Strahlentherapie und Onkologie

, Volume 188, Issue 12, pp 1074–1079

Expander/implant breast reconstruction before radiotherapy

Outcomes in a single-institute cohort
  • C. Aristei
  • L. Falcinelli
  • V. Bini
  • I. Palumbo
  • A. Farneti
  • R.P. Petitto
  • S. Gori
  • E. Perrucci
Original article

Abstract

Background and purpose

Radiotherapy (RT) of reconstructed breasts was associated with major complications and poor cosmetic outcome. The present study assessed complication rates, the link between risk factors and prosthesis removal, as well as cosmetic outcomes.

Patients and methods

From 1997 to 2009, 101 consecutive patients received RT after breast reconstruction because of risk factors for relapse (92) or because relapse had occurred (9). At RT, 90 patients had temporary tissue expanders and 11 had permanent implants. Twelve patients underwent neo-adjuvant chemotherapy; all patients received adjuvant chemo- and/or hormone therapy.

Results

At a median follow-up of 50 months, late toxicities occurred in 28 patients: pain in 7, lymphedema in 6, G1 cutaneous toxicity in 5, and subcutaneous toxicity in 19 (2G1, 9G2, 7G3, 1G4), with more than one side effect in 12. In 8 patients the prosthesis ruptured (3), was displaced (3), was displaced and ruptured (1), or lost shape (1). Capsular contracture was classified in 89 patients as IA in 14, IB in 47, II in 10, III in 11, and IV in 7. Twelve prostheses (11.9%) were removed. The only significant factor for prosthesis removal was age (p = 0.007). Judgments of cosmetic results were available from 81 physicians and 84 patients. Outcome was excellent/good in 58/81 physician judgments and in 57/84 patient evaluations. Overall inter-rater agreement on outcome was good (κ-value 0.64; 95% CI: 0.48–0.79).

Conclusion

RT to reconstructed breasts was associated with low rates of late toxicity and prosthesis removal. Cosmetic outcomes were, on the whole, good to excellent.

Keywords

Mastectomy Immediate expander/implant reconstruction Radiotherapy Relapse Prosthesis removal 

Expander-/Implantatrekonstruktion vor Radiotherapie

Ergebnisse einer Einzelzenterkohorte

Zusammenfassung

Hintergründe und Ziel

Radiotherapie (RT) rekonstruierter Brüste hatte oft hohe Komplikationsraten und schlechte kosmetische Ergebnisse.

Diese Studie untersuchte Komplikationsraten, Zusammenhänge zwischen Risikofaktoren und Prothesenentfernung sowie kosmetische Ergebnisse.

Patienten und Methoden

Von 1997 bis 2009 erhielten 101 konsekutive Patientinnen eine RT nach Brustrekonstruktion wegen des Vorliegens von Risikofaktoren für ein Rezidiv (92), oder weil es zu einem Rezidiv gekommen war (9).

Zum Zeitpunkt der RT hatten 90 Patienten vorläufige Gewebeexpander und elf dauerhafte Implantate. Zwölf Patienten erhielten eine neo-adjuvante Chemotherapie; alle Patienten erhielten adjuvante Chemo- und/oder Hormon – Therapie.

Ergebnisse

Bei einer mittleren Nachbeobachtungszeit von 50 Monaten kam eine späte Toxizität bei 28 Patientinnen vor: Schmerzen in sieben, Lymphödem in sechs, G1 Hauttoxizität in fünf, subkutane Toxizität in 19 (2G1, 9G2, 7G3, 1G4). Mehr als eine Nebenwirkung hatten zwölf Patientinnen. In acht Patienten rupturierte die Prothese (3), dislozierte (3), dislozierte und rupturierte (1) oder verlor ihre Form (1). Kapselzusammenziehung wurde bei 89 Patientinnen als IA in 14, IB in 47, II in 10, III in 11 und IV in 7 Fällen klassifiziert. Zwölf Prothesen (11,9%) wurden entfernt. Der einzige bedeutende Faktor für die Protheseentfernung war das Alter (p = 0,007). Urteile zu kosmetischen Ergebnissen waren von 81 Ärzten und 84 Patienten verfügbar. Das Ergebnis war auch bei 58/81 der Arzturteile und 57/84 der Patientinneneinschätzungen ausgezeichnet bis gut. Die Inter-Rater-Übereinstimmung über das Ergebnis war insgesamt gut (κ-Wert 0,64; 95-%-CI: 0,48–0,79).

Schlussfolgerung

RT bei rekonstruierten Brüsten hatte niedrige Komplikationsraten in Bezug auf spätere Nebenwirkungen und Prothesenentfernung. Kosmetische Ergebnisse waren überwiegend ausgezeichnet bis gut.

Schlüsselwörter

Brustamputation Unmittelbare Expander/Implant Rekonstruktion Strahlentherapie Rezidiv Prothesenentfernung 

References

  1. 1.
    Anderson PR, Freedman G, Nicolaou N et al (2009) Postmastectomy chest wall radiation to a temporary tissue expander or permanent implant-is there a difference in complication rates? Int J Radiat Oncol Biol Phys 74:81–85PubMedCrossRefGoogle Scholar
  2. 2.
    Anderson PR, Hanlon AL, McNeeley SW et al (2004) Low complications rates are achievable after postmastectomy breast reconstruction and radiation therapy. Int J Radiat Oncol Biol Phys 59:1080–1087PubMedCrossRefGoogle Scholar
  3. 3.
    Barry M, Kell MR (2011) Radiotherapy and breast reconstruction: a meta-analysis. Breast Cancer Res Treat 127:15–22PubMedCrossRefGoogle Scholar
  4. 4.
    Buchholz TA, Strom EA, Perkins GH et al (2002) Controversies regarding the use of radiation after mastectomy in breast cancer. Oncologists 7:539–46CrossRefGoogle Scholar
  5. 5.
    Chawla AK, Kachnic LA, Taghian AG et al (2002) Radiotherapy and breast reconstruction: complications and cosmesis with tram versus tissue expander/implant. Int J Radiat Oncol Biol Phys 54:520–526PubMedCrossRefGoogle Scholar
  6. 6.
    Chevray PM (2008) Timing of breast reconstruction: immediate versus delayed. Cancer J 14:223–229PubMedCrossRefGoogle Scholar
  7. 7.
    Cordeiro PG, McCarthy CM (2006) A single surgeon’s 12-year experience with tissue expander/implant breast reconstruction: part II. An analysis of long-term complications, aesthetic outcomes, and patient satisfaction. Plast Reconstr Surg 118:832–839PubMedCrossRefGoogle Scholar
  8. 8.
    Cordeiro PG, Pusic AL, Disa JJ et al (2004) Irradiation after immediate tissue expander/implant breast reconstruction: outcomes, complications, aesthetic results, and satisfaction among 156 patients. Plast Reconstr Surg 113:877–881PubMedCrossRefGoogle Scholar
  9. 9.
    Cowen D, Gross E, Rouannet P et al (2010) Immediate post-mastectomy breast reconstruction followed by radiotherapy: risk factors for complications. Breast Cancer Res Treat 121:627–634PubMedCrossRefGoogle Scholar
  10. 10.
    Cox JD, Stetz J, Pajak TF (1995) Toxicity criteria of the Radiation Therapy Oncology Group (RTOG) and the European Organization for Research and Treatment of Cancer (EORTC). Int J Radiat Oncol Biol Phys 31:1341–1346PubMedCrossRefGoogle Scholar
  11. 11.
    Early Breast Cancer Trialists’ Collaborative Group (EBCTCG) (2005) 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 366:2087–2106Google Scholar
  12. 12.
    Goodman CM, Miller R, Patrick CW Jr et al (2002) Radiotherapy: effects on expanded skin. Plast Reconstr Surg 110:1080–1083PubMedCrossRefGoogle Scholar
  13. 13.
    Harris JR, Levene MB, Svensson G et al (1979) Analysis of cosmetic results following primary radiation therapy for stages I and II carcinoma of the breast. Int J Radiat Oncol Biol Phys 5:257–261PubMedCrossRefGoogle Scholar
  14. 14.
    Jhaveri JD, Rush SC, Kostroff K et al (2008) Clinical outcomes of postmastectomy radiation therapy after immediate breast reconstruction. Int J Radiat Oncol Biol Phys 72:859–865PubMedCrossRefGoogle Scholar
  15. 15.
    Kronowitz SJ, Robb GL (2009) Radiation therapy and breast reconstruction: a critical review of the literature. Plast Reconstr Surg 124:395–408PubMedCrossRefGoogle Scholar
  16. 16.
    Krueger EA, Wilkins EG, Strawderman M et al (2001) Complications and patient satisfaction following expander/implant breast reconstruction with and without radiotherapy. Int J Radiat Oncol Biol Phys 43:713–721CrossRefGoogle Scholar
  17. 17.
    Kuske RR, Schuster R, Klein E et al (1991) Radiotherapy and breast reconstruction: clinical results and dosimetry. Int J Radiat Oncol Biol Phys 21:339–346PubMedCrossRefGoogle Scholar
  18. 18.
    Landis JR, Koch GG (1977) The measurement of observer agreement for categorical data. Biometrics 33:159–174PubMedCrossRefGoogle Scholar
  19. 19.
    McCarthy CM, Mehrara BJ, Riedel E et al (2008) Predicting complications following expander/implant breast reconstruction: an outcomes analysis based on preoperative clinical risk. Plast Reconstr Surg 121:1886–1892PubMedCrossRefGoogle Scholar
  20. 20.
    Motwani SB, Strom EA, Schechter NR et al (2006) The impact of immediate breast reconstruction on the technical delivery of postmastectomy radiotherapy. Int J Radiat Oncol Biol Phys 66:76–82PubMedCrossRefGoogle Scholar
  21. 21.
    Nava MB, Pennati AE, Lozza L et al (2011) Outcome of different timings of radiotherapy in implant-based breast reconstructions. Plast Reconstr Surg 128:353–359PubMedCrossRefGoogle Scholar
  22. 22.
    NCCN (National Comprehensive Cancer Network) Clinical practice guidelines in oncologyTM. Breast Cancer Version 2.2011. (Accessed 20 Oct 2011 http://www.nccn.org/professionals/physician_gls/pdf/breast.pdf.)Google Scholar
  23. 23.
    Overgaard M, Hansen PS, Overgaard J et al (1997) Postoperative radiotherapy in high-risk menopausal women with breast cancer who receive adjuvant chemotherapy. N Engl J Med 337:949–955PubMedCrossRefGoogle Scholar
  24. 24.
    Overgaard M, Jensen MB, Overgaard J et al (1999) Postoperative radiotherapy in high-risk postmenopausal breast cancer patients given adjuvant tamoxifen: Danish Breast Cancer Cooperative Group DBCG 82c randomised trial. Lancet 353:1641–1648PubMedCrossRefGoogle Scholar
  25. 25.
    Piroth MD, Piroth DM, Pinkawa M et al (2009) Immediate reconstruction with an expander/implant following ablatio mammae because of breast cancer. Strahlenther Onkol 185:669–674PubMedCrossRefGoogle Scholar
  26. 26.
    Ragaz J, Olivotto IA, Spinelli JJ et al (2005) 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 97:116–1126PubMedCrossRefGoogle Scholar
  27. 27.
    Spear SL, Baker JL Jr (1995) Classification of capsular contracture after prosthetic breast reconstruction. Plast Reconstr Surg 96:1119–1123PubMedCrossRefGoogle Scholar
  28. 28.
    Spear SL, Onyewu C (2000) Staged breast reconstruction with saline-filled implants in the irradiated breast: recent trends and therapeutic implications. Plast Reconstr Surg 105:930–942PubMedCrossRefGoogle Scholar
  29. 29.
    Tallet AV, Salem N, Moutardier V et al (2003) Radiotherapy and immediate two-stage breast reconstruction with a tissue expander and implant: complications and esthetic results. Int J Radiat Oncol Biol Phys 57:136–142PubMedCrossRefGoogle Scholar
  30. 30.
    Van de Steene J, Soete G, Storme G (2000) Adjuvant radiotherapy for breast cancer significantly improves overall survival: the missing link. Radiother Oncol 55:263–272CrossRefGoogle Scholar
  31. 31.
    Vandeweyer E, Deraemaecker R (2000) Radiation therapy after immediate breast reconstruction with implants. Plast Reconstr Surg 106:56–58PubMedCrossRefGoogle Scholar
  32. 32.
    Vu TTT, Pignol JP, Rakovitch E et al (2007) Variability in radiation oncologists’ opinion on the indication of a bolus in post-mastectomy radiotherapy: an international survey. Clin Oncol (R Coll Radiol) 19:115–119Google Scholar
  33. 33.
    Whelan TJ, Julian J, Wright J et al (2000) Does locoregional radiation therapy improve survival in breast cancer? A meta-analysis. J Clin Oncol 18:1220–1229PubMedGoogle Scholar
  34. 34.
    Whitfield GA, Horan G, Irwin MS et al (2009) Incidence of severe capsular contracture following implant-based immediate breast reconstruction with or without postoperative chest wall radiotherapy using 40 Gray in 15 fractions. Radiother Oncol 90:141–147PubMedCrossRefGoogle Scholar
  35. 35.
    Wong JS, Ho AY, Kaelin CM et al (2008) Incidence of major corrective surgery after post-mastectomy breast reconstruction and radiation therapy. Breast J 14:49–54PubMedCrossRefGoogle Scholar

Copyright information

© Urban & Vogel 2012

Authors and Affiliations

  • C. Aristei
    • 1
  • L. Falcinelli
    • 2
  • V. Bini
    • 3
  • I. Palumbo
    • 1
  • A. Farneti
    • 4
  • R.P. Petitto
    • 2
  • S. Gori
    • 5
  • E. Perrucci
    • 2
  1. 1.Radiation Oncology Section, Department of Surgery, Radiology and DentistryUniversity of Perugia and Santa Maria della Misericordia HospitalPerugiaItaly
  2. 2.Radiation Oncology DivisionSanta Maria della Misericordia HospitalPerugiaItaly
  3. 3.Department of Internal MedicineUniversity of PerugiaPerugiaItaly
  4. 4.Radiation Oncology SectionUniversity of PerugiaPerugiaItaly
  5. 5.Medical Oncology DivisionSanta Maria della Misericordia HospitalPerugiaItaly

Personalised recommendations