provide a survival benefit, but also have the potential to adversely affect the surgical course of immediate and delayed breast reconstruction. The use of new biologic and hormonal agents may also have effects on surgery and reconstruction. Furthermore, chemotherapeutic agents as a whole may impair cellular functions necessary for normal recovery from surgery. In this paper we present a concise review for the reconstructive surgeon on adverse effects of chemotherapeutic, hormonal and biologic agents used for treatment of breast cancer, important perioperative issues, and also discuss their potential effect on breast reconstruction.
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Affiliation(s)
- Eugene Oh
- Department of Plastic Surgery, Case School of Medicine, 11100 Euclid Avenue, Cleveland, OH 44106, USA
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Lambert K, Mokbel K. Does post-mastectomy radiotherapy represent a contraindication to skin-sparing mastectomy and immediate reconstruction: an update. Surg Oncol 2012; 21:e67-74. [PMID: 22296996 DOI: 10.1016/j.suronc.2011.12.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2011] [Revised: 12/01/2011] [Accepted: 12/15/2011] [Indexed: 01/15/2023]
Abstract
The use of skin-sparing mastectomy (SSM) to facilitate breast reconstruction is increasing due to a wide acceptance of improved cosmetic outcomes and evidence of equivalence in oncologic outcomes. The rates of patients undergoing mastectomy for whom post-mastectomy radiotherapy (PMRT) will be recommended is increasing as evidence of decreased loco-regional recurrence and increased survival mounts. PMRT may adversely effect complication rates and cosmetic outcomes for patients undergoing immediate breast reconstruction and PMRT--although the evidence for this is methodologically flawed. This article summarises the above evidence and highlights a reconstructive algorithm that may be used to mitigate the possible deleterious effects of PMRT on results.
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Affiliation(s)
- K Lambert
- The Breast Unit, University Hospitals Leicester, 56 Stretton Road, Leicester, UK.
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Monrigal E, Dauplat J, Gimbergues P, Le Bouedec G, Peyronie M, Achard J, Chollet P, Mouret-Reynier M, Nabholtz J, Pomel C. Mastectomy with immediate breast reconstruction after neoadjuvant chemotherapy and radiation therapy. A new option for patients with operable invasive breast cancer. Results of a 20 years single institution study. Eur J Surg Oncol 2011; 37:864-70. [DOI: 10.1016/j.ejso.2011.07.009] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2010] [Revised: 06/27/2011] [Accepted: 07/25/2011] [Indexed: 11/16/2022] Open
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