Optimal breast reconstruction type for patients treated with neoadjuvant chemotherapy, mastectomy followed by radiation therapy

The Relationship Between Radiation History and Outcomes of Immediate Implant-Based Breast Reconstruction

BACKGROUND

Postmastectomy Radiotherapy (PMRT) has become standard of care for patients with breast cancer. However, local recurrence following breast conserving therapy is increasing in incidence due to increased survivorship. The relationship between prior radiation therapy, PMRT and immediate breast reconstruction (IBR) outcomes has not been widely studied. We aim to assess factors that correlate with post-IBR complications in the face of radiation therapy.

METHODS

An IRB approved retrospective cohort review of 262 patients was completed using our tumor registry to identify female patients age ≥ 18 with and without history of radiation who underwent mastectomy with IBR. Operative, clinical, and pathological data was collected, and univariate and multiple logistic regression analyses were conducted to evaluate the relationship between receipt of radiation and major and minor complications. Kaplan-Meier analysis was also conducted to assess the differences between the time to receipt of radiation and cancer recurrence amongst the 3 treatment groups.

RESULTS

There was no correlation between major or minor complications and a history of prior radiation. Patients with PMRT demonstrated a higher incidence of "other" minor complications (OR 2.8, CI 1.27-6.28, P = .01), such as erythema and edema. There was a higher incidence of implant exposure requiring reoperation (OR 5.7, CI 1.36-23.78, P = .01) and "other'' minor complications (OR 3.1, CI 1.32-7.35, P < .001) in patients with PMRT. Receipt of PMRT was associated with lower survival in compared to patients with no history of radiation treatment.

CONCLUSION

Our study found no significant associations between history of prior radiation and surgical complications after mastectomy and IBR. However, patients with PMRT were at increased risk of developing minor complications requiring reoperation. This suggests that we should discuss radiation concerns preoperatively and manage expectations regarding its effect on outcome.

Impact of Prepectoral Implant Placement and Radiation Modalities (Protons/Photons/Dosimetry) in Mastectomy Patients Undergoing Immediate Single Stage Direct-to-Implant Breast Reconstruction

PURPOSE

For patients with breast cancer receiving mastectomy with direct-to-implant (DTI) immediate breast reconstruction, placing the implant in the prepectoral or subpectoral plane remains debatable, especially in settings of postmastectomy radiation therapy (PMRT).

METHODS AND MATERIALS

We reviewed 3039 patients who underwent mastectomy and reconstruction at our institution between 2005 and 2020. Patients receiving DTI with and without PMRT were included. PMRT was delivered either with a photon (3-dimensional-conformal or volumetric arc therapy) or proton therapy, mainly with pencil-beam-scanning. All patients received conventional fractionation (50-50.4 Gy in 25-28 fractions). Primary endpoints were reconstruction complications defined as infection/necrosis requiring debridement; capsular contracture requiring capsulotomy; absolute reconstruction failure entailing permanent removal of the implant without replacement (ie, no salvage reconstruction); and overall reconstruction failure (removal of the implant for any complication with and without salvage reconstruction). Different subgroup analyses were done.

RESULTS

A total of 815 patients met inclusion criteria, with an overall median follow-up of 6.2 years. We found that there is no significant difference between prepectoral versus subpectoral for infection/necrosis (odds ratio [OR], 1.5; P = .3); capsular contracture (OR, 0.97; P = .9); absolute reconstruction failure (OR, 1.9; P = .12); and overall reconstruction failure (OR, 1.2; P = .5). Findings were confirmed using both logistic regression, time-to-event analysis, and multivariable analyses for the entire cohort and subgroups with and without PMRT. There was no significant difference between protons and photons in terms of infection/necrosis (OR, 1.6; P = .4) and absolute reconstruction failure (OR, 1.2; P = .7), but there were significantly higher risks for capsular contracture with protons (OR, 4.4; P < .001) and overall reconstruction failure compared with photons (OR, 2.0; P = .05). We did not find a significant correlation pattern between different dosimetry factors (the average dose, the maximum dose, and volume in cubic centimeter) in either the reconstructed chest wall target or the skin structure, about reconstruction complications, whether for proton or photon patients.

CONCLUSIONS

For patients receiving single-stage DTI reconstruction with and without PMRT, prepectoral implant placement had similar rates of complications and reconstruction failure compared with subpectoral reconstruction. Protons compared with photons did not increase the risk of infection/necrosis but significantly increased capsular contracture risks.

The Impact of Preoperative Radiotherapy and Chemotherapy on Autologous Breast Reconstruction Outcomes-A Retrospective Single-Center Study

BACKGROUND

While radiotherapy (RT) and chemotherapy (CT) significantly improve breast cancer outcomes, they may affect breast reconstruction by causing vascular damage and delayed wound healing. This retrospective study evaluates how preoperative RT, CT, or the combination of both impacts intraoperative and postoperative outcomes in immediate or delayed deep inferior epigastric perforator (DIEP) flap breast reconstructions.

METHODS

We conducted a single-center review of all patients undergoing autologous DIEP flap reconstruction after mastectomy between 2018 and 2024. Patients were divided into four groups: RT only, CT only, a combination of RT and CT, and a control group with no preoperative therapies. Intraoperative and postoperative outcomes were then compared among these groups, with statistical significance defined as p < 0.05.

RESULTS

We included 114 patients representing 141 DIEP-flap breast reconstructions. Flap survival rate was 98.5%. In the univariate analysis, total microvascular recipient site complications were significantly higher in the RT + CT group (14.0%, p = 0.021). Donor-site complication rates differed significantly among the four groups (p = 0.025), with the highest rate observed in the RT + CT group (44.7%). In the logistic regression analysis, ischemia time was found as an independent risk factor for total recipient site complications, but not for microvascular complications (OR = 1.019, 95%-CI = 1.004-1.035, p = 0.014).

CONCLUSIONS

Combined RT + CT significantly increased microsurgical complications. Ischemia time correlated with higher odds of total recipient site complications. Individualized patient management and diminished ischemia time are likely to improve flap survival.

Post-mastectomy hypofractionated versus conventionally fractionated radiation therapy for patients receiving immediate breast reconstruction: Subgroup analysis of a phase III randomized trial

•The incidence of complications is higher for patients with TE irradiated, then for those with PI, and the lowest for those with AT.•The use of hypofractionation in patients with any type of IBR does not seem to increase complications as compared to conventional fractionation.•Our findings might help to support further implementation of the hypofractionated schedule after IBR.

Implants versus autologous tissue flaps for breast reconstruction following mastectomy

BACKGROUND

Women who have a mastectomy for breast cancer treatment or risk reduction may be offered different options for breast reconstruction, including use of implants or the woman's own tissue (autologous tissue flaps). The choice of technique depends on factors such as the woman's preferences, breast characteristics, preoperative imaging, comorbidities, smoking habits, prior chest or breast irradiation, and planned adjuvant therapies.

OBJECTIVES

To assess the effects of implants versus autologous tissue flaps for postmastectomy breast reconstruction on women's quality of life, satisfaction, and short- and long-term surgical complications.

SEARCH METHODS

We searched the Cochrane Breast Cancer Group's Specialised Register, CENTRAL, MEDLINE, Embase, and two trials registries in July 2022.

SELECTION CRITERIA

We included studies that compared implant-based reconstruction with autologous tissue-based reconstruction following mastectomy for breast cancer treatment or risk reduction. The minimum eligible sample size was 100 participants.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed risk of bias and extracted data using standard Cochrane procedures. We used GRADE to assess the certainty of the evidence.

MAIN RESULTS

Thirty-five non-randomised studies with 57,555 participants met our inclusion criteria. There were nine prospective cohort studies and 26 retrospective cohort studies. We judged 26 studies at serious overall risk of bias and the remaining studies at moderate overall risk of bias. Some studies measured quality of life and satisfaction using the BREAST-Q (scale of 0 to 100, higher is better). Implants may reduce postoperative psychosocial well-being compared with autologous tissue flaps (mean difference (MD) -4.26 points, 95% confidence interval (CI) -4.91 to -3.61; I² = 0%; 6 studies, 3335 participants; low-certainty evidence). Implants may reduce or have little to no effect on postoperative physical well-being compared with autologous tissue flaps, but the evidence is very uncertain (MD -1.92 points, 95% CI -4.44 to 0.60; I² = 87%; 6 studies, 3335 participants; very low-certainty evidence). Implants may reduce postoperative sexual well-being compared with autologous reconstruction (MD -6.63 points, 95% CI -7.55 to -5.72; I² = 0; 6 studies, 3335 participants; low-certainty evidence). Women who undergo breast reconstruction with implants versus autologous tissue flaps may be less satisfied with the breast, but the evidence is very uncertain (MD -8.17 points, 95% CI -11.41 to -4.92; I² = 90%; 6 studies, 3335 participants; very low-certainty evidence). This outcome refers to a woman's satisfaction with breast size, bra fit, appearance in the mirror (clothed or unclothed), and how the breast feels to touch. Women who undergo breast reconstruction with implants versus autologous tissue flaps may be less satisfied with the reconstruction (MD -5.96 points, 95% CI -10.24 to -1.68; I² = 62%; 4 studies, 1196 participants; low-certainty evidence). This outcome refers to whether the aesthetic outcome has met the woman's expectations, the impact surgery has had on her life, and whether she thinks she made the right decision to have the reconstruction. Implants may reduce or have little to no effect on the risk of short-term complications compared with autologous tissue flaps, but the evidence is very uncertain (risk ratio (RR) 0.80, 95% CI 0.63 to 1.03; I² = 91%; 22 studies, 34,244 participants; very low-certainty evidence). Implants may increase long-term complications compared with autologous tissue flaps, but the evidence is very uncertain (RR 1.56, 95% CI 1.09 to 2.22; I² = 94%; 17 studies, 26,930 participants; very low-certainty evidence). Implants may have little to no effect on the need for reintervention compared with autologous tissue flaps, but the evidence is very uncertain (RR 1.23, 95% CI 0.91 to 1.68; I² = 93%; 15 studies, 14,171 participants; very low-certainty evidence). Implants may reduce the duration of surgery compared with autologous tissue flaps, but the evidence is very uncertain (MD -125.04 minutes, 95% CI -131.41 to -118.67; I² = 0; 2 studies, 836 participants; very low-certainty evidence).

AUTHORS' CONCLUSIONS

The findings of this review show that autologous tissue-based reconstruction compared with implant-based reconstruction may improve participant-reported outcomes such as psychosocial well-being, sexual well-being, and satisfaction with the reconstruction. There is also very uncertain evidence to suggest that autologous tissue-based reconstruction increases satisfaction with the breast and reduces the risk of long-term complications compared with implants. Implant-based reconstruction may be a shorter procedure, but the evidence is very uncertain. Despite the growing demand for breast reconstruction, the best technique has not been adequately studied in randomised controlled trials (RCTs), and the evidence provided by non-randomised studies is often unsatisfactory. There is no superior breast reconstruction technique for all women. Future research should focus on the definition of decisional drivers to guide an evidence-based shared decision-making process in reconstructive breast surgery.

The impact of neoadjuvant chemotherapy on surgical outcomes following autologous and implant-based immediate breast reconstruction: A systematic review and meta-analysis

BACKGROUND

The impact of neoadjuvant chemotherapy (NACT) on the complication rate after implant-based and autologous breast reconstruction remains unclear. The aim of this study was to systematically review and perform a meta-analysis of previously published studies on immediate breast reconstruction (IBR) in breast cancer patients treated with NACT compared with controls.

METHODS

PubMed and EMBASE were searched to identify studies assessing the impact of NACT on major and minor complications after IBR. The primary effect measures were relative risk (RR), 95% confidence interval (95% CI), and p-value.

RESULTS

Eight studies comprising 51,731 patients were included in the meta-analysis. Of these, 5161 patients received NACT and 46,570 patients did not receive NACT. In regard to major complications, NACT did not statistically significant increase the rate of reconstructive failure (RR = 1.35, 95% CI = 0.96-1.91, p = 0.09), the rate of mastectomy skin-flap necrosis (RR = 1.39, 95% CI = 0.61-3.17, p = 0.44), or the rate of reoperation (RR = 1.09, 95% CI = 0.87-1.37, p = 0.45). Regarding minor complications, NACT did not significantly increase the rate of wound complications (RR = 1.05, 95% CI = 0.87-1.28, p = 0.62). In a subgroup analysis of implant-based breast reconstruction following NACT, single-stage direct-to-implant (DTI) had a significantly lower implant failure rate compared with two-staged tissue expander/implant (TE/I) (RR = 0.43, 95% CI = 0.26-0.71, p = 0.0011).

CONCLUSION

NACT did not increase the major or minor complication rate after IBR with either autologous tissue or implants. Thus, NACT and IBR should be considered safe procedures. The review of studies describing patients undergoing implant-based breast reconstruction following NACT could indicate that single-stage DTI was a safer procedure than two-staged TE/I. However, the association requires further evaluation.

Immediate Breast Reconstruction After Neoadjuvant Chemotherapy: Factors Associated With Surgical Selection and Complications

BACKGROUND

Breast reconstruction has become an integral component of breast cancer treatment, especially for patients who are unable to undergo breast-conserving surgery after neoadjuvant chemotherapy (NAC). We analyzed factors influencing the type of immediate reconstruction surgery after NAC, as well as the complication rates for each surgery type.

METHODS

The study included patients with breast cancer who underwent mastectomy following NAC from 2010 to 2021. Clinicopathological characteristics, unplanned reoperation rates, and the duration of postoperative hospitalization were analyzed in patients undergoing autologous tissue reconstruction (ATR, n = 127), implant-based reconstruction (IBR, n = 60), and combined autologous tissue and implant reconstruction (n = 60).

RESULTS

A total of 1651 patients who received NAC before mastectomy were enrolled. Among them, 247 (15.0%) patients underwent immediate reconstruction (IR), whereas 1404 underwent mastectomy only. Patients in the IR group were younger ( P < 0.001), had lower body mass index ( P < 0.001), and exhibited earlier clinical ( P = 0.003) and nodal ( P < 0.001) stage than those in the non-IR group. Patients in the ATR group were older ( P < 0.001) and had higher body mass index ( P = 0.007), larger tumor size ( P = 0.024), and more frequent childbearing history ( P = 0.011) than those in the other groups. Complications resulting in unplanned reoperations were more frequent in the IBR group ( P = 0.039). The duration of postoperative hospitalization was longest after ATR ( P = 0.008).

CONCLUSIONS

Age and clinical tumor/nodal stage at presentation are associated with IR for patients undergoing mastectomy after NAC. For patients undergoing IR after NAC, ATR may be safer and more suitable than IBR.

The Effect of Adjuvant Radiotherapy on One- and Two-Stage Prosthetic Breast Reconstruction and on Autologous Reconstruction: A Multicenter Italian Study among 18 Senonetwork Breast Centres

Purpose

In modern breast cancer treatment, a growing role has been observed for breast reconstruction together with an increase in clinical indications for postmastectomy radiotherapy (PMRT). Choosing the optimum type of reconstructive technique is a clinical challenge. We therefore conducted a national multicenter study to analyze the impact of PMRT on breast reconstruction.

Methods

We conducted a retrospective case-control multicenter study on women undergoing breast reconstruction. Data were collected from 18 Italian Breast Centres and stored in a cumulative database which included the following: autologous reconstruction, direct-to-implant (DTI), and tissue expander/immediate (TE/I). For all patients, we described complications and surgical endpoints to complications such as reconstruction failure, explant, change in type of reconstruction, and reintervention.

Results

From 2001 to April 2020, 3116 patients were evaluated. The risk for any complication was significantly increased in patients receiving PMRT (aOR, 1.73; 95% CI, 1.33-2.24; p < 0.001). PMRT was associated with a significant increase in the risk of capsular contracture in the DTI and TE/I groups (aOR, 2.24; 95% CI, 1.57-3.20; p < 0.001). Comparing type of procedures, the risk of failure (aOR, 1.82; 95% CI, 1.06-3.12, p=0.030), explant (aOR, 3.34; 95% CI, 3.85-7.83, p < 0.001), and severe complications (aOR, 2.54; 95% CI, 1.88-3.43, p < 0.001) were significantly higher in the group undergoing DTI reconstruction as compared to TE/I reconstruction.

Conclusion

Our study confirms that autologous reconstruction is the procedure least impacted by PMRT, while DTI appears to be the most impacted by PMRT, when compared with TE/I which shows a lower rate of explant and reconstruction failure. The trial is registered with NCT04783818, and the date of registration is 1 March, 2021, retrospectively registered.

Post-Mastectomy Tissue Expander Placement Followed by Radiation Therapy: A Cost-Effectiveness Analysis of Staged Autologous Versus Implant-Based Unilateral Reconstruction

BACKGROUND

There is no preferred approach to breast reconstruction for patients with locally advanced breast cancer (LABC) who require post-mastectomy radiation therapy (PMRT). Staged implant and autologous reconstruction both have unique risks and benefits. No previous study has compared their cost-effectiveness with utility scores.

METHODS

A literature review determined the probabilities and outcomes for mastectomy and staged implant or autologous reconstruction. Utility scores were used to calculate the quality-adjusted life years (QALYs) associated with successful surgery and postoperative complications. Medicare billing codes were used to assess costs. A decision analysis tree was constructed with rollback and incremental cost-effectiveness ratio (ICER) analyses. Sensitivity analyses were performed to validate results and account for uncertainty.

RESULTS

Mastectomy with staged deep inferior epigastric perforator (DIEP) flap reconstruction is costlier ($14,104.80 vs $3216.93), but more effective (QALYs, 29.96 vs 24.87). This resulted in an ICER of 2141.00, favoring autologous reconstruction. One-way sensitivity analysis showed that autologous reconstruction was more cost-effective if less than $257,444.13. Monte Carlo analysis showed a confidence of 99.99% that DIEP flap reconstruction is more cost-effective.

CONCLUSIONS

For patients with LABC who require PMRT, staged autologous reconstruction is significantly more cost-effective than reconstruction with implants. Despite the decreased morbidity, staged implant reconstruction has greater rates of complication.

Implant vs. autologous tissue-based breast reconstruction: A systematic review and meta-analysis of the studies comparing surgical approaches in 55,455 patients

BACKGROUND

The choice of reconstruction type is of utmost importance in treating breast cancer. There are two major reconstructive pathways in this group of patients: autologous breast reconstruction (ABR) and implant-based breast reconstruction (IBR). The aim of this systematic review and meta-analysis was to assess and compare IBR vs. ABR.

METHODS

A review of studies reporting the differences between the procedures was performed. The MEDLINE/PubMed, ScienceDirect, EMBASE, BIOSIS, SciELO, Scopus, and Web of Science databases were thoroughly searched in September 2021. The data concerning group characteristics, BREAST-Q scores, complication rates, length of stay (LOS), and costs were extracted. The Cochrane risk-of-bias tool was used for randomized studies, while Newcastle-Ottawa Quality Assessment for Cohort Studies was used for other types of research.

RESULTS

Our meta-analysis included 32 studies (n = 55,455). We observed significantly better outcomes following ABR when it comes to esthetic satisfaction (mean difference [MD] -8.51; 95% confidence interval [CI] -10.70, -6.33; p<0.001) and satisfaction with the entire reconstructive treatment (MD -6.56; 95% CI -9.97, -3.14; p<0.001). Both methods appeared to be comparable in terms of safety, while the complication rates varied insignificantly between the groups (odds ratio [OR] 1.06; 95% CI 0.71, 1.59; p = 0.76). ABR seems to be correlated with significantly higher costs (standard mean difference [SMD] -0.69; 95% CI -1.21, -0.17; p = 0.010).

CONCLUSIONS

The results obtained from this evidence-based study will improve the understanding of the different clinical pathways that patients can be assigned to. The study emphasized the advantages and disadvantages of both methods.

Advances in Prepectoral Breast Reconstruction

Breast reconstruction can be divided into prepectoral breast reconstruction (PPBR) and subpectoral breast reconstruction (SPBR) according to the implant plane. The original prepectoral breast reconstruction was abandoned for a long time due to the frequent and severe complications. Now, advances in materials technology and improved methods of mastectomy have made safe prepectoral breast reconstruction possible. Moreover, a number of studies have gradually demonstrated the advantages of prepectoral breast reconstruction. As prepectoral breast reconstruction becomes more and more attractive, it is time to review the current advances in prepectoral breast reconstruction.

Individualized Risk Prediction Tool for Serious Wound Complications After Mastectomy With and Without Immediate Reconstruction

BACKGROUND

A greater proportion of patients with surgical risk factors are undergoing immediate breast reconstruction after mastectomy, resulting in the need for better risk prediction to inform decisions about the procedure. The objective of this study was to leverage clinical data to restructure a previously developed risk model to predict serious infectious and noninfectious wound complications after mastectomy alone and mastectomy plus immediate reconstruction for use during a surgical consultation.

METHODS

The study established a cohort of women age 21 years or older treated with mastectomy from 1 July 2010 to 31 December 2015 using electronic health records from two hospitals. Serious infectious and non-infectious wound complications, defined as surgical-site infection, dehiscence, tissue necrosis, fat necrosis requiring hospitalization, or surgical treatment, were identified within 180 days after surgery. Risk factors for serious wound complications were determined using modified Poisson regression, with discrimination and calibration measures. Bootstrap validation was performed to correct for overfitting.

RESULTS

Among 2159 mastectomy procedures, 1410 (65.3%) included immediate implant or flap reconstruction. Serious wound complications were identified after 237 (16.8%) mastectomy-plus-reconstruction and 30 (4.0%) mastectomy-only procedures. Independent risk factors for serious wound complications included immediate reconstruction, bilateral mastectomy, higher body mass index, depression, and smoking. The optimism-corrected C statistic of the risk prediction model was 0.735.

CONCLUSIONS

Immediate reconstruction, bilateral mastectomy, obesity, depression, and smoking were significant risk factors for serious wound complications in this population of women undergoing mastectomy. Our risk prediction model can be used to counsel women before surgery concerning their individual risk of serious wound complications after mastectomy.

Radiation Modality (Proton/Photon), Timing, and Complication Rates in Patients With Breast Cancer Receiving 2-Stages Expander/Implant Reconstruction

PURPOSE

Our purpose is to explore the effect of postmastectomy radiation therapy (PMRT) modality and timing on complication rates in breast cancer patients receiving immediate 2-stages expander/implant.

METHODS AND MATERIALS

We reviewed the charts of 661 patients who underwent immediate 2-stages expander/implant with/without PMRT at our institution from 2000 to 2019. Patients were divided into 3 cohorts: no radiation, PMRT to expanders (RTE), and PMRT to implants after expander exchange (RTI). PMRT was delivered either with 3-dimensional conformal photon with or without chest wall boost (CWB) or proton therapy. Reconstruction complications were defined as infection/necrosis requiring debridement, capsular-contracture requiring capsulotomy, and reconstruction failure requiring prothesis removal. Logistic regression and Cox models were used to assess the effect of different radiation therapy modalities on complication rates and local control.

RESULTS

Among 661 patients, 309 (46.7%) received PMRT, 220 of the 309 (71.2%) received RTE before exchange, and 89 (28.8%) received RTI after exchange. Seventeen out of 309 (5.5%) patients received proton therapy. The complications among RTE versus RTI cohorts were 22.7% versus 15.7% for infection/necrosis, 13.6% versus 19.1% for capsular-contracture, and 39.5% versus 31.5% for overall reconstruction failure, respectively. Among proton patients, 8/17 (47%) developed capsular contracture compared with 16.4% (24/146) and 10.3% (15/146) in CWB and non-CWB groups, respectively. Adjusted multivariable analysis showed no significant difference between RTI and RTE in terms of infection/necrosis and capsular contracture. Yet, RTE significantly increased overall reconstruction failure compared with RTI (39.5% vs 31.5%; odds ratio [OR], 2.11; P = .02). Protons significantly increased capsular contracture compared with both CWB and non-CWB groups (OR, 5.4; P = .01 and OR, 10.9; P < .001, respectively). Moreover, proton significantly increased overall reconstruction failure. The 5-year local control rates were 95.3% and 97.7% for RTE and RTI, respectively (hazard ratio, 1.2; P = .7).

CONCLUSIONS

Early radiation to the expander before the exchange to implant significantly increased overall reconstruction failure without improving local control. Protons significantly increased capsular contracture rates and overall reconstruction failure leading to more revision surgeries.

Radiotherapy and Breast Reconstruction: What Is the Ideal Timing? A Narrative Review

INTRODUCTION

Women undergoing mastectomy choose to pursue breast reconstruction (BR) in order to reduce their body image distress.Adjuvant chest wall irradiation is associated with a negative cosmetic outcome. The aim of our review was to identify the optimal timing of BR relating to radiotherapy delivery.

MATERIALS AND METHODS

Using Cochrane Library, Embase, PubMed, Springer, Wanfang and CNKI, we performed a non-systematic review of articles published up to August 2021.

RESULTS

There is no hard evidence in favor of immediate, delayed or 2-stage BR when post-mastectomy radiation is indicated. Immediate and 2-stage BR seem to be valid alternatives to delayed BR.

CONCLUSIONS

Further research is essential in order to assess clinician and patient reported aesthetic outcomes and determine the optimal timing of BR in view of post-mastectomy radiotherapy, in breast cancer survivors.

Implant-based versus Autologous Reconstruction after Mastectomy for Breast Cancer: A Systematic Review and Meta-analysis

For women undergoing breast reconstruction after mastectomy, the comparative benefits and harms of implant-based reconstruction (IBR) and autologous reconstruction (AR) are not well known. We performed a systematic review with meta-analysis of IBR versus AR after mastectomy for breast cancer.

Methods

We searched Medline, Embase, Cochrane CENTRAL, CINAHL, and ClinicalTrials.gov for studies from inception to March 23, 2021. We assessed the risk of bias of individual studies and strength of evidence (SoE) of our findings using standard methods.

Results

We screened 15,936 citations and included 40 studies (two randomized controlled trials and 38 adjusted nonrandomized comparative studies). Compared with patients who undergo IBR, those who undergo AR experience clinically significant better sexual well-being [summary adjusted mean difference (adjMD) 5.8, 95% CI 3.4-8.2; three studies] and satisfaction with breasts (summary adjMD 8.1, 95% CI 6.1-10.1; three studies) (moderate SoE for both outcomes). AR was associated with a greater risk of venous thromboembolism (moderate SoE), but IBR was associated with a greater risk of reconstructive failure (moderate SoE) and seroma (low SoE) in long-term follow-up (1.5-4 years). Other outcomes were comparable between groups, or the evidence was insufficient to merit conclusions.

Conclusions

Most evidence regarding IBR versus AR is of low or moderate SoE. AR is probably associated with better sexual well-being and satisfaction with breasts and lower risks of seroma and long-term reconstructive failure but a higher risk of thromboembolic events. New high-quality research is needed to address the important research gaps.

The Impact of Adjuvant Radiotherapy on Immediate Implant-based Breast Reconstruction Surgical and Satisfaction Outcomes: A Systematic Review and Meta-analysis

Adjuvant radiotherapy could be a necessary step in the oncological treatment for breast cancer. However, radiotherapy may have negative effects on implant-based immediate breast reconstruction. The aim of this study was to determine the impact of adjuvant radiation therapy on surgical results and patient-reported satisfaction outcomes in women undergoing immediate implant-based breast reconstruction.

Methods

A systematic search in PubMed was conducted on September 2019 and updated on April 2021. The risk of bias of the included studies was assessed using the Newcastle-Ottawa Quality Assessment Form for Observational Studies. RevMan 5 was used for statistical analysis. We obtained relative risks to determine the complication incidence and mean differences for 2-year BREAST-Q scores.

Results

Fourteen studies were included. A total of 11,958 implant-based immediate reconstructions were performed, 2311 received postmastectomy radiation therapy, and 9647 were considered as control group. Surgical complications, reoperation rates, and reconstruction failure were significantly higher among irradiated breasts. Significantly lower BREAST-Q scores were reported by irradiated women receiving radiotherapy.

Conclusions

This systematic review and meta-analysis combines reconstruction complication rates with aesthetic and patient-reported satisfaction outcomes. Adjuvant radiotherapy is consistently associated with greater complication rates and poorer aesthetic and satisfaction outcomes. The magnitude of association is significantly lower when the reconstruction is based on autologous tissues.