Immediate and delayed autologous abdominal microvascular flap breast reconstruction in patients receiving adjuvant, neoadjuvant or no radiotherapy: a meta-analysis of clinical and quality-of-life outcomes

Abstract

Background Effects of postmastectomy radiotherapy (PMRT) on autologous breast reconstruction (BRR) are controversial regarding surgical complications, cosmetic appearance and quality of life (QOL). This systematic review evaluated these outcomes after abdominal free flap reconstruction in patients undergoing postoperative adjuvant radiotherapy (PMRT), preoperative radiotherapy (neoadjuvant radiotherapy) and no radiotherapy, aiming to establish evidence‐based optimal timings for radiotherapy and BRR to guide contemporary management. Methods The study was registered on PROSPERO (CRD42017077945). Embase, MEDLINE, Google Scholar, CENTRAL, Science Citation Index and ClinicalTrials.gov were searched (January 2000 to August 2018). Study quality and risk of bias were assessed using GRADE and Cochrane's ROBINS‐I respectively. Results Some 12 studies were identified, involving 1756 patients (350 PMRT, 683 no radiotherapy and 723 neoadjuvant radiotherapy), with a mean follow‐up of 27·1 (range 12·0–54·0) months for those having PMRT, 16·8 (1·0–50·3) months for neoadjuvant radiotherapy, and 18·3 (1·0–48·7) months for no radiotherapy. Three prospective and nine retrospective cohorts were included. There were no randomized studies. Five comparative radiotherapy studies evaluated PMRT and four assessed neoadjuvant radiotherapy. Studies were of low quality, with moderate to serious risk of bias. Severe complications were similar between the groups: PMRT versus no radiotherapy (92 versus 141 patients respectively; odds ratio (OR) 2·35, 95 per cent c.i. 0·63 to 8·81, P = 0·200); neoadjuvant radiotherapy versus no radiotherapy (180 versus 392 patients; OR 1·24, 0·76 to 2·04, P = 0·390); and combined PMRT plus neoadjuvant radiotherapy versus no radiotherapy (272 versus 453 patients; OR 1·38, 0·83 to 2·32, P = 0·220). QOL and cosmetic studies used inconsistent methodologies. Conclusion Evidence is conflicting and study quality was poor, limiting recommendations for the timing of autologous BRR and radiotherapy. The impact of PMRT and neoadjuvant radiotherapy appeared to be similar.

Immediate versus secondary DIEP flap breast reconstruction: a multicenter outcome study

“…Reports show better aesthetic outcome, less psychological distress and lower treatment costs following IBR [ 6 , 17 , 18 ]. However, most studies focus on comparing autologous with implant-based reconstructions [ 6 – 8 , 11 ], or immediate and delayed autologous reconstructions in women who require post-mastectomy radiation therapy (PMRT) [ 19 , 20 ]. To date, there is a paucity of significant data on overall complications after immediate versus delayed autologous flap reconstruction.…”

Evolving Trends in Surgical Management of Breast Cancer: An Analysis of 30 Years of Practice Changing Papers

“…While radiotherapy after immediate autologous reconstruction had been thought to have a detrimental impact on flap outcome, several systematic reviews have shown no significant differences in measurable postoperative complications when comparing irradiated versus non-irradiated reconstructions. As such, immediate DIEP flap reconstruction in patients who need post-mastectomy radiation is an acceptable treatment option ( 82 , 83 ). In the setting of inflammatory breast cancer where the presence of dermal lymphatic invasion often requires skin excision, a delayed reconstruction is more appropriate.…”

Breast Reconstruction: Necessity for Further Standardization of the Current Surgical Techniques Attempting to Facilitate Scientific Evaluation and Select Tailored Individualized Procedures Optimizing Patient Satisfaction

“…Although autologous free flap reconstruction appears to be more resistant in the setting of radiation than alloplastic reconstruction, effects of PMRT are controversial regarding cosmetic appearance, quality of life, and surgical complications [59, 60].…”

“…A comparison of cosmetic outcomes based on timing of PMRT has been difficult among the studies presented due to a lack of standardization in reporting aesthetic outcomes, while late effects of radiation, up to more than a latency period of 5 years has not yet been assessed. Notably, inclusion of patient satisfaction scores and aesthetic results appear contradictory in the literature [58-60].…”

“…Notably, there is a lack of high-quality evidence in favor of NART as an alternative to PMRT in immediate or delayed autologous procedures, obstructing a further establishment of evidence-based optimal timings for radiotherapy and BRR to guide contemporary management. Interestingly, the expert panel inclined to a delayed-immediate implant-based approach, however without reaching a consensus regarding preferring to irradiate the expander-implant versus the permanent implant [71, 72].…”