A 10-Year Experience with Mastectomy and Tissue Expander Placement to Facilitate Subsequent Radiation and Reconstruction

Ayoub, Zeina; Strom, Eric A.; Ovalle, V.; Perkins, George H.; Woodward, Wendy A.; Tereffe, Welela; Smith, Benjamin D.; Shaitelman, Simona F.; Stauder, Michael C.; Hoffman, Karen E.; DeSnyder, Sarah M.; Garvey, Patrick B.; Clemens, Mark W.; Barcenas, Carlos H.; Kuerer, Henry Mark; Kronowitz, Steven J.

doi:10.1245/s10434-017-5956-6

Cited by 21 publications

(12 citation statements)

References 26 publications

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“…24 However, TEs are subject to their own unique set of complications, including skin necrosis, infection, and exposure, with explantation prior to reconstruction reported to be required in up to 18% of cases. 8 9 10…”

Section: Discussionmentioning

confidence: 99%

“…In a 10-year follow-up, the authors reported that 13% of patients required TE explanation prior to reconstruction due to radiation complications, but 89.6% of patients eventually completed successful reconstructions. 9 Several other groups have since reported their experiences with DI-ABR, either in isolation or in comparison to delayed reconstruction, with varying results. 10 11 12 13…”

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confidence: 99%

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A Comparative Analysis of Immediate and Delayed-immediate Breast Reconstruction after Postmastectomy Radiation Therapy

Christopher

Morris

Broach

et al. 2021

J Reconstr Microsurg

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Background Postmastectomy radiation therapy (PMRT) is an important component in the treatment of locally advanced breast cancer. Optimal timing of therapy in relation to autologous breast reconstruction (ABR) remains clinically debated. Herein, we comparatively analyze short- and long-term outcomes between immediate ABR (I-ABR) and delayed-immediate ABR (DI-ABR) in the setting of PMRT. Methods Adult patients undergoing ABR with PMRT were separated into cohorts based on reconstructive timeline: I-ABR or DI-ABR. The groups were propensity matched 1:1 by age, body mass index, and comorbidities. Surgical site events and long-term clinical outcomes (readmissions, reoperations, and revision procedures) were collected. Univariate analyses were completed using Pearson's chi-squared tests and Fisher's exact tests, and statistical significance was set at p < 0.05. Results One hundred and thirty-two flaps (66 in each cohort) were identified for inclusion. Patients with I-ABR were more likely to experience fat necrosis (p = 0.034) and skin necrosis (p < 0.001), require additional office visits (p < 0.001) and outpatient surgeries (p = 0.015) to manage complications, and undergo revision surgery after reconstruction (p < 0.001). DI-ABR patients, however, had a 42.4% incidence of complications following tissue expander placement prior to reconstruction, with 16.7% of patients requiring reoperation during this time. Only one patient (I-ABR) experienced flap loss due to a vascular complication. Conclusion The complications encountered in both of these groups were not prohibitive to offering either treatment. Patients should be made aware of the specific and unique risks of these reconstruction timelines and involved throughout the entire decision-making process. Plastic surgeons should continue to strive to elucidate innovative approaches that facilitate enhanced quality of life without compromising oncologic therapy.

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Section: Discussionmentioning

confidence: 99%

mentioning

confidence: 99%

A Comparative Analysis of Immediate and Delayed-immediate Breast Reconstruction after Postmastectomy Radiation Therapy

Christopher

Morris

Broach

et al. 2021

J Reconstr Microsurg

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“…As recent evidence has widened the indications of post-mastectomy radiation therapy (RT) to early-stage node-positive breast cancer (4), an increasing number of patients is currently referred for adjuvant RT to the reconstructed breast, which has put treating physicians in a challenging situation. There is substantial evidence from small case series and prospective cohort studies demonstrating that RT significantly increases complications following breast reconstruction regardless of the type of reconstructive surgery and timing of surgery (5, 6). Breasts reconstructed with implants are known to be more susceptible to RT-related complications compared with breasts reconstructed with autologous tissue (7).…”

Section: Introductionmentioning

confidence: 99%

Influence of Radiation Dose to Reconstructed Breast Following Mastectomy on Complication in Breast Cancer Patients Undergoing Two-Stage Prosthetic Breast Reconstruction

Chang

Song

et al. 2019

Front. Oncol.

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Purpose: This study investigated the association between radiation dose and complication rate in patients who underwent breast reconstruction to understand the role of radiation hypofractionated regimen, boost radiation therapy (RT), and RT techniques. Methods: We retrospectively evaluated 75 patients treated with post-mastectomy adjuvant RT for breast cancer in the setting of two-stage prosthetic breast reconstruction. Near maximum radiation dose (D max ) in the 2 or 0.03 cc of reconstructed breast or overlying breast skin was obtained from dose-volume histograms. Results: Post-RT complications occurred in 22.7% of patients. Receiver operating characteristic analysis showed that all near D max parameters were able to predict complication risk, which retained statistical significance after adjusting other variables (odds ratio 1.12 per Gy, 95% confidence interval 1.02–1.23) with positive dose-response relationship. In multiple linear regression model ( R 2 = 0.92), conventional fractionation (β = 11.7) and 16 fractions in 2.66 Gy regimen (β = 3.9) were the major determinants of near D max compared with 15 fractions in 2.66 Gy regimen, followed by utilization of boost RT (β = 3.2). The effect of bolus and dose inhomogeneity seemed minor ( P > 0.05). The location of hot spot was not close to the high density metal area of the expander, but close to the surrounding areas of partially deflated expander bag. Conclusions: This study is the first to demonstrate a dose-response relationship between risk of complications and near D max , where hypofractionated regimen or boost RT can play an important role. Rigorous RT-quality assurance program and modification of dose constraints could be considered as a critically important component for ongoing trials of hypofractionation. Based on our findings, we initiated a multi-center retrospective study (KROG 18-04) and a prospective study (NCT03523078) to validate our findings.

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“…The generic reference to ‘breast reconstruction’ was intended to capture all articles addressing the type and timing of breast reconstruction. Two authors independently reviewed abstracts of all studies published between 1985 and 2014, and the full texts of those studies published in 2015–2017. Levels of clinical evidence (LoE) were evaluated for each publication and scored from I to V by employing Oxford criteria.…”

Section: Methodsmentioning

confidence: 99%

International multidisciplinary expert panel consensus on breast reconstruction and radiotherapy

Nava

Benson

Audretsch

et al. 2019

British Journal of Surgery

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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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A 10-Year Experience with Mastectomy and Tissue Expander Placement to Facilitate Subsequent Radiation and Reconstruction

Abstract: Tissue expander placement at skin-sparing mastectomy in patients who require radiotherapy appears to be a viable strategy for combining reconstruction and radiotherapy.

Cited by 21 publications

References 26 publications

A Comparative Analysis of Immediate and Delayed-immediate Breast Reconstruction after Postmastectomy Radiation Therapy

A Comparative Analysis of Immediate and Delayed-immediate Breast Reconstruction after Postmastectomy Radiation Therapy

Influence of Radiation Dose to Reconstructed Breast Following Mastectomy on Complication in Breast Cancer Patients Undergoing Two-Stage Prosthetic Breast Reconstruction

International multidisciplinary expert panel consensus on breast reconstruction and radiotherapy

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