Paraphrased from Plastic and Reconstructive Surgery Journal. June 2017.

Postmastectomy Irradiation and the case for immediate or delayed Autogenous Tissue Breast Reconstruction

Colwell, Amy S. M.D.
Plastic & Reconstructive Surgery: June 2017 - Volume 139 - Issue 6 - p 1289–1290

The evolution of mastectomy has advanced from radical to modified radical and now skin- and nipple-preserving mastectomy procedures without oncologic detriment to the patients.

In a similar way, radiotherapy has undergone significant changes from rudimentary two-dimensional planning with cobalt to more targeted three-dimensional planning with intensity-modulated radiation therapy, volumetric-modulated arc therapy, and proton therapy with pencil beam scanning.

This specificity has allowed improved targeted therapy and reduced the bystander effect on surrounding normal tissue, and this has been essential to the paradigm shift of radiation therapy as a salvage modality to radiation therapy as an integral part of modern breast cancer treatment.

Autologous reconstruction is an ideal option for many patients following mastectomy, particularly in the setting of radiotherapy.

Immediate autologous reconstruction has several advantages, including the psychological benefit of awakening from mastectomy surgery with a breast mound, and the practical benefits of fewer operations and decreased operative time if the reconstruction is begun simultaneously with the mastectomy.

However, experience gained from large series in the past showed high incidences of fat and flap necrosis, volume loss, and complications when immediate autologous reconstruction was performed before radiation therapy.

Therefore, delayed autologous reconstruction has been the most common choice in patients destined to undergo postmastectomy radiotherapy.

However, with improvements in surgery and radiation techniques combined, several authors have begun to reexplore immediate autologous reconstruction in this setting.

The Mastectomy Reconstruction Outcomes Consortium Study offered a potential way to answer the question of whether immediate autologous reconstruction should be performed in women who require postmastectomy radiation therapy.

In this article, immediate reconstruction was performed in 108 patients. This cohort was unique in having no total or partial flap losses and a very low (3.7 percent) rate of fat necrosis, which is a testament to the technical skills of the surgeons involved.

Information regarding the delivery of radiotherapy specifics was not collected at all sites, but the regimen at this center used slightly smaller fractions of radiation for delivery compared to other sites where doses were known, there were no radiation boosts, and selected nodal treatment was performed.

In comparison, the delayed cohort (67 patients) offered a true multicenter experience and reported rates of partial flap necrosis (7.5 percent) and fat necrosis (10.5 percent) comparable to those in the literature.

Overall, there was no difference in total breast complications between immediate and delayed reconstruction.

Furthermore, patient-reported satisfaction scores between immediate and delayed cohorts were similar at 1 and 2 years.

The results from this study show that as surgery and radiation therapy continue to evolve, immediate breast reconstruction should definitely be considered.

However, the question of whether immediate breast reconstruction should be performed can only be answered at each institute based on surgical expertise and radiotherapy delivery unique to each health care system.

REFERENCES

1. Clarke M, Collins R, Darby S, et al. Early Breast Cancer Trialists’ Collaborative Group (EBCTCG). Effects of
radiotherapy and of differences in the extent of surgery for early breast cancer on local recurrence and 15-year
survival: An overview of the randomised trials. Lancet 2005;366:2087–2106.
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2. Katz A, Strom EA, Buchholz TA, et al. Locoregional recurrence patterns after mastectomy and doxorubicin-based
chemotherapy: Implications for postoperative irradiation. J Clin Oncol. 2000;18:2817–2827.
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3. Kronowitz SJ, Robb GL. Radiation therapy and breast reconstruction: A critical review of the literature. Plast
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Paraphrased from Plastic and Reconstructive Surgery, Jun 2017:

The case for Autologous Breast Reconstruction rather than Implant Reconstruction in Irradiated Patients.

Methods: From the 2009 to 20130, irradiated breast cancer patients who underwent implant or autologous reconstruction were selected.

Results: There were 2964 study patients. Most (78 percent) underwent implant reconstruction. The unadjusted mean costs for implant and autologous reconstructions were $22,868 and $30,527, respectively.

Thirty-two percent of implant reconstructions failed, compared with 5 percent of autologous cases.

Twelve percent of the implant reconstructions had two or more failures and required subsequent autologous reconstruction.

The cost of implant reconstruction failure requiring a flap was $47,214, and the cost for autologous failures was $48,344.

In aggregate, failures constituted more than 20 percent of the cumulative costs of implant reconstruction compared with less than 5 percent for
autologous reconstruction.

Conclusions: More than one in 10 patients who had implant reconstruction in the setting of radiation therapy to the breast eventually required a flap for failure.

These findings make a case for autologous reconstruction being primarily considered in irradiated patients who have this option available.

Reference:
Comparing Health Care Resource Use between Implant and Autologous Reconstruction of the Irradiated Breast: A National Claims-Based Assessment

Aliu, Oluseyi M.D., M.S.; Zhong, Lin M.D., M.P.H.; Chetta, Matthew D. M.D.; Sears, Erika D. M.D., M.S.; Ballard, Tiffany M.D.; Waljee, Jennifer
F. M.D., M.S.; Chung, Kevin C. M.D., M.S.; Momoh, Adeyiza O. M.D.

Plastic & Reconstructive Surgery: June 2017 - Volume 139 - Issue 6 - p 1224e–1231e