Thursday, August 4, 2011

Timing of Radiotherapy in Implant-Based Breast Reconstruction

 Updated 3/2017-- all links (except to my own posts) removed as many no longer active.

As Jackie Fox, Dispatch From Second Base, writes the choices after getting diagnosed with breast cancer can be overwhelming.  These choices (dependent on type and stage of breast cancer, desire for reconstruction, treatment needed, etc) can make the timing tricky when it comes to radiotherapy and reconstruction choices. 
The current issue of Plastic and Reconstructive Surgery Journal (first reference below) seeks to shed some light on the question of timing in implant-based breast reconstruction.
The authors looked at three populations  who received implant-based reconstruction from October of 2003 to October of 2007, a total of 257 patients (mean age, 49 years) were prospectively involved in this study.  All patients underwent a two-stage immediate breast reconstruction with subpectoral temporary expanders (ST 133; Allergan, Inc., Irvine, Calif.) and permanent implants (ST 410-510; Allergan).  Median followed up was 50 months.
  • The first population (group 1, n = 109 patients) was made up of women affected by early-stage breast cancer with extensive nodal involvement that required postmastectomy radiotherapy and adjuvant chemotherapy.  This group received radiation on permanent implants (radiotherapy plus permanent implants).
  • The second population (group 2, n = 50 patients) was made up of patients with locally advanced breast cancer who preoperatively were candidates for radiotherapy and who received chemotherapy before surgery.  This group  received radiation during the expansion phase of STE (radiotherapy plus tissue expanders).
  • A third population (n = 98 patients) who did not receive radiotherapy was included as a control group.
The estimate of the totally failed reconstruction rate was the principal endpoint of this study. Capsular contracture rates and patients' and surgeons' subjective evaluations were the secondary endpoints.

Highlights of the study:
The totally failed reconstruction rate was significantly higher in group 2, with 40% (20/50) of unsuccessful reconstructions, compared with 6.4% (7/109) in group 1 and 2.3% (2/98)  in the control group (p < 0.0001).
Half (10/20) the failed reconstructions in group 2 involved those stopped at the first stage with removal of temporary expander for extrusion (5 cases) or infection (5 cases).
The other half of the failed reconstructions in group 2 occurred during the second stage and were converted to flap surgery --  2 due to extrusion, 3 due to infection, and 5 due to poor results (e.g., asymmetry, Baker grade IV capsular contracture).
The 7 failures in group 1 were due to severe capsular contracture (5), wound dehiscence (1), and an infection that required implant removal (1).
The incidence of Baker grade IV capsular contracture rate was significantly higher for group 1 (10.1%) and group 2 (13.3%) compared with the control group which did not receive any radiation (0%),  p = 0.0001).
The shape assessment performed by the surgeons demonstrated a higher incidence of good results in group 1, although the highest value was still reported in the control group (group 1, 58.7 %; group 2, 30.8 %; control group, 74.2 %; p = 0.0009).
The estimate of patients' opinions demonstrated a higher prevalence of good results in group 1 in comparison with group 2, although as with the surgeons assessment it was highest in the control group (good opinion: group 1, 52.2%; group 2, 46.2%; and control group, 68.1%; p = 0.04)

The study authors conclusions:
This study demonstrated that a higher total failure rate affects breast reconstructions that undergo irradiation during tissue expansion. For this reason, we suggest that if tissue expansion can be performed during postoperative chemotherapy, chest wall irradiation should be delivered on permanent implants. The second surgical step can be scheduled 3 weeks after the end of chemotherapy, and the irradiation should not begin more than 3 weeks later. Patients whose need for radiotherapy is not known preoperatively can, in this way, improve their surgical outcome.

Outcome of Different Timings of Radiotherapy in Implant-Based Breast Reconstructions; Nava, Maurizio B.; Pennati, Angela E.; Lozza, Laura; Spano, Andrea; Zambetti, Milvia; Catanuto, Giuseppe; Plastic & Reconstructive Surgery. 128(2):353-359, August 2011; doi: 10.1097/PRS.0b013e31821e6c10  When Is Radiation Appropriate?, last updated August 6, 2008

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