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The Role of Surgical Axillary Staging Prior to Immediate Breast Reconstruction in the Era of De-Escalation of Axillary Management in Early Breast Cancer. J Pers Med 2022; 12:jpm12081283. [PMID: 36013232 PMCID: PMC9410323 DOI: 10.3390/jpm12081283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Revised: 07/27/2022] [Accepted: 08/02/2022] [Indexed: 11/16/2022] Open
Abstract
Postmastectomy radiotherapy (PMRT) following immediate breast reconstruction (IBR) is associated with postoperative complications. Although the incidence of node-positive breast cancer is declining, a separate sentinel lymph node biopsy (SLNB) is still performed before mastectomy when IBR is planned, in order to evaluate nodal status and the need for PMRT. This study assessed the impact of staged SLNB on the breast reconstructive planning, and presents common clinicopathological characteristics of breast cancer with macrometastatic nodal spread where staged SLNB would be beneficial to indicate PMRT. Medical records of breast cancer patients scheduled for mastectomy and IBR at Skåne University Hospital, Sweden, from November 2014 to February 2020, were reviewed. Of 92 patients, node-positive disease was present in 15 (16%). Fifty-three patients underwent staged SLNB before mastectomy and IBR, and 10 (19%) presented with nodal metastasis. All patients with macrometastatic sentinel nodes were presented with palpable, multifocal, ER+ breast carcinoma of no special type with tumor size > 17.0 mm. Overall, four women received PMRT after verified metastasis by staged SLNB, and IBR was cancelled for three patients. These findings question the benefit of routine staged SLNB before mastectomy and IBR in breast cancer populations within established mammography screening programs with low risk of nodal metastasis.
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Baker NF, Baecher KM, Hart AM, Styblo TM, Carlson GW, Losken A. The impact of axillary node surgery on outcomes following immediate breast reconstruction. Breast J 2020; 26:2170-2176. [DOI: 10.1111/tbj.14070] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 09/15/2020] [Accepted: 09/16/2020] [Indexed: 12/15/2022]
Affiliation(s)
- Nusaiba F. Baker
- Emory Division of Plastic and Reconstructive Surgery Atlanta GA USA
| | | | | | | | - Grant W. Carlson
- Emory Division of Plastic and Reconstructive Surgery Atlanta GA USA
| | - Albert Losken
- Emory Division of Plastic and Reconstructive Surgery Atlanta GA USA
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3
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Nava MB, Benson JR, Audretsch W, Blondeel P, Catanuto G, Clemens MW, Cordeiro PG, De Vita R, Hammond DC, Jassem J, Lozza L, Orecchia R, Pusic AL, Rancati A, Rezai M, Scaperrotta G, Spano A, Winters ZE, Rocco N. International multidisciplinary expert panel consensus on breast reconstruction and radiotherapy. Br J Surg 2019; 106:1327-1340. [PMID: 31318456 DOI: 10.1002/bjs.11256] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Revised: 12/11/2018] [Accepted: 05/06/2019] [Indexed: 11/06/2022]
Abstract
BACKGROUND Conflicting evidence challenges clinical decision-making when breast reconstruction is considered in the context of radiotherapy. Current literature was evaluated and key statements on topical issues were generated and discussed by an expert panel at the International Oncoplastic Breast Surgery Meeting in Milan 2017. METHODS Studies on radiotherapy and breast reconstruction (1985 to September 2017) were screened using MEDLINE, Embase and CENTRAL. The literature review yielded 30 controversial key questions. A set of key statements was derived and the highest levels of clinical evidence (LoE) for each of these were summarized. Nineteen panellists convened for dedicated discussions at the International Oncoplastic Breast Surgery Meeting to express agreement, disagreement or abstention for the generated key statements. RESULTS The literature review identified 1522 peer-reviewed publications. A list of 22 key statements was produced, with the highest LoE recorded for each statement. These ranged from II to IV, with most statements (11 of 22, 50 per cent) supported by LoE III. There was full consensus for nine (41 per cent) of the 22 key statements, and more than 75 per cent agreement was reached for half (11 of 22). CONCLUSION Poor evidence exists on which to base patient-informed consent. Low-quality studies are conflicting with wide-ranging treatment options, precluding expert consensus regarding optimal type and timing of breast reconstruction in the context of radiotherapy. There is a need for high-quality evidence from prospective registries and randomized trials in this field.
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Affiliation(s)
- M B Nava
- Department of Plastic Surgery, University of Milan, Milan, Italy
| | - J R Benson
- Cambridge Breast Unit, Addenbrooke's Hospital, Cambridge, UK.,School of Medicine, Anglia Ruskin University, Cambridge and Chelmsford, UK
| | - W Audretsch
- Department of Senology and Breast Surgery, Heinrich Heine University, Dusseldorf, Germany
| | - P Blondeel
- Department of Plastic Surgery, University Hospital Ghent, Ghent, Belgium
| | - G Catanuto
- Multidisciplinary Breast Unit, Azienda Ospedaliera Cannizzaro, Catania, Italy
| | - M W Clemens
- Plastic and Reconstructive Surgery Unit, MD Anderson Cancer Center, Houston, Texas
| | - P G Cordeiro
- Department of Plastic and Reconstructive Surgery, Weill Cornell Medicine and.,Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, USA
| | - R De Vita
- Department of Plastic Surgery, National Cancer Institute 'Regina Elena', Rome, Italy
| | - D C Hammond
- Partners in Plastic Surgery of West Michigan, Grand Rapids, Michigan, USA
| | - J Jassem
- Department of Oncology and Radiotherapy, Medical University of Gdansk, Gdansk, Poland
| | - L Lozza
- Radiotherapy Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - R Orecchia
- Department of Radiotherapy, European Institute of Oncology, Milan, Italy
| | - A L Pusic
- Division of Plastic and Reconstructive Surgery, Brigham and Women's Hospital, Harvard University, Boston, Massachusetts, USA
| | - A Rancati
- Oncoplastic Surgery, Instituto Henry Moore, University of Buenos Aires, Buenos Aires, Argentina
| | - M Rezai
- European Breast Centre, Dusseldorf, Germany
| | - G Scaperrotta
- Radiology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - A Spano
- Plastic Surgery Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Z E Winters
- Division of Surgery and Interventional Science, Faculty of Medical Sciences, University College London, London, UK
| | - N Rocco
- Department of Clinical Medicine and Surgery, University of Naples 'Federico II', Naples, Italy
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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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Wilson M, Dordea M, Light A, Serra MP, Aspinall SR. Accuracy of a multidisciplinary team-led discussion in predicting postmastectomy radiotherapy. Ann R Coll Surg Engl 2015; 97:198-203. [PMID: 26263804 DOI: 10.1308/003588414x14055925061153] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Immediate breast reconstruction (IBR) is performed increasingly following mastectomy for breast cancer. The literature suggests higher reconstructive failure and poorer cosmesis in the subgroup of patients receiving postmastectomy radiotherapy (PMRT) following IBR. We set out to determine the accuracy of a multidisciplinary team (MDT) discussion in predicting PMRT. METHODS Preoperative MDT discussions were recorded prospectively over a 12-month period (from February 2011) in a symptomatic breast unit. The estimated need for PMRT was stratified into 'PMRT not required', 'PMRT possibly required', 'PMRT probably required' and 'PMRT required' groups. RESULTS Of 156 referrals included in the study, 76 patients (49%) underwent mastectomy: 61 simple mastectomy, 10 skin sparing mastectomy (SSM) and delayed-immediate breast reconstruction, 3 SSM and implant-based IBR, and 2 mastectomy IBR with an autologous flap. The IBR rate was therefore 19.7%. The proportion of patients who received PMRT was 14% (3/21) in the 'PMRT not required', 30% (7/23) in the 'PMRT possibly required', 65% (9/14) in the 'PMRT probably required' and 94% (17/18) in the 'PMRT required' groups. Assigning a linear numerical score (1-4) to these groups (higher score representing greater likelihood of receiving PMRT), the predicted need for PMRT correlated with the proportion of patients who ultimately received PMRT (linear regression r(2)=0.98, p=0.01). CONCLUSIONS This study has examined the factors influencing MDT discussions regarding IBR, demonstrating that the MDT is reasonably accurate at predicting need for PMRT. Whether such accuracy is clinically adequate and/or reproducible across units is debatable.
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Affiliation(s)
- M Wilson
- Northumbria Healthcare NHS Foundation Trust , UK
| | - M Dordea
- Northumbria Healthcare NHS Foundation Trust , UK
| | - A Light
- Northumbria Healthcare NHS Foundation Trust , UK
| | - M P Serra
- Northumbria Healthcare NHS Foundation Trust , UK
| | - S R Aspinall
- Northumbria Healthcare NHS Foundation Trust , UK
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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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Mannu GS, Navi A, Hussien M. Sentinel lymph node biopsy before mastectomy and immediate breast reconstruction does not significantly delay surgery in early breast cancer. ANZ J Surg 2014; 85:438-43. [DOI: 10.1111/ans.12603] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/08/2014] [Indexed: 12/19/2022]
Affiliation(s)
- Gurdeep S. Mannu
- Breast Surgery Unit; Norfolk and Norwich University Hospital; Norwich UK
- General Surgery; Oxford University Hospitals; Oxford UK
| | - Ali Navi
- Breast Surgery Unit; Norfolk and Norwich University Hospital; Norwich UK
| | - Maged Hussien
- Breast Surgery Unit; Norfolk and Norwich University Hospital; Norwich UK
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Mannu GS, Farooq N, Down S, Burger A, Hussien MI. Avoiding back wound dehiscence in extended latissimus dorsi flap reconstruction. ANZ J Surg 2012; 83:359-64. [DOI: 10.1111/j.1445-2197.2012.06292.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/11/2012] [Indexed: 11/28/2022]
Affiliation(s)
- Gurdeep S. Mannu
- Breast Surgery Unit; Norfolk and Norwich University Hospital; Norfolk; UK
| | - Naheed Farooq
- Breast Surgery Unit; Norfolk and Norwich University Hospital; Norfolk; UK
| | - Sue Down
- Breast Surgery Unit; Norfolk and Norwich University Hospital; Norfolk; UK
| | - Amy Burger
- Breast Surgery Unit; Norfolk and Norwich University Hospital; Norfolk; UK
| | - Maged I. Hussien
- Breast Surgery Unit; Norfolk and Norwich University Hospital; Norfolk; UK
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