Setting Of Postmastectomy Radiation Therapy Research Articles

Optimal reconstructive strategies in the setting of post-mastectomy radiotherapy - A systematic review and network meta-analysis

BackgroundA third of breast cancer patients require mastectomy. In some high-risk cases postmastectomy radiotherapy (PMRT) is indicated, threatening reconstructive complications. Several PMRT and reconstruction combinations are used. Autologous flap (AF) reconstruction may be immediate (AF→PMRT), delayed-immediate with tissue expander (TE [TE→PMRT→AF]) or delayed (PMRT→AF). Implant-based breast reconstruction (IBBR) includes immediate TE followed by PMRT and conversion to permanent implant (PI [TE→PMRT→PI]), delayed TE insertion (PMRT→TE→PI), and prosthetic implant conversion prior to PMRT (TE→PI→PMRT). AimPerform a network metanalysis (NMA) assessing optimal sequencing of PMRT and reconstructive type. MethodsA systematic review and NMA was performed according to PRISMA-NMA guidelines. NMA was conducted using R packages netmeta and Shiny. Results16 studies from 4182 identified, involving 2322 reconstructions over three decades, met predefined inclusion criteria. Studies demonstrated moderate heterogeneity. Multiple comparisons combining direct and indirect evidence established AF-PMRT as the optimal approach to avoid reconstructive failure, compared with IBBR strategies (versus PMRT→TE→PI; OR [odds ratio] 0.10, CrI [95% credible interval] 0.02 to 0.55; versus TE→PMRT→PI; OR 0.13, CrI 0.02 to 0.75; versus TE→PI→PMRT OR 0.24, CrI 0.05 to 1.05). PMRT→AF best avoided infection, demonstrating significant improvement versus PMRT→TE→PI alone (OR 0.12, CrI 0.02 to 0.88). Subgroup analysis of IBBR found TE→PI→PMRT reduced failure rates (OR 0.35, CrI 0.15–0.81) compared to other IBBR strategies but increased capsular contracture. ConclusionImmediate AF reconstruction is associated with reduced failure in the setting of PMRT. However, optimal reconstructive strategy depends on patient, surgeon and institutional factors. If IBBR is chosen, complication rates decrease if performed prior to PMRT. Prospero registrationCRD 42020157077.

The use of bolus in postmastectomy radiation therapy for breast cancer: A systematic review.

Post mastectomy radiation therapy (PMRT) reduces locoregional recurrence (LRR) and breast cancer mortality for selected patients. Bolus overcomes the skin-sparing effect of external-beam radiotherapy, ensuring adequate dose to superficial regions at risk of local recurrence (LR). This systematic review summarizes the current evidence regarding the impact of bolus on LR and acute toxicity in the setting of PMRT. 27 studies were included. The use of bolus led to higher rates of acute grade 3 radiation dermatitis (pooled rates of 9.6% with bolus vs. 1.2% without). Pooled crude LR rates from thirteen studies (n = 3756) were similar with (3.5%) and without (3.6%) bolus. Bolus may be indicated in cases with a high risk of LR in the skin, but seems not to be necessary for all patients. Further work is needed to define the role of bolus in PMRT.

Breast Reconstruction and Post Mastectomy Radiotherapy: A Primer for Members of a Multidisciplinary Team

Background: Post-mastectomy radiation therapy (PMRT) is a key component in managing breast cancer with increased potential for locoregional recurrence. Breast reconstruction has evolved to include various techniques that can be categorized according to the type of reconstruction (implant-based versus autologous reconstruction), and the timing of reconstruction (one versus two-step techniques). Methods/Results: This review article aims to provide a digestible summary of PMRT in the context of breast reconstruction by summarizing salient existing literature with a focus on considerations of the plastic surgeon. The main findings summarized in this review include the technique and timing of breast reconstruction, how breast reconstruction can affect radiation delivery, and the type of reconstruction. Within implant-based reconstruction, existing data on the location of the implant in the context of PMRT and PMRT delivery to the tissue expander versus permanent implant are reviewed. Each consideration may alter the probability of successful reconstruction and patient satisfaction.Conclusion: It is essential for the multidisciplinary breast cancer team to have knowledge of the various reconstructive options, and to understand the safety and comparative effectiveness of staged reconstruction in the setting of PMRT. Additionally, one must consider that reconstructive procedures may have implications on the timely administration of PMRT. This review serves as a reference for members of the oncologic care team when discussing reconstructive options with patients who will receive PMRT as part of their treatment plan.

How to Optimize Prepectoral Breast Reconstruction.

Prepectoral breast reconstruction has become a popular method of postmastectomy breast reconstruction due to its numerous benefits in properly selected patients. Prepectoral reconstruction, as compared with retropectoral position, offers the advantage of leaving the pectoralis muscle undisturbed and in its original anatomic position, resulting in significantly decreased acute and chronic pain, improved upper extremity strength and range of motion, and avoidance of animation deformity. The use of acellular dermal matrices (ADMs) allows for precise control of the breast pocket, resulting in aesthetic outcomes and high patient satisfaction. ADMs have the added benefit of reducing capsular contracture, especially in the setting of postmastectomy radiation therapy. Although prepectoral breast reconstruction is effective, the breast implant is placed closer to the skin flap with less vascularized soft tissue coverage. Therefore, optimizing outcomes in prepectoral breast reconstruction requires careful patient selection, intraoperative mastectomy flap evaluation, and perioperative surgical algorithms specific to prepectoral reconstruction.

Hypofractionated vs Conventional Fractionated Post-Mastectomy Radiotherapy After Immediate-Autologous Reconstruction: Acute Toxicity and Patient Satisfaction

Immediate autologous reconstruction (IAR) is associated with less morbidity than implants in the setting of post-mastectomy radiotherapy (PMRT) in breast cancer patients (BCP). When PMRT is needed, conventional fractionated RT (CFRT) has been the standard schedule. However, the use of hypofractionated RT (HFRT) is increasing and is considered the standard of care nowadays. Our aim was to evaluate acute side-effects and patient’s satisfaction receiving PMRT after IAR, comparing CFRT vs HFRT. Between June 2015 and February 2020, 43 patients received either CF or HF PMRT after IAR in a tertiary hospital. IAR was performed with latissimus dorsi (LD) or deep inferior epigastric perforator (DIEP) flaps at the time of mastectomy. Prescribed radiotherapy dose was 50Gy over 25 fractions In the CF schedule and 40,05Gy over 15 fractions in the HF schedule. Target volume was the reconstructed chest-wall and axillary-supraclavicular nodes if indicated, and treatment technique was intensity-modulated radiotherapy. Acute toxicity was evaluated using CTCAE v.5.0 criteria, and patient’s global satisfaction was assessed using a self-evaluation questionnaire from 1-5 points. Chi square test was used for the statistical comparison. Median age was 48 years (28-77) and median follow-up was 19 months (6-56). 19 patients received HFRT and 24 CFRT. DIEP and LD flaps were performed in 20 (46%) and 23 (54%) patients respectively. Acute side effects after PMRT and tolerance until 6 months with HFRT schedule are shown in Table 1. No relationship was found between incidence of acute side effects and RT fractionation. Mean patient’s satisfaction was 3.8 in the CFRT schedule and 3.9 in the HFRT schedule. According to our findings, HFRT after IAR is comparable to CFRT in terms of acute toxicity and patient’s satisfaction.Abstract 2153; TableSix months side effects of Hypofractionated radiotherapy after mastectomy and immediate autologous reconstruction in 19 patientsAt the end of RTOne month after RTSix months after RTEventn (%)Eventn (%)Eventn (%)Dermatitis (grade 1-2)9 (47)Dermatitis (any grade)0 (0)Dermatitis (any grade)0 (0)Dermatitis (grade 3)0 (0)Flap induration (grade 1)0 (0)Hyperpigmentation (any grade)0 (0)Fatigue (grade 1-2)2 (10)Fatigue (any grade)3 (15)Lymphedema (grade 2)1 (5)Esophagitis (grade 1)2 (10)Dysphagia (any grade)0 (0)Breast induration (grade 1-2)9 (39)Dysphagia (grade 1-2)2 (9)Hyperpigmentation (grade 1-2)9 (47)Flap induration (grade 1)0 (0)Dysphagia (grade 3)0 (0)Fat necrosis (grade 1)2 (10)Fat necrosis (grade 3)2 (10)RT = Radiotherapy; All events are graded following Common Terminology Criteria for Adverse Events (CTCAE) v5.0 Open table in a new tab

A Meta-Analysis of Autologous Microsurgical Breast Reconstruction and Timing of Adjuvant Radiation Therapy.

Postmastectomy radiation therapy (PMRT) decreases loco-regional recurrence and improves survival in patients with locally advanced breast cancer. Autologous free flap reconstruction, while more durable in the setting of radiation than alloplastic reconstruction, is still susceptible to radiation-induced fibrosis, contracture, fat necrosis, volume loss, and distortion of breast shape. Options for reconstruction timing (immediate vs. delayed) have been discussed to mitigate these effects, but a clear optimum is not known. A systematic review of the literature was conducted according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines using search terms "breast reconstruction AND (radiation OR irradiation OR radiotherapy)" were used. Inclusion criteria consisted of studies reporting complications for free flap breast reconstruction in the setting of PMRT. Patients who underwent PMRT were pooled into two groups: those who underwent immediate free flap reconstruction prior to PMRT and those who underwent delayed reconstruction after PMRT. Out of the 23 studies, 12 focused on immediate reconstruction, seven focused on delayed reconstruction, and four studies included both groups. Overall, 729 patients underwent immediate reconstruction, while 868 underwent delayed reconstruction. Complete and partial flap loss rates were significantly higher in patients undergoing delayed reconstruction, while infection and wound-healing complication rates were higher in those undergoing immediate reconstructions. Rates of unplanned reoperations, vascular complications, hematoma/seroma, and fat necrosis did not differ significantly between the two groups. However, rates of planned revision surgeries were higher in the delayed reconstruction group. Immediate free flap breast reconstruction is associated with superior flap survival compared with delayed reconstruction. Rates of complications are largely comparable, and rates of revision surgeries are equivalent. The differences in long-term aesthetic outcomes are not, however, clearly assessed by the available literature. Even in the face of PMRT, immediate free flap breast reconstruction is an effective approach.

Postmastectomy radiotherapy and immediate implant-based breast reconstruction: attitudes and practices of Australian and New Zealand breast surgeons.

Postmastectomy radiotherapy and immediate implant-based breast reconstruction: attitudes and practices of Australian and New Zealand breast surgeons.

ESTRO ACROP consensus guideline for target volume delineation in the setting of postmastectomy radiation therapy after implant-based immediate reconstruction for early stage breast cancer

Immediate breast reconstruction (IBR) rates after mastectomy are increasing. Postmastectomy radiation therapy (PMRT) contouring guidelines for target volumes in the setting of IBR are lacking. Therefore, many patients who have had IBR receive PMRT to target volumes similar to conventional simulator-based whole breast irradiation. The aim of this paper is to describe delineation guidelines for PMRT after implant-based IBR based on a thorough understanding of the surgical procedures, disease stage, patterns of recurrence and radiation techniques. They are based on a consensus endorsed by a global multidisciplinary group of breast cancer experts.

Salvage of the failed implant-based breast reconstruction using the Deep Inferior Epigastric Perforator Flap: A single centre experience with tertiary breast reconstruction

The longevity and durability of implant-based reconstruction is limited and many patients who develop complications seek alternative reconstruction. Recent studies have shown tertiary reconstruction with autologous tissue to be safe in the short term. But no study has looked in-depth at the motivation for seeking referral and its long-term outcome. This was a retrospective study using patient case-notes and a prospectively-collated database. One hundred and fifteen patients underwent tertiary breast reconstruction with a Deep Inferior Epigastric Perforator (DIEP) flap between 1998 and 2016. Mean age was 49 (23-67). The predominant initial reconstruction was expander (71%). Twenty nine percent received a definitive reconstruction (implant with acellular dermal matrix or pedicled latissimus dorsi). The proportion of patients who received post-mastectomy radiotherapy (PMRT) to their implant was 72%. Thirty four percent underwent surgical salvage prior to referral for autologous tissue and this was significantly higher in the group that did not receive PMRT (29% vs 40, p = 0.04). Predominant motivation for autologous reconstruction was poor cosmesis (62%) and/or grade III/IV capsular contracture (27%). Mean time from implant to DIEP was 4 years 5 months. Ten percent had complications requiring re-operation. Flap loss was 0.7%. Fifty five percent required an additional ipsilateral procedure and 47% required symmetrization. Median follow-up was 20-months (6-months to 7-years). We present the largest UK series of tertiary breast reconstruction. Tertiary reconstruction is safe with a surgical outcome comparable to delayed autologous reconstruction. Patients with implant complications often had multiple failed attempts at salvage prior to referral. We advocate careful consideration of implants in the setting of PMRT and early referral for autologous tissue once complications become apparent.

Prepectoral breast reconstruction and radiotherapy-a closer look.

Prosthetic breast reconstruction in the setting of post-mastectomy radiation therapy (PMRT) has historically been plagued by complications and poor outcomes. We study the effects of PMRT in the setting of prepectoral prosthetic breast reconstruction in an attempt to ascertain the value of this muscle sparing technique as it relates to complications and outcomes. A retrospective analysis was performed on patients who underwent immediate, prepectoral, direct-to-implant or two-staged expander/implant breast reconstruction following skin-sparing mastectomy (SSM) or nipple-sparing mastectomy (NSM) and had postmastectomy radiotherapy. Results and complications were recorded. In patients who underwent two-staged reconstruction, at the second stage, on visual inspection, the acellular dermal matrix was noted to be completely integrated in all breasts, including those that had been irradiated after expander placement. Postoperative complications in irradiated breasts were limited to two breasts. In one breast, there was one incidence of wound dehiscence after expander irradiation, which led to expander removal and salvage with transverse rectus abdominis musculocutaneous (TRAM) flap reconstruction. In the second breast, there was one incidence of seroma after implant irradiation, which was managed conservatively as an outpatient. The seroma was drained and the patient treated with oral antibiotics. There were no complications in nonirradiated breasts. There was no incidence of clinically significant capsular contracture (grade III/IV) in irradiated or nonirradiated breasts. Prepectoral breast reconstruction has been an important addition to our reconstructive armamentarium and is proving to be a safe and effective means of performing prosthetic breast reconstruction in a wide array of patient populations. We have seen excellent physiologic and aesthetic outcomes in our patients following PMRT with minimal complications. Indeed, long-term follow-up will be required to elucidate the true effectiveness of this technique but preliminary results are quite promising.

Prepectoral Breast Reconstruction in the Setting of Postmastectomy Radiation Therapy: An Assessment of Clinical Outcomes and Benefits.

Prepectoral breast reconstruction following mastectomy has become a more widely performed technique in recent years because of its numerous benefits for women. These include full pectoralis muscle preservation, reduced loss of strength, reduced pain, and elimination of animation deformity. As with any breast reconstruction technique, widespread adoption is dependent on a low morbidity profile in the setting of postmastectomy radiation therapy, as this adjuvant therapy is routine in breast cancer treatment. The authors assess the clinical outcomes of patients undergoing postmastectomy radiation therapy following prepectoral breast reconstruction, and compare these to outcomes of patients undergoing postmastectomy radiation therapy with submuscular reconstruction. A single surgeon's experience with immediate prepectoral breast reconstruction, followed by postmastectomy radiation therapy, from 2015 to 2017 was reviewed. Patient demographics and incidence of complications during the tissue expander stage were assessed. In addition, the morbidity profile of these patients was compared to that of patients undergoing submuscular/dual-plane reconstruction and postmastectomy radiation therapy over the same period. Over 3 years, 175 breasts underwent immediate prepectoral reconstruction, and 236 breasts underwent immediate submuscular/dual-plane reconstruction. Overall rates of adjuvant radiation therapy (postmastectomy radiation therapy) were similar between prepectoral [26 breasts (14.9 percent)] and submuscular [31 breasts (13.1 percent)] (p = 0.6180) reconstruction. There were no significant differences in complication rates between the two reconstructive cohorts, in the setting of postmastectomy radiation therapy, including rates of explantation (15.4 percent versus 19.3 percent; p = 0.695). Prepectoral breast reconstruction is a safe and effective option in the setting of postmastectomy radiation therapy. The morbidity profile is similar to that encountered with submuscular reconstruction in this setting. Therapeutic, III.

Discussion: Prepectoral Breast Reconstruction in the Setting of Postmastectomy Radiation Therapy: An Assessment of Clinical Outcomes and Benefits.

Discussion: Prepectoral Breast Reconstruction in the Setting of Postmastectomy Radiation Therapy: An Assessment of Clinical Outcomes and Benefits.

PO8 A survey of Australian and New Zealand breast surgeons' current attitudes to breast reconstruction in women with breast cancer needing postmastectomy radiation therapy

Background & purpose: Breast reconstruction has psychological advantages that contribute to improved quality of life in breast cancer (BC) survivors. Surgical decision-making for women requiring reconstruction and post-mastectomy radiotherapy (PMRT) remains a challenge. As yet, there is no consensus on best practice in this setting. This study aims to quantitatively assess current Australian and New Zealand breast surgeons’ attitudes to breast reconstruction options in the setting of PMRT.

The use of acellular dermal matrix in immediate two-stage prosthetic breast reconstruction provides protection from postmastectomy radiation therapy: a clinicopathologic perspective.

Although there is ample evidence showing that radiation therapy increases the risk of complications of breast reconstruction, the efficacy of human acellular dermal matrix (CGCryoDerm®) in immediate tissue expander breast reconstruction in the setting of postmastectomy radiation therapy has not been fully elucidated. In this study, we report our institutional experience with pertinent refined surgical technique, and determine whether acellular dermal matrices have a protective effect in this increasingly prevalent clinical setting. Twenty-six patients who underwent immediate two-stage breast reconstruction in the setting of postmastectomy radiation therapy with at least 2 years of follow-up were retrieved. Fifteen patents were reconstructed with ADM, whereas 11 patients were reconstructed without ADM. The occurrence of complications was assessed according to the reconstruction type (with ADM vs without ADM). Furthermore, in patients reconstructed with ADM (n = 15), immunohistochemistry was performed to analyze the breast capsule with ADM compared with that without ADM in the same patient, according to the expression of alpha-smooth muscle actin (α-SMA). The occurrence of complications was significantly associated with the reconstruction type (with ADM vs. without ADM, p = 0.015). On the basis of the results of α-SMA staining, α-SMA+ myofibroblasts were relatively highly expressed throughout the breast capsule without ADM. On the contrary, α-SMA+ myofibroblasts present at the breast capsule adjacent to the ADM were scarce and irregularly scattered. Use of an acellular dermal matrix may be recommended to patients who are concerned about complications after immediate two-stage breast reconstruction in the setting of postmastectomy radiation therapy.

Radiotherapy and breast reconstruction.

Indications for post mastectomy radiotherapy are widening to a larger group of mastectomy patients and breast reconstruction rates following mastectomy are rising all over the world, this leading breast surgeons to face breast reconstruction in a growing number of patients who will undergo radiotherapy. Increased morbidity is associated with all forms of breast reconstruction in the setting of postmastectomy radiotherapy and in patients who previously underwent chest wall radiotherapy. Different attitudes towards breast reconstruction in the radiotherapy setting are presented in literature. The level of evidence and quality of studies investigating breast reconstruction in the setting of PMRT and in patients who previously underwent chest wall radiotherapy are low. The reconstructive option in the radiotherapy setting must be tailored on the single patient according with patients' characteristics and wishes, always considering that the best reconstructive timing must be driven by the best oncological timing.

Breast Reconstruction and Radiation Therapy.

Purpose:The optimal approach to the integration of postmastectomy reconstruction and radiation therapy is not well-established. This review will summarize current literature pertaining to the most common types of reconstruction in the setting of postmastectomy radiation therapy (PMRT).Data Sources:Literature from PubMed was reviewed from 2000 to 2016.Study Selection:Studies were selected with relevance to “postmastectomy breast reconstruction,” “breast reconstruction,” and “breast reconstructive methods and PMRT.” Surgical outcomes, patient satisfaction, and cost-effectiveness were examined.Data Extraction:Data from publications was extracted, summarized, and converted to a table.Results of Data Synthesis:Implant-based techniques are on the rise, in the setting of PMRT. Implant-based methods are more affordable in the short term and result in immediate breast-mound formation compared to autologous methods. When compared to implant-based reconstruction with PMRT, autologous reconstruction with PMRT results in better quality of life (QoL) and sensory recovery as well as fewer complications and failures. Among autologous flaps, deep inferior epigastric perforator flaps are considered superior to transverse rectus abdominal muscle (TRAM) pedicled flaps and may be more suitable for PMRT. Latissimus dorsi and muscle-sparing free TRAM flaps are also viable options. In delayed autologous, which may be advantageous for high-risk patients, the optimal timing to delay surgery after radiation therapy is unknown. Reconstruction with a 2-stage tissue expander-implant technique offers good to excellent cosmetic outcomes in the setting of PMRT, although there may be complications in this 2-stage process.Conclusion:Surgical, cosmetic, quality of life, and life expectancy must be taken into account when selecting the way to integrate breast reconstruction and PMRT.

Impact of Evolving Radiation Therapy Techniques on Implant-Based Breast Reconstruction.

BACKGROUND Patients undergoing implant-based reconstruction in the setting of postmastectomy radiation therapy suffer from increased complications and inferior outcomes compared with those not irradiated, but advances in radiation delivery have allowed for more nuanced therapy. The authors investigated whether these advances impact patient outcomes in implant-based breast reconstruction. METHODS Retrospective chart review identified all implant-based reconstructions performed at a single institution from November of 2010 to November of 2013. These data were cross-referenced with a registry of patients undergoing breast irradiation. Patient demographics, treatment characteristics, and outcomes were analyzed. RESULTS Three hundred twenty-six patients (533 reconstructions) were not irradiated, whereas 83 patients (125 reconstructions) received radiation therapy; mean follow-up was 24.7 months versus 26.0 months (p = 0.49). Overall complication rates were higher in the irradiated group (35.2 percent versus 14.4 percent; p < 0.01). Increased maximum radiation doses to the skin were associated with complications (maximum dose to skin, p = 0.05; maximum dose to 1 cc of skin, p = 0.01). Different treatment modalities (e.g., three-dimensional conformal, intensity-modulated, field-in-field, and hybrid techniques) did not impact complication rates. Prone versus supine positioning significantly decreased the maximum skin dose (58.5 Gy versus 61.7 Gy; p = 0.05), although this did not translate to significantly decreased complication rates in analysis of prone versus supine positioning. CONCLUSIONS As radiation techniques evolve, the maximum dose to skin should be given consideration similar to that for heart and lung dosing, to optimize reconstructive outcomes. Prone positioning significantly decreases the maximum skin dose and trends toward significance in reducing reconstructive complications. With continued study, this may become clinically important. Interdepartmental studies such as this one ensure quality of care. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.

Toxicity Outcomes for Immediate and Delayed Autologous Reconstruction in Patients Receiving Post-mastectomy Radiation Therapy: Is It Time to Reconsider Sequencing?

Delayed autologous reconstruction is usually recommended in patients anticipating postmastectomy radiation therapy (PMRT). However, it has been suggested that immediate autologous reconstruction (AR) may be acceptable for many patients. In this study, we sought to assess toxicity outcomes in patients receiving PMRT and AR. Retrospective chart review was performed in all patients receiving PMRT and AR, both immediate and delayed, at a single institution between April 2012 and November 2016. PMRT was designed using 3D planning and included treatment of the internal mammary, supraclavicular, and un-dissected axillary nodes typically prescribing 50 Gy over 25 fractions. A mastectomy scar line boost was delivered in 48.5% of patients. Incidence of major and minor complications were assessed. Preoperative and postoperative photos were also assessed for subjective outcome. Statistical analysis was performed with Students t-tests. Of the 739 patients that underwent AR, 60 received PMRT, 33 of which had at least 3 months of follow up from either date of RT completion in immediate AR or date of surgery in delayed AR, as well as evaluable 3D planned radiotherapy. Unilateral AR occurred in 82% and bilateral in 18%. Median age was 47 years (31 to 62) and median follow up was 7 months (3 to 36 months). All patients received either neoadjuvant or adjuvant chemotherapy. A total of 11 patients underwent immediate AR at the time of mastectomy and 23 patients underwent delayed AR 10 months (median; 4-36 range) after PMRT. The time interval in weeks from surgery to start of PMRT was 3 months (range 1 to 7) in immediate AR and the interval from RT to surgery was 7 months (range 4 to 36) in delayed AR. The infection rate in the entire group was 12% (N=3 immediate; N=1 delayed, p=0.062). Fat necrosis occurred in 9.1% (N=1) in the immediate group and 26% (N=6) in the delayed group (p=0.24). Incidence of revision operations was 54.5% (N=6) in the immediate group and 35% (N=8) in the delayed group (p=0.33). Unplanned reoperation rates were 13% (N=3) and 0% (p=0.21), flap failures were encountered in 1 delayed AR patient and 0 immediate AR (p=0.48), respectively. Total operation time was 9 hours 21 minutes for immediate AR vs 7 hours 49 minutes for delayed AR (p=0.055); and 90-day readmission rates were 9.1% (N=1) vs 8.7% (N=2), (p=0.21) respectively, in immediate and delayed cases. Photo ratings were comparable between the two groups. In a more modern treatment era, immediate autologous reconstruction in the setting of PMRT appears to show acceptable toxicity results that are comparable to delayed reconstruction. Increased patient numbers to corroborate these early findings and assessment of patient reported outcomes are needed to support that a change in sequencing AR with PMRT is warranted.

Abstract 120: Implant-Based Breast Reconstruction and the Timing of Adjuvant Radiotherapy: A Systematic Review and Meta-Analysis of Surgical Outcomes

PURPOSE: Implant-based breast reconstruction is the most common type of reconstruction. Outcomes of breast reconstruction are worse following post-mastectomy radiation therapy (PMRT), however, the impact of factors like timing, duration and dosage remain poorly understood. The impact of the timing of PMRT relative to the course of reconstruction is perhaps one factor that can be potentially modified by reconstructive surgeons. The systematic review aims to evaluate surgical outcomes following implant-based reconstruction in the setting of PMRT. METHODS: A systematic review of the English literature published from 2000 to 2016 in the PubMed/MEDLINE electronic database was performed to identify all manuscripts reporting outcomes of implant-based breast reconstruction in patients receiving PMRT. Patients in each study were grouped by timing of PMRT relative to reconstructive course; whether radiotherapy was administered to a tissue expander or permanent implant. Primary outcomes of interest were the most major of complications: reconstructive failure and capsular contracture. Overall rates and associations were determined via established methods; effect sizes (z-values), risk ratios (RRs), and heterogeneity scores (I2) were calculated on meta-analysis using a random and fixed effect models. RESULTS: Twenty studies met our inclusion criteria for a total of 2,348 patients undergoing implant-based breast reconstruction treated with PMRT. Five studies (25%) were performed prospectively while the remaining 15 (75%) were performed retrospectively. Most studies represented Level III evidence (16/20, 80%). The remaining minority was equally comprised of Level II (2/20, 10%) and Level IV studies (2/20, 10%). Mean follow-up was 39.5 months with a minimum average of 14.5 months and a maximum average of 73.5 months. Mean time to tissue expander exchange for permanent implant was 10.1 months in the 12 studies reporting this information. Pooled analysis of all patients revealed a rate of reconstructive failure of 17.5% and a rate of Baker grade III/IV capsular contracture of 37.5%. Overall, compared to patients receiving PMRT to permanent implants, patients who had PMRT applied to tissue expanders experienced higher rates of reconstructive failure (20% vs. 13.4%, p=0.001), but lower rates of capsular contracture (24.5% vs. 49.4%, p=0.0001). Meta-analysis demonstrated consistent findings by revealing a large effect size of 1.82 (RR=1.99, 95% CI 0.95–4.20) for reconstructive failure and a smaller effect size of -0.34 (RR=0.87, 95% CI 0.39–2.00) for capsular contracture. CONCLUSION: Regardless of timing, PMRT applied to implant-based breast reconstruction was associated with an unacceptably high risk of adverse events. Surgeons should strongly consider alternative methods of breast reconstruction, such as autologous-based reconstruction, as an alternative for patients who will require radiotherapy as part of their treatment protocol.

National Breast Reconstruction Utilization in the Setting of Postmastectomy Radiotherapy.

Background Immediate breast reconstruction (IBR) is often deferred, when postmastectomy radiotherapy (PMRT) is anticipated, due to high complication rates. Nonetheless, because of robust data supporting improved health-related quality of life associated with reconstruction, physicians and patients may be more accepting of tradeoffs. The current study explores national trends of IBR utilization rates and methods in the setting of PMRT, using the National Cancer Database (NCDB). The study hypothesis is that prosthetic techniques have become the most common method of IBR in the setting of PMRT. Methods NCDB was queried from 2004 to 2013 for women, who underwent mastectomy with or without IBR. Patients were grouped according to PMRT status. Multivariate logistic regression was used to calculate odds of IBR in the setting of PMRT. Trend analyses were done for rates and methods of IBR using Poisson regression to determine incidence rate ratios (IRRs). Results In multivariate analysis, radiated patients were 30% less likely to receive IBR (p < 0.05). The rate increase in IBR was greater in radiated compared with nonradiated patients (IRR: 1.12 vs. 1.09). Rates of reconstruction increased more so in radiated compared with nonradiated patients for both implants (IRR 1.15 vs. 1.11) and autologous techniques (IRR 1.08 vs. 1.06). Autologous reconstructions were more common in those receiving PMRT until 2005 (p < 0.05), with no predominant technique thereafter. Conclusion Although IBR remains a relative contraindication, rates of IBR are increasing to a greater extent in patients receiving PMRT. Implants have surpassed autologous techniques as the most commonly used method of breast reconstruction in this setting.