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Liu J, Chen C, Chen H, Xiang A, Zheng R, Hu S, Guo J, Qu L, Zhou J, Wu J. Patient-Reported Outcomes and Complication Profiles of Implant-Based Breast Reconstruction in Patients With Postmastectomy Radiation Therapy. Ann Plast Surg 2024; 93:22-29. [PMID: 38885161 DOI: 10.1097/sap.0000000000003974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/20/2024]
Abstract
OBJECTIVE This study aims to investigate the patient-reported outcomes (PROs) and complications of distinct implant-based breast reconstruction modality for patients with postmastectomy radiation therapy (PMRT). METHODS A retrospective review was conducted on breast cancer patients with stage II-III disease who performed implant-based breast reconstruction following with PMRT between September 2016 and April 2022. The patients were categorized into two matched groups: (1) patients receiving prepectoral breast reconstruction (PBR) or (2) subpectoral breast reconstruction (SBR) followed by PMRT. Following reconstruction, the patients were further compared for PMRT with the tissue expander (PMRT-TE) versus PMRT with permanent implant (PMRT-PI). PROs were measured with BREAST-Q questionnaire. Early and late complications were recorded and analyzed. RESULTS A total of 55 eligible patients were recruited. Patients who underwent PBR reported significantly higher satisfaction with breasts scores (P = 0.003) compared with the SBR group. The PMRT-TE group had higher satisfaction with breasts (P = 0.001) but lower physical well-being (P = 0.029) scores compared with PMRT-PI group. Moreover, patients in SBR cohort had a higher risk of capsular contracture (Baker grade III or IV) (20.5% vs 6.3%) and implant dislocation (48.7% vs 12.5%) than patients in PBR cohort. Patients in PMRT-PI group had a slightly higher rate of capsular contracture (Baker grade III or IV) than PMRT-TE group (20.8% vs 12.9%). CONCLUSIONS PBR was associated with lower rates of late complications, especially for implant dislocation, and higher satisfaction with breasts scores compared to SBR. In addition, compared to PMRT-TE with PMRT-PI, patients in PMRT-TE cohort reported superior PROs of satisfaction with breasts.
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Affiliation(s)
- Jian Liu
- From the Department of Breast Surgery, Affiliated Hangzhou First People's Hospital, School of Medicine, Westlake University, Hangzhou
| | - Cong Chen
- From the Department of Breast Surgery, Affiliated Hangzhou First People's Hospital, School of Medicine, Westlake University, Hangzhou
| | - Honggang Chen
- From the Department of Breast Surgery, Affiliated Hangzhou First People's Hospital, School of Medicine, Westlake University, Hangzhou
| | - Aizhai Xiang
- From the Department of Breast Surgery, Affiliated Hangzhou First People's Hospital, School of Medicine, Westlake University, Hangzhou
| | - Ruzhen Zheng
- From the Department of Breast Surgery, Affiliated Hangzhou First People's Hospital, School of Medicine, Westlake University, Hangzhou
| | - Shufang Hu
- From the Department of Breast Surgery, Affiliated Hangzhou First People's Hospital, School of Medicine, Westlake University, Hangzhou
| | - Jufeng Guo
- From the Department of Breast Surgery, Affiliated Hangzhou First People's Hospital, School of Medicine, Westlake University, Hangzhou
| | - Li Qu
- From the Department of Breast Surgery, Affiliated Hangzhou First People's Hospital, School of Medicine, Westlake University, Hangzhou
| | - Jun Zhou
- From the Department of Breast Surgery, Affiliated Hangzhou First People's Hospital, School of Medicine, Westlake University, Hangzhou
| | - Jiong Wu
- Department of Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai, China
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D'Alessandro GS, Munhoz AM, Takeuchi FM, Povedano A, Sampaio Goes JC. Immediate Breast Reconstruction With Latissimus Dorsi Myocutaneous Flap and Silicone Implant Followed by Adjuvant Radiotherapy for Breast Cancer. Ann Plast Surg 2024; 92:625-634. [PMID: 38718327 DOI: 10.1097/sap.0000000000003882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/21/2024]
Abstract
BACKGROUND About 30% to 50% of women with breast cancer undergo mastectomy, and approximately 50% of them will receive adjuvant radiotherapy (ART). This study evaluates the medium- and long-term impact of ART after immediate breast reconstruction (IBR) with latissimus dorsi myocutaneous (LDM) flap and silicone implants. METHODS Clinical, surgical, and oncological data were retrospectively collected and analyzed based on the medical records of 176 patients who had undergone IBR with LDM flap and silicone implants. RESULTS The data showed that 7.4% of patients had a history of previous radiotherapy, 56.3% received ART, 31.8% developed capsular contracture with a mean follow-up of 58.1 months, and 14.2% of surgeries were categorized as procedures with a prolonged operating time, lasting above 1 SD of the observed mean. Those who experienced prolonged operating time (odds ratio, 4.72; 95% confidence interval, 1.72-12.93; P = 0.003) and those who received ART (odds ratio, 7.38; 95% confidence interval, 3.18-17.10; P < 0.001) were more likely to develop capsular contracture. Thirty-two patients (18%) underwent capsulectomy with implant replacement, and 7 patients (4%) had the implant removed. The mean time between IBR and reoperation was 29.1 months. Patients who received ART were 2.84 times more likely to experience reconstruction failure or undergo implant-related reoperation ( P = 0.002). CONCLUSIONS The results indicated that IBR with LDM flap and silicone implant followed by ART is a safe procedure, resulting in low rates of reconstruction failure. However, ART increased the likelihood of capsular contracture development and implant-related reoperation, having a negative effect on reconstructed breasts.
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Jørgensen AK, Bille C, Jylling AMB, Kaidar-Person O, Tramm T. Pathology and resection margins following mastectomy prior to immediate breast reconstruction. Gland Surg 2024; 13:561-570. [PMID: 38720674 PMCID: PMC11074653 DOI: 10.21037/gs-23-407] [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: 09/29/2023] [Accepted: 03/01/2024] [Indexed: 05/12/2024]
Abstract
Risk of local recurrence (LR) (and even distant disease-free survival) after mastectomy is associated with margin status. Furthermore, the vast majority of LR are located at the anterior (superficial) margin. Margins in mastectomy are considered anatomical borders and not true resection margins; such a conception may erroneously lead to underestimation of the risk of LR after mastectomy. If dissection is accurate along the fascia, only skin, subcutaneous tissue and minimal residual breast gland tissue (rBGT) are expected to remain in the patient. However, the subcutaneous fascia is an inconsistent anatomical structure that may be absent in almost half of patients. Studies and routine clinical practice suggest that resection may frequently, though often focally, be within the breast glandular tissue leaving various amounts of rBGT. Such areas may be nidus for subsequent de novo or recurrent premalignant or malignant disease. There is no consensus on handling of close/positive margins and intervention is extrapolated from studies on breast conserving surgery with subsequent radiotherapy. Handling of a close/positive margin is complicated by poor correlation between the ex vivo findings on the specimen and the attempt to relocate the area of concern in a patient with reconstructed breasts. In this clinical practice review, we strongly advocate for reporting of the lesion-to-margin distance in mastectomies to collect further evidence on the association between LR and margin status.
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Affiliation(s)
| | - Camilla Bille
- Department of Plastic Surgery, Odense University Hospital, Odense, Denmark
| | - Anne Marie Bak Jylling
- Department of Pathology, Odense University Hospital, Odense, Denmark
- Research Unit of Pathology, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Orit Kaidar-Person
- Breast Cancer Radiation Therapy Unit, Sheba Medical Center, Ramat Gan, Israel
- The School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Trine Tramm
- Department of Pathology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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Kaidar-Person O, Offersen BV, Tramm T, Christiansen P, Damsgaard TE, Kothari A, Poortmans P. The King is in the altogether: Radiation therapy after oncoplastic breast surgery. Breast 2023; 72:103584. [PMID: 37783134 PMCID: PMC10562190 DOI: 10.1016/j.breast.2023.103584] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Accepted: 09/24/2023] [Indexed: 10/04/2023] Open
Abstract
Breast cancer is the most common malignancy, and the majority of the patients are diagnosed at an early disease stage. Breast conservation is the preferred locoregional approach, and oncoplastic breast conservation surgery is becoming more popular. This narrative review aims to discuss the challenges and uncertainties in target volume definition for postoperative radiation after these procedures, to improve radiation therapy decisions and encourage multidisciplinary.
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Affiliation(s)
- Orit Kaidar-Person
- Breast Radiation Unit, Oncology Institute, Sheba Tel Hashomer, Ramat Gan, Israel; Tel Aviv University, Israel.
| | | | - Trine Tramm
- Department of Pathology, Aarhus University Hospital, and Department of Clinical Medicine, Aarhus University, Denmark
| | - Peer Christiansen
- Department of Plastic and Breast Surgery, Aarhus University Hospital, Denmark
| | - Tine Engberg Damsgaard
- Department of Plastic Surgery and Burns Treatment, Copenhagen University Hospital, Copenhagen, Denmark
| | | | - Philip Poortmans
- Department of Radiation Oncology, Iridium Netwerk, Antwerp, Belgium; Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium.
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Alkner S, de Boniface J, Lundstedt D, Mjaaland I, Ryden L, Vikstrom J, Bendahl PO, Holmberg E, Sackey H, Wieslander E, Karlsson P. Protocol for the T-REX-trial: tailored regional external beam radiotherapy in clinically node-negative breast cancer patients with 1-2 sentinel node macrometastases - an open, multicentre, randomised non-inferiority phase 3 trial. BMJ Open 2023; 13:e075543. [PMID: 37751948 PMCID: PMC10533703 DOI: 10.1136/bmjopen-2023-075543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 09/07/2023] [Indexed: 09/30/2023] Open
Abstract
INTRODUCTION Modern systemic treatment has reduced incidence of regional recurrences and improved survival in breast cancer (BC). It is thus questionable whether regional radiotherapy (RT) is still beneficial in patients with sentinel lymph node (SLN) macrometastasis. Postoperative regional RT is associated with an increased risk of arm morbidity, pneumonitis, cardiac disease and secondary cancer. Therefore, there is a need to individualise regional RT in relation to the risk of recurrence. METHODS AND ANALYSIS In this multicentre, prospective randomised trial, clinically node-negative patients with oestrogen receptor-positive, HER2-negative BC and 1-2 SLN macrometastases are eligible. Participants are randomly assigned to receive regional RT (standard arm) or not (intervention arm). Regional RT includes the axilla level I-III, the supraclavicular fossa and in selected patients the internal mammary nodes. Both groups receive RT to the remaining breast. Chest-wall RT after mastectomy is given in the standard arm, but in the intervention arm only in cases of widespread multifocality according to national guidelines. RT quality assurance is an integral part of the trial.The trial aims to include 1350 patients between March 2023 and December 2028 in Sweden and Norway. Primary outcome is recurrence-free survival (RFS) at 5 years. Non-inferiority will be declared if outcome in the de-escalation arm is not >4.5 percentage units below that with regional RT, corresponding to an HR of 1.41 assuming 88% 5-year RFS with standard treatment. Secondary outcomes include locoregional recurrence, overall survival, patient-reported arm morbidity and health-related quality of life. Gene expression analysis and tumour tissue-based studies to identify prognostic and predictive markers for benefit of regional RT are included. ETHICS AND DISSEMINATION The trial protocol is approved by the Swedish Ethics Authority (Dnr-2022-02178-01, 2022-05093-02, 2023-00826-02, 2023-03035-02). Results will be presented at scientific conferences and in peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT05634889.
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Affiliation(s)
- Sara Alkner
- Department of Oncology, Institute of Clinical Sciences, Lund University Faculty of Medicine, Lund, Sweden
- Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital Lund, Lund, Sweden
| | - Jana de Boniface
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
- Department of Surgery, Capio St Göran's Hospital, Stockholm, Sweden
| | - Dan Lundstedt
- Department of Oncology, Institute of Clinical Sciences, University of Gothenburg Sahlgrenska Academy, Göteborg, Sweden
| | - Ingvil Mjaaland
- Department of Radiotherapy, Stavanger University Hospital, Stavanger, Norway
| | - Lisa Ryden
- Department of Oncology, Institute of Clinical Sciences, Lund University Faculty of Medicine, Lund, Sweden
| | - Johan Vikstrom
- Department of Radiotherapy, Stavanger University Hospital, Stavanger, Norway
| | - Pär-Ola Bendahl
- Department of Oncology, Institute of Clinical Sciences, Lund University Faculty of Medicine, Lund, Sweden
| | - Erik Holmberg
- Department of Oncology, Institute of Clinical Sciences, University of Gothenburg Sahlgrenska Academy, Göteborg, Sweden
| | - Helena Sackey
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
- Department of Breast, Endocrine Tumors and Sarcoma, Karolinska University Hospital, Stockholm, Sweden
| | - Elinore Wieslander
- Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital Lund, Lund, Sweden
| | - Per Karlsson
- Department of Oncology, Institute of Clinical Sciences, University of Gothenburg Sahlgrenska Academy, Göteborg, Sweden
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Zaborowski AM, Heeney A, Walsh S, Barry M, Kell MR. Immediate breast reconstruction. Br J Surg 2023; 110:1039-1042. [PMID: 36972211 DOI: 10.1093/bjs/znad064] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 02/12/2023] [Indexed: 08/12/2023]
Affiliation(s)
| | - Anna Heeney
- Department of Breast Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Siun Walsh
- Department of Breast Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Mitchel Barry
- Department of Breast Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Malcolm R Kell
- Department of Breast Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
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Zaborowski AM, Wong SM. Neoadjuvant systemic therapy for breast cancer. Br J Surg 2023; 110:765-772. [PMID: 37104057 PMCID: PMC10683941 DOI: 10.1093/bjs/znad103] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 04/02/2023] [Indexed: 04/28/2023]
Affiliation(s)
| | - Stephanie M Wong
- Department of Surgery and Oncology, McGill University Medical School, Montreal, Quebec, Canada
- Segal Cancer Centre, Sir Mortimer B. Davis Jewish General Hospital, Montreal, Quebec, Canada
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Tramm T, Kaidar-Person O. Optimising post-operative radiation therapy after oncoplastic and reconstructive procedures. Breast 2023; 69:366-374. [PMID: 37023565 PMCID: PMC10119683 DOI: 10.1016/j.breast.2023.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 02/16/2023] [Accepted: 03/25/2023] [Indexed: 03/30/2023] Open
Abstract
Surgical techniques for breast cancer have been refined over the past decades to deliver an aesthetic outcome as close as possible to the contralateral intact breast. Current surgery further allows excellent aesthetic outcome even in case of mastectomy, by performing skin sparing or nipple sparing mastectomy in combination with breast reconstruction. In this review we discuss how to optimise post-operative radiation therapy after oncoplastic and breast reconstructive procedures, including dose, fractionation, volumes, surgical margins, and boost application.
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