International Journal of Radiation Oncology*Biology*Physics
Clinical investigation: breastComplications and patient satisfaction following expander/implant breast reconstruction with and without radiotherapy☆
Introduction
Breast conservation therapy is the preferred local management in Stages I and II breast cancer, but there are contraindications to its use1, 2. These include two or more gross tumors in separate quadrants of the breast, diffuse indeterminate or malignant-appearing microcalcifications, pregnancy, active collagen vascular disease, and history of prior irradiation to the breast. Mastectomy is the recommended treatment in these cases. Until recently, postmastectomy radiotherapy was generally reserved for patients with four or more positive lymph nodes, positive margins, and T3 tumors. However, with the publication of three trials now demonstrating a survival advantage in favor of postmastectomy radiotherapy in all node positive Stage II disease, more women are being referred for therapy in the postmastectomy setting 3, 4, 5.
Many patients will desire breast reconstruction after mastectomy. The primary options for reconstruction are autologous tissue reconstruction and tissue expansion with subsequent prosthetic expander/implant (E/I). Most autologous tissue reconstructions consist of a transverse rectus abdominus musculocutaneous (TRAM) flap or a latissimus dorsi muscle flap with an implant. Autologous reconstruction in patients requiring radiotherapy has resulted in acceptable rates of reconstruction failure and complications 6, 7, 8, 9. A two-staged expander/implant procedure is an alternative option for breast reconstruction for patients who are not candidates for autologous reconstruction or who prefer an implant reconstruction. Little data exist, however, comparing E/I reconstruction in irradiated and nonirradiated patients. Prior reports of limited numbers of patients have suggested increased rates of complications and adverse cosmetic results in women with implants treated with locoregional radiotherapy 10, 11, 12, 13, 14. There are even fewer studies that analyze patient satisfaction in the E/I reconstruction setting 11, 14, 15, 16. Therefore, our goals were to compare complications and rates of breast reconstruction failure in patients undergoing E/I reconstruction treated with and without radiation, and to analyze patient satisfaction by cohort.
Section snippets
Patients
The Michigan Breast Reconstruction Outcomes Study (MBROS) was initiated in 1994 to evaluate the outcomes of first time mastectomy reconstructions. Patients were enrolled if they were acceptable candidates for either autologous tissue or implant reconstruction. Twelve hospitals across the United States and Canada participated in the study. Patients were prospectively followed for complications and patient satisfaction. Our study included a cohort who underwent E/I reconstruction. A subset of
Results
Twenty-four patients (30%) had bilateral reconstructions, and 57 (70%) had unilateral reconstructions. In the no RT group, 19 (31%) had bilateral, and 43 (69%) had unilateral reconstructions. Forty-four of the no RT group had immediate reconstruction, and 14 had delayed reconstruction. Four of the no RT group had bilateral surgeries consisting of an immediate reconstruction on one side and delayed on the other. In the RT group, 5 (26%) had bilateral, and 14 (74%) had unilateral reconstruction.
Discussion
In our study of E/I reconstruction with or without radiotherapy, we report a higher rate of complications and implant failure in women who received radiotherapy compared to the nonirradiated cohort. This has also been shown by others in retrospective reports 10, 13, 15, 16. A comparison of irradiated and nonirradiated patients was evaluated in implant only reconstructions (excluding expanders) at M.D. Anderson (12). In their 20-year experience, complication rates of 43% (6 of 14) and 12% (33 of
Conclusion
Patients requiring radiotherapy had a higher rate of E/I reconstruction failure and complications compared to patients who did not receive RT. Despite these findings, our pilot data suggest that both general and esthetic satisfaction, as assessed by the patient, were not significantly different following radiotherapy compared to rates of satisfaction in patients who did not receive RT. For patients who are not candidates for TRAM but are motivated to pursue reconstruction, E/I may be an
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2022, Journal of Plastic, Reconstructive and Aesthetic SurgeryCitation Excerpt :The strength of association with group was high for all these variables (Table 3). Capsular contracture is a common complication in patients with implant-based breast reconstruction after PMRT, and also one of most challenging issues due to the high risk of drawbacks reported for alloplastic reconstruction.1,9–11,16–22 In our systematic review of articles on capsule histology, we found accordance in literature that even if the pathophysiological pathway that binds PMRT and capsular contracture is still unclear, the inflammatory process and the resulting fibrosis of the breast soft tissues seems to be the key factors involved.
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Supported in part by a Cancer Center Core Grant 3P30 CA 46592-12.