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Surgical Outcomes of Mastectomy with Immediate Autologous Reconstruction Followed by Radiation

  • Breast Oncology
  • Published:
Annals of Surgical Oncology Aims and scope Submit manuscript

Abstract

Introduction

Timing of autologous reconstruction relative to postmastectomy radiation therapy (PMRT) is debated. Benefits of immediate reconstruction must be weighed against a possibly heightened risk of complications from flap irradiation. We reviewed flap outcomes after single operation plus PMRT in a large institutional cohort.

Methods

Medical records were reviewed for women who underwent simultaneous mastectomy–autologous reconstruction with PMRT from 2007 to 2016. Primary endpoints were rates and types of radiation-related flap complications and reoperations, whose predictors were assessed by multivariable analysis. A p value < 0.10 was deemed significant to avoid type II error. Non-parametric logistic regression generated a model of PMRT timing associated with probabilities of complications and reoperations.

Results

One-hundred and thirty women underwent 208 mastectomy reconstruction operations, with a median follow up of 35.1 months (interquartile range 23.6–56.5). Forty-seven (36.2%) women experienced radiation-related complications, commonly fat necrosis (44.1%) and chest wall asymmetry (28.8%). Complications were higher among women who received PMRT < 3 months after surgery (46.8% for < 3 months vs. 29.3% for ≥ 3 months; p = 0.06), most of whom received neoadjuvant chemotherapy, and among women treated with internal mammary nodal (IMN) radiation (65.2% vs. 26.4%; p < 0.01); IMN radiation remained strongly associated in multivariable analysis (odds ratio [OR] 5.24; p < 0.01). Thirty-two (24.6%) women underwent 70 reoperations, commonly fat grafting (51.9%) and fat necrosis excision (17.1%). Reoperations were higher among women who received PMRT < 3 months after surgery (48.9 for < 3 months vs. 36.6 for ≥ 3 months; p = 0.19), which was significantly associated in multivariable analysis (OR 0.42; p = 0.08 for ≥ 3 months). The probabilities of complications and reoperations were lowest when PMRT was administered ≥ 3 months after surgery.

Conclusions

Among a large institutional cohort, immediate autologous reconstruction was associated with similar rates of adverse flap outcomes as historically reported alternatively sequenced protocols. IMN radiation increased risk, while PMRT ≥ 3 months after surgery decreased risk. Additional studies are needed to elaborate the impact of IMN radiation and early PMRT in immediate versus delayed autologous reconstruction.

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References

  1. National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology for Breast Cancer, Version 1.2019. Available at: https://www.nccn.org/professionals/physician_gls/pdf/breast.pdf. Accessed 22 Mar 2019.

  2. Recht A, Comen EA, Fine RE, et al. Postmastectomy radiotherapy: an American Society of Clinical Oncology, American Society for Radiation Oncology, and Society of Surgical Oncology focused guideline update. Pract Radiat Oncol. 2016;6:219–34.

    Article  Google Scholar 

  3. Hellman S. Stopping metastases at their source. N Engl J Med. 1997;337:996–7.

    Article  CAS  Google Scholar 

  4. Overgaard M, Hansen PS, Overgaard J, et al. Postoperative radiotherapy in high-risk premenopausal women with breast cancer who receive adjuvant chemotherapy. Danish Breast Cancer Cooperative Group 82b Trial. N Engl J Med. 1997;337:949–55.

    Article  CAS  Google Scholar 

  5. Overgaard M, Jensen MB, Overgaard J, et al. Postoperative radiotherapy in high-risk postmenopausal breast-cancer patients given adjuvant tamoxifen: Danish Breast Cancer Cooperative Group DBCG 82c randomised trial. Lancet. 1999;353:1641–8.

    Article  CAS  Google Scholar 

  6. Ragaz J, Olivotto IA, Spinelli JJ, et al. Locoregional radiation therapy in patients with high-risk breast cancer receiving adjuvant chemotherapy: 20-year results of the British Columbia randomized trial. J Natl Cancer Inst. 2005;97:116–26.

    Article  Google Scholar 

  7. Recht A, Edge SB, Solin LJ, et al. Postmastectomy radiotherapy: clinical practice guidelines of the American Society of Clinical Oncology. J Clin Oncol. 2001;19:1539–69.

    Article  CAS  Google Scholar 

  8. Early Breast Cancer Trialists’ Collaborative. Effect of radiotherapy after mastectomy and axillary surgery on 10-year recurrence and 20-year breast cancer mortality: meta-analysis of individual patient data for 8135 women in 22 randomised trials. Lancet. 2014;383:2127–35.

    Article  Google Scholar 

  9. Olivotto IA, Whelan TJ, Parpia S, et al. Interim cosmetic and toxicity results from RAPID: a randomized trial of accelerated partial breast irradiation using three-dimensional conformal external beam radiation therapy. J Clin Oncol. 2013;31(32):4038–45.

    Article  Google Scholar 

  10. Burt LM, Ying J, Poppe MM, et al. Risk of secondary malignancies after radiation therapy for breast cancer: comprehensive results. Breast. 2017;35:122–9.

    Article  Google Scholar 

  11. Early Breast Cancer Trialists’ Collaborative Group. Estimating the Risks of Breast Cancer Radiotherapy: evidence from modern radiation doses to the lungs and heart and from previous randomized trials. J Clin Oncol. 2017;35(15):1641–9.

    Article  Google Scholar 

  12. Darby SC, Ewertz M, McGale P, et al. Risk of ischemic heart disease in women after radiotherapy for breast cancer. N Engl J Med. 2013;368(11):987–98.

    Article  CAS  Google Scholar 

  13. Henson KE, McGale P, Taylor C, Darby SC. Radiation-related mortality from heart disease and lung cancer more than 20 years after radiotherapy for breast cancer. Br J Cancer. 2013;108(1):179–82.

    Article  CAS  Google Scholar 

  14. Jagsi R, Momoh AO, Qi J, et al. Impact of radiotherapy on complications and patient-reported outcomes after breast reconstruction. J Natl Cancer Inst. 2017;110(2):157–65.

    Article  Google Scholar 

  15. Ho AY, Hu ZI, Mehrara BJ, Wilkins EG. Radiotherapy in the setting of breast reconstruction: types, techniques and timing. Lancet Oncol. 2017;18:742–53.

    Article  Google Scholar 

  16. Billig J, Jagsi R, Qi J, et al. Should immediate autologous breast reconstruction be considered in women who require post-mastectomy radiation therapy? A prospective analysis of outcomes. Plast Reconstr Surg. 2017;139:1279–88.

    Article  CAS  Google Scholar 

  17. Zhong T, Hu J, Bagher S, et al. A comparison of psychological response, body image, sexuality, and quality of life between immediate and delayed autologous tissue breast reconstruction: a prospective long-term outcome study. Plast Reconstr Surg. 2016;138(4):772–80.

    Article  CAS  Google Scholar 

  18. Kelley BP, Ahmed R, Kidwell KM, et al. A systematic review of morbidity associated with autologous breast reconstruction before and after exposure to radiotherapy: are current practices ideal? Ann Surg Oncol. 2014;21:1732–8.

    Article  Google Scholar 

  19. Berbers J, Baardwijk AV, Houben R, et al. Reconstruction: Before or after postmastectomy radiotherapy? A systematic review of the literature. Eur J Cancer. 2014;50:2752–62.

    Article  Google Scholar 

  20. Kronowitz SJ, Hunt KK, Kuerer HM, et al. Delayed-immediate breast reconstruction. Plast Reconstr Surg. 2004;113:1617–28.

    Article  Google Scholar 

  21. Tran NV, Chang DW, Gupta A, et al. Comparison of immediate and delayed free TRAM flap breast reconstruction in patients receiving postmastectomy radiation therapy. Plast Reconstr Surg. 2001;108:78–82.

    Article  CAS  Google Scholar 

  22. Schaverien MV, Macmillan RD, McCulley SJ. Is immediate autologous breast reconstruction with postoperative radiotherapy good practice? A systematic review of the literature. J Plast Reconstr Aesthet Surg. 2013;66:1637–51.

    Article  Google Scholar 

  23. Veld EH, Long C, Sue G, et al. Analysis of aesthetic outcomes and patient satisfaction after delayed-immediate autologous breast reconstruction. Ann Plast Surg. 2018;80(5):303–7.

    Article  Google Scholar 

  24. Yoon AP, Alfred P, Qi J, et al. Outcomes of immediate versus delayed breast reconstruction: results of a multicenter prospective study. Breast. 2018;37:72–9.

    Article  Google Scholar 

  25. ACS-NSQIP. American College of Surgeon National Surgical Quality Improvement Program. Available at: https://www.facs.org/~/media/files/quality%20programs/nsqip/nsqip_puf_userguide_2017.ashx. Accessed 22 March 2019.

  26. Fischer JP, Wes AM, Tuggle CT, et al. Risk analysis and stratification of surgical morbidity after immediate breast reconstruction. J Am Coll Surg. 2013;217:780–7.

    Article  Google Scholar 

  27. Moore DS, McCabe GP, Craig BA. Introduction to the practice of statistics, 8th edn. New York: W.H. Freeman and Company; 2018.

    Google Scholar 

  28. Atisha D, Alderman AK, Lowery JC, et al. Prospective analysis of long-term psychosocial outcomes in breast reconstruction: two-year postoperative results from the Michigan breast reconstruction outcomes study. Ann Surg. 2008;247(6):1019–28.

    Article  Google Scholar 

  29. Hu ES, Pusic, AL, Waljee, JF. Patient-reported aesthetic satisfaction with breast reconstruction during the long-term survivorship period. Plast Reconstr Surg. 2009;124(1):1–8.

    Article  CAS  Google Scholar 

  30. Sullivan S, Fletcher D, Isom C, Isik F. True incidence of all complications following immediate and delayed breast reconstruction. Plast Reconstr Surg. 2008;122(1):19–28.

    Article  CAS  Google Scholar 

  31. Beugels J, Hoekstra LT, Tuinder SM. Complications in unilateral versus bilateral deep inferior epigastric artery perforator flap breast reconstructions: a multicentre study. J Plast Reconstr Aesthet Surg. 2016;69(9):1291–8.

    Article  CAS  Google Scholar 

  32. Singh P, Hoffman K, Schaverien MV, et al. Neoadjuvant radiotherapy to facilitate immediate breast reconstruction: a systematic review and current clinical trials. Ann Surg Oncol. 2019;26:3312–20.

    Article  Google Scholar 

  33. Zhang L, Jin K, Wang X, et al. The impact of radiotherapy on reoperation rates in patients undergoing mastectomy and breast reconstruction. Ann Surg Oncol. 2019;26(4):961–8.

    Article  Google Scholar 

  34. Hofer S. Damen T, Mureau M, et al. A critical review of perioperative complications in 175 free deep inferior epigastric perforator flap breast reconstructions. Ann Plast Surg. 2007;59(2):137–42.

    Article  CAS  Google Scholar 

  35. Shechter S, Arad E, Inbal A, et al. DIEP flap breast reconstruction complication rate in previously irradiated internal mammary nodes. J Reconstr Microsurg. 2018;34(06):399–403.

    Article  Google Scholar 

  36. Sadideen H, Cleator S, McNaught P, et al. The safety of early adjuvant internal mammary lymph node irradiation following mastectomy and immediate autologous reconstruction. Plast Reconstr Surg. 2018;141(3):467e–8e.

    Article  CAS  Google Scholar 

  37. Tsoutsou PG, Koukourakis MI, Azria D, Belkacémi Y. Optimal timing for adjuvant radiation therapy in breast cancer: A comprehensive review and perspectives. Crit Rev Oncol Hematol. 2009;71(2):102–16.

    Article  Google Scholar 

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Authors and Affiliations

  1. Department of Surgery, Yale University School of Medicine, New Haven, CT, USA

    Danielle R. Heller MD, MHS & Stefano Fusi MD, MBA

  2. School of Public Health, Yale University School of Medicine, New Haven, CT, USA

    Haoran Zhuo MPH & Yawei Zhang MD, PhD

  3. Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, CT, USA

    Nisha Parikh PA-C & Susan A. Higgins MD

  4. Division of Plastic and Reconstructive Surgery, Yale University School of Medicine, New Haven, CT, USA

    Michael Alperovich MD, MSc & Tomer Avraham MD

  5. The Breast Center, Department of Surgery, Yale University School of Medicine, New Haven, CT, USA

    Donald R. Lannin MD & Brigid K. Killelea MD, MPH

Authors
  1. Danielle R. Heller MD, MHS
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  2. Haoran Zhuo MPH
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  3. Yawei Zhang MD, PhD
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  4. Nisha Parikh PA-C
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  5. Stefano Fusi MD, MBA
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  10. Brigid K. Killelea MD, MPH
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Correspondence to Brigid K. Killelea MD, MPH.

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Disclosures

Brigid K. Killelea, was a member of the Advisory Board for Genentech, August 2017, to discuss data from the APHINITY trial; however, she does not believe this represents a conflict of interest.

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Heller, D.R., Zhuo, H., Zhang, Y. et al. Surgical Outcomes of Mastectomy with Immediate Autologous Reconstruction Followed by Radiation. Ann Surg Oncol 28, 2169–2179 (2021). https://doi.org/10.1245/s10434-020-09122-0

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  • DOI: https://doi.org/10.1245/s10434-020-09122-0

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