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Implant Breast Reconstruction: Should Reconstruction be Delayed?
Radiotherapy and Immediate Expander/Implant Breast Reconstruction: Should Reconstruction be Delayed? Drucker-Zertuche M, Bargallo-Rocha E, Zamora-Del RR (Natl Cancer Inst of Mexico City) Breast J 17:365-370, 2011
Chest wall irradiation is very common for mastectomy patients that have opted for immediate breast reconstruction. We reviewed a 6 year experience with tissue expander implant reconstruction with and without radiotherapy in 97 patients. All patients were evaluated with respect to aesthetic outcome, infection, implant exposure, capsular contracture, displacement and failure of the reconstruction; more than 50% of our irradiated patients resulted in a complication. The findings of this study demonstrate that the rate of complications and the rate of patients requiring corrective surgeries in irradiated patients is significant in early follow up. This article is authored by surgeons from the Divisions of Plastic and Reconstructive Surgery and Breast Surgery at the National Cancer Institute of Mexico City. This is a retrospective review of tissue expander/ implant breast reconstructions from January 2002 to September 2008 performed at their institution on patients with invasive and noninvasive breast cancer. Surprisingly, no radiation oncologist was listed as an author or contributor, despite the vastly important radiation oncology perspective on this particular topic with regard to the effect of breast reconstruction on radiation treatment plans.
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Of the 97 patients who underwent breast reconstruction during this time period, 37 received 50 Gy of postoperative radiation and 60 received no radiation. The mean ages and follow-up times of the patients in each group were similar; the overall mean follow-up was 39.2 months. As the authors reported, “The mean time between insertion of an expander and replacement with a permanent implant was 6.2 months,” and the implant exchange was always performed after completion of the radiation therapy to avoid irradiating the final implant. Consistent with the preponderance of the medical literature, the overall complication rate in irradiated patients was 45.9% versus 11.6% in the nonirradiated group. The most common individual complication was severe capsular contracture in 21.6% of irradiated patients compared with 3.3% of nonirradiated patients. Aesthetic evaluations were done by an independent plastic surgeon at least 12 months after the initial procedure. In the nonirradiated group, 58 of 60 patients had an excellent or good result compared with 13 of 37 in the irradiated group. Six (16.2%) irradiated patients experienced reconstruction failure. Citing a long list of the negative outcomes of implant-based reconstruction after radiation therapy, the authors reported that more than 50% of the irradiated patients experienced a complication, an unfavorable result, or a failure of the reconstruction. Consequently, their recommendation focused on delayed reconstruction, even when the need for postoperative radiation therapy is unknown, because delayed reconstruction may be associated with a lower incidence of
Breast Diseases: A Year BookÒ Quarterly Vol 23 No 1 2012
complications. Irradiated patients may have to wait at least a year for the reconstruction to experience a reduction in the incidence of complications. An alternative recommendation from the authors is that the patients undergo an autologous reconstruction and then receive postoperative radiation therapy. They offered no comment, however, regarding the likely postradiation unpredictable volume, contour, and symmetry changes to the autologous reconstruction or the potentially negative effect of the immediate reconstruction on the radiation treatment plans, all of which have been well documented in the literature.1,2 It is difficult to predict if many informed patients faced with planned or possible postoperative radiation therapy will be receptive to either of these options. Perhaps the authors should more critically consider “delayed-immediate” reconstruction, which could also be an effective option and does not require postoperative radiation treatment. In the patients who require radiation therapy with this approach, at least the autologous reconstruction site would not be irradiated. Furthermore, an additional benefit of the delayedimmediate process is preservation of the breast skin envelope when oncologically safe, which has generally been a significant aesthetic advantage. G. L. Robb, MD
References 1. Tran NV, Chang DW, Gupta A, Kroll SS, Robb GL. Comparison of immediate and delayed free TRAM flap breast reconstruction in patients
receiving postmastectomy radiation therapy. Plast Reconstr Surg. 2001; 108:78-82.
2. Schechter NR, Strom EA, Perkins GH, et al. Immediate breast reconstruction can impact
postmastectomy irradiation. Am J Clin Oncol. 2005;28:485-494.
BREAST-CONSERVING THERAPY Increased Risk of Locoregional Recurrence for Women With T1-2N0 Triple-Negative Breast Cancer Treated With Modified Radical Mastectomy Without Adjuvant Radiation Therapy Compared With BreastConserving Therapy Abdulkarim BS, Cuartero J, Hanson J, et al (Univ of Alberta, Edmonton, Canada) J Clin Oncol 29:2852-2858, 2011
Purpose.dTo evaluate the risk of locoregional recurrence (LRR) associated with locoregional treatment of women with primary breast cancer tumors negative for estrogen receptor, progesterone receptor, and human epidermal growth factor receptor 2 (triple-negative breast cancer [TNBC]). Patients and Methods.dPatients diagnosed with TNBC were identified from a cancer registry in a single institution (n ¼ 768). LRR-free survival was estimated using Kaplan-Meier analysis. The Cox proportional hazards regression model was used to determine risk of LRR on the basis of locoregional management: breast-conserving therapy (BCT; ie, lumpectomy and adjuvant radiation therapy [RT]) and modified radical mastectomy (MRM) in the TNBC population and T1-2N0 subgroup. Results.dAt a median follow-up of 7.2 years, 77 patients (10%) with TNBC developed LRR. Five-year LRR-free
survival was 94%, 85%, and 87% in the BCT, MRM, and MRM + RT groups, respectively (P < .001). In multivariate analysis, MRM (compared with BCT), lymphovascular invasion and lymph node positivity were associated with increased LRR. Conversely, adjuvant chemotherapy was associated with decreased risk of LRR. For patients with T1-2N0 tumors, 5-year LRR-free survival was 96% and 90% in the BCT and MRM groups, respectively (P ¼ .027), and MRM was the only independent prognostic factor associated with increased LRR compared with BCT (hazard ratio, 2.53; 95% CI, 1.12 to 5.75; P ¼.0264). Conclusion.dWomen with T12N0 TNBC treated with MRM without RT have a significant increased risk of LRR compared with those treated with BCT. Prospective studies are warranted to investigate the benefit of adjuvant RT after MRM in TNBC. Although the risk of LRR after breast-conserving surgery is generally low, several recent retrospective series have identified subgroups of patients with higher-than-expected risk. When estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor 2 (HER2) were used to approximate the molecular subtype, patients with TNBC were found to have a higher risk of LRR than those with luminal A (ER or PR positive and HER2 negative) characteristics.1,2 In an
update of the Dana-Farber Cancer Institute/Massachusetts General Hospital experience,3 in which luminal A was approximated as grade 1 or 2, the 5-year cumulative incidence of LRR was 0.8% (95% confidence interval [CI], 0.4%-1.8%) for patients with luminal A disease and 6.7% (95% CI, 3.6%12.2%) for those with TNBC. Given the higher risk of LRR observed in patients with TNBC (compared with luminal A cancers) undergoing BCT, Abdulkarim and colleagues, as reported in this article, studied the LRR rate in patients with TNBC who underwent BCT compared with mastectomy. This is particularly relevant, given the lower overall survival rate now recognized as a direct result of LRR.4,5 In this retrospective study of 768 patients with TNBC who underwent BCT, MRM, or MRM and RT, patients who underwent MRM without RT had a higher risk of LRR than those who underwent BCT. As expected, patients who underwent MRM and RT also had a greater risk of LRR than those who underwent BCT, but these were generally high-risk patients, and 40% had 3 or more involved axillary nodes (compared with 4% in the MRM-alone group and 6% in the BCT group). The authors also examined LRR in a subset of patients with T1 or T2, N0 disease and similar risk factors for LRR, and this analysis was perhaps most relevant to the comparison of LRR rates following MRM or BCT. In this subset, the 5-year
Breast Diseases: A Year BookÒ Quarterly Vol 23 No 1 2012
97
Chest wall irradiation is very common for mastectomy patients that have opted for immediate breast reconstruction. We reviewed a 6 year experience with tissue expander implant reconstruction with and without radiotherapy in 97 patients. All patients were evaluated with respect to aesthetic outcome, infection, implant exposure, capsular contracture, displacement and failure of the reconstruction; more than 50% of our irradiated patients resulted in a complication. The findings of this study demonstrate that the rate of complications and the rate of patients requiring corrective surgeries in irradiated patients is significant in early follow up. This article is authored by surgeons from the Divisions of Plastic and Reconstructive Surgery and Breast Surgery at the National Cancer Institute of Mexico City. This is a retrospective review of tissue expander/ implant breast reconstructions from January 2002 to September 2008 performed at their institution on patients with invasive and noninvasive breast cancer. Surprisingly, no radiation oncologist was listed as an author or contributor, despite the vastly important radiation oncology perspective on this particular topic with regard to the effect of breast reconstruction on radiation treatment plans.
96
Of the 97 patients who underwent breast reconstruction during this time period, 37 received 50 Gy of postoperative radiation and 60 received no radiation. The mean ages and follow-up times of the patients in each group were similar; the overall mean follow-up was 39.2 months. As the authors reported, “The mean time between insertion of an expander and replacement with a permanent implant was 6.2 months,” and the implant exchange was always performed after completion of the radiation therapy to avoid irradiating the final implant. Consistent with the preponderance of the medical literature, the overall complication rate in irradiated patients was 45.9% versus 11.6% in the nonirradiated group. The most common individual complication was severe capsular contracture in 21.6% of irradiated patients compared with 3.3% of nonirradiated patients. Aesthetic evaluations were done by an independent plastic surgeon at least 12 months after the initial procedure. In the nonirradiated group, 58 of 60 patients had an excellent or good result compared with 13 of 37 in the irradiated group. Six (16.2%) irradiated patients experienced reconstruction failure. Citing a long list of the negative outcomes of implant-based reconstruction after radiation therapy, the authors reported that more than 50% of the irradiated patients experienced a complication, an unfavorable result, or a failure of the reconstruction. Consequently, their recommendation focused on delayed reconstruction, even when the need for postoperative radiation therapy is unknown, because delayed reconstruction may be associated with a lower incidence of
Breast Diseases: A Year BookÒ Quarterly Vol 23 No 1 2012
complications. Irradiated patients may have to wait at least a year for the reconstruction to experience a reduction in the incidence of complications. An alternative recommendation from the authors is that the patients undergo an autologous reconstruction and then receive postoperative radiation therapy. They offered no comment, however, regarding the likely postradiation unpredictable volume, contour, and symmetry changes to the autologous reconstruction or the potentially negative effect of the immediate reconstruction on the radiation treatment plans, all of which have been well documented in the literature.1,2 It is difficult to predict if many informed patients faced with planned or possible postoperative radiation therapy will be receptive to either of these options. Perhaps the authors should more critically consider “delayed-immediate” reconstruction, which could also be an effective option and does not require postoperative radiation treatment. In the patients who require radiation therapy with this approach, at least the autologous reconstruction site would not be irradiated. Furthermore, an additional benefit of the delayedimmediate process is preservation of the breast skin envelope when oncologically safe, which has generally been a significant aesthetic advantage. G. L. Robb, MD
References 1. Tran NV, Chang DW, Gupta A, Kroll SS, Robb GL. Comparison of immediate and delayed free TRAM flap breast reconstruction in patients
receiving postmastectomy radiation therapy. Plast Reconstr Surg. 2001; 108:78-82.
2. Schechter NR, Strom EA, Perkins GH, et al. Immediate breast reconstruction can impact
postmastectomy irradiation. Am J Clin Oncol. 2005;28:485-494.
BREAST-CONSERVING THERAPY Increased Risk of Locoregional Recurrence for Women With T1-2N0 Triple-Negative Breast Cancer Treated With Modified Radical Mastectomy Without Adjuvant Radiation Therapy Compared With BreastConserving Therapy Abdulkarim BS, Cuartero J, Hanson J, et al (Univ of Alberta, Edmonton, Canada) J Clin Oncol 29:2852-2858, 2011
Purpose.dTo evaluate the risk of locoregional recurrence (LRR) associated with locoregional treatment of women with primary breast cancer tumors negative for estrogen receptor, progesterone receptor, and human epidermal growth factor receptor 2 (triple-negative breast cancer [TNBC]). Patients and Methods.dPatients diagnosed with TNBC were identified from a cancer registry in a single institution (n ¼ 768). LRR-free survival was estimated using Kaplan-Meier analysis. The Cox proportional hazards regression model was used to determine risk of LRR on the basis of locoregional management: breast-conserving therapy (BCT; ie, lumpectomy and adjuvant radiation therapy [RT]) and modified radical mastectomy (MRM) in the TNBC population and T1-2N0 subgroup. Results.dAt a median follow-up of 7.2 years, 77 patients (10%) with TNBC developed LRR. Five-year LRR-free
survival was 94%, 85%, and 87% in the BCT, MRM, and MRM + RT groups, respectively (P < .001). In multivariate analysis, MRM (compared with BCT), lymphovascular invasion and lymph node positivity were associated with increased LRR. Conversely, adjuvant chemotherapy was associated with decreased risk of LRR. For patients with T1-2N0 tumors, 5-year LRR-free survival was 96% and 90% in the BCT and MRM groups, respectively (P ¼ .027), and MRM was the only independent prognostic factor associated with increased LRR compared with BCT (hazard ratio, 2.53; 95% CI, 1.12 to 5.75; P ¼.0264). Conclusion.dWomen with T12N0 TNBC treated with MRM without RT have a significant increased risk of LRR compared with those treated with BCT. Prospective studies are warranted to investigate the benefit of adjuvant RT after MRM in TNBC. Although the risk of LRR after breast-conserving surgery is generally low, several recent retrospective series have identified subgroups of patients with higher-than-expected risk. When estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor 2 (HER2) were used to approximate the molecular subtype, patients with TNBC were found to have a higher risk of LRR than those with luminal A (ER or PR positive and HER2 negative) characteristics.1,2 In an
update of the Dana-Farber Cancer Institute/Massachusetts General Hospital experience,3 in which luminal A was approximated as grade 1 or 2, the 5-year cumulative incidence of LRR was 0.8% (95% confidence interval [CI], 0.4%-1.8%) for patients with luminal A disease and 6.7% (95% CI, 3.6%12.2%) for those with TNBC. Given the higher risk of LRR observed in patients with TNBC (compared with luminal A cancers) undergoing BCT, Abdulkarim and colleagues, as reported in this article, studied the LRR rate in patients with TNBC who underwent BCT compared with mastectomy. This is particularly relevant, given the lower overall survival rate now recognized as a direct result of LRR.4,5 In this retrospective study of 768 patients with TNBC who underwent BCT, MRM, or MRM and RT, patients who underwent MRM without RT had a higher risk of LRR than those who underwent BCT. As expected, patients who underwent MRM and RT also had a greater risk of LRR than those who underwent BCT, but these were generally high-risk patients, and 40% had 3 or more involved axillary nodes (compared with 4% in the MRM-alone group and 6% in the BCT group). The authors also examined LRR in a subset of patients with T1 or T2, N0 disease and similar risk factors for LRR, and this analysis was perhaps most relevant to the comparison of LRR rates following MRM or BCT. In this subset, the 5-year
Breast Diseases: A Year BookÒ Quarterly Vol 23 No 1 2012
97