Abstract
The objective is to prospectively determine the factors responsible for reconstruction failure and capsular contracture in mastectomized breast cancer patients who underwent immediate two-stage breast reconstruction with a tissue expander and implant, followed by radiotherapy. This is a multicenter, prospective, non-randomized study. Between February 1998 and September 2006, we prospectively examined 141 consecutive patients, each of which received an implant after mastectomy, followed by chest wall radiotherapy at 46–50 Gy in 23–25 fractions. Radiotherapy was delivered during immediate post-mastectomy reconstruction. Patients were evaluated by both a radiation oncologist and a surgeon 24–36 months after treatment. The median follow-up duration was 37 months. According to Baker’s classification, capsular contracture was grade 0, 1, or 2 in 67.5% of cases; it was grade 3 or 4 in 32.5% of cases. In total, 32 breast reconstruction failures required surgery. In univariate analysis, the following factors were associated with Baker grade 3 and 4 capsular contraction: adjuvant hormone therapy (P = 0.02), the surgeon (P = 0.04), and smoking (P = 0.05). Only one factor was significant in multivariate analysis: the surgeon (P = 0.009). Three factors were associated with immediate post-mastectomy breast reconstruction failure in multiple logistic regression analysis: T3 or T4 tumors (P = 0.0005), smoking (P = 0.001), and pN+ axillary status (P = 0.004). Patients with none, 1, 2, or all 3 factors have a probability of failure equal to 7, 15.7, 48.3, and 100%, respectively (P = 3.6 × 10−6). The model accurately predicts 80% of failures. Mastectomy, immediate reconstruction (expander followed by implant), and radiotherapy should be considered when conservative surgery is contraindicated. Three factors may be used to select patients likely to benefit from this technique with a low failure rate.
Similar content being viewed by others
References
Allweis TM, Boisvert ME, Otero SE, Perry DJ, Dubin NH, Priebat DA (2002) Immediate reconstruction after mastectomy for breast cancer does not prolong the time to starting adjuvant chemotherapy. Am J Surg 183:218–221
Anderson PR, Freedman G, Nicolaou N, Sharma N, Li T, Topham N et al (2009) Postmastectomy chest wall radiation to a temporary tissue expander or permanent breast implant—is there a difference in complication rates? Int J Radiat Oncol Biol Phys 74:81–85
Ascherman JA, Hanasono MM, Newman MI, Hughes DB (2006) Implant reconstruction in breast cancer patients treated with radiation therapy. Plast Reconstr Surg 117:359–365
Bentzen SM, Agrawal RK, Aird EG, Barrett JM, Barrett-Lee PJ, Bentzen SM et al (2008) The UK Standardisation of Breast Radiotherapy (START) Trial B of radiotherapy hypofractionation for treatment of early breast cancer: a randomised trial. Lancet 371:1098–1107
Canney PA, Dean S (1990) Transforming growth factor beta: a promotor of late connective tissue injury following radiotherapy? Br J Radiol 63:620–623
Chang DW, Reece GP, Wang B, Robb GL, Miller MJ, Evans GR et al (2000) Effect of smoking on complications in patients undergoing free TRAM flap breast reconstruction. Plast Reconstr Surg 105:2374–2380
Chavaudra J, Bridier A (2001) Definition of volumes in external radiotherapy: ICRU reports 50 and 62. Cancer Radiother 5:472–478
Chawla AK, Kachnic LA, Taghian AG, Niemierko A, Zapton DT, Powell SN (2002) Radiotherapy and breast reconstruction: complications and cosmesis with TRAM versus tissue expander/implant. Int J Radiat Oncol Biol Phys 54:520–526
Colletta AA, Wakefield LM, Howell FV, van Roozendaal KE, Danielpour D, Ebbs SR et al (1990) Anti-oestrogens induce the secretion of active transforming growth factor beta from human fetal fibroblasts. Br J Cancer 62:405–409
Cordeiro PG, Pusic AL, Disa JJ, McCormick B, VanZee K (2004) Irradiation after immediate tissue expander/implant breast reconstruction: outcomes, complications, aesthetic results, and satisfaction among 156 patients. Plast Reconstr Surg 113:877–881
Forbes JF, Cuzick J, Buzdar A, Howell A, Tobias JS, Baum M (2008) Effect of anastrozole and tamoxifen as adjuvant treatment for early-stage breast cancer: 100-month analysis of the ATAC trial. Lancet Oncol 9:45–53
Harcourt DM, Rumsey NJ, Ambler NR, Cawthorn SJ, Reid CD, Maddox PR et al (2003) The psychological effect of mastectomy with or without breast reconstruction: a prospective, multicenter study. Plast Reconstr Surg 111:1060–1068
Jhaveri JD, Rush SC, Kostroff K, Derisi D, Farber LA, Maurer VE et al (2008) Clinical outcomes of postmastectomy radiation therapy after immediate breast reconstruction. Int J Radiat Oncol Biol Phys 72:859–865
Khoo A, Kroll SS, Reece GP, Miller MJ, Evans GR, Robb GL et al (1998) A comparison of resource costs of immediate and delayed breast reconstruction. Plast Reconstr Surg 101:964–968 discussion 969–970
Kraemer O, Andersen M, Siim E (1996) Breast reconstruction and tissue expansion in irradiated versus not irradiated women after mastectomy. Scand J Plast Reconstr Surg Hand Surg 30:201–206
Krueger EA, Wilkins EG, Strawderman M, Cederna P, Goldfarb S, Vicini FA et al (2001) Complications and patient satisfaction following expander/implant breast reconstruction with and without radiotherapy. Int J Radiat Oncol Biol Phys 49:713–721
Kwiatkowski F, Girard M, Hacene K, Berlie J (2000) Sem: a suitable statistical software adapted for research in oncology. Bull Cancer 87:715–721
Mehta VK, Goffinet D (2004) Postmastectomy radiation therapy after TRAM flap breast reconstruction. Breast J 10:118–122
Mikeljevic JS, Haward R, Johnston C, Crellin A, Dodwell D, Jones A et al (2004) Trends in postoperative radiotherapy delay and the effect on survival in breast cancer patients treated with conservation surgery. Br J Cancer 90:1343–1348
Motwani SB, Strom EA, Schechter NR, Butler CE, Lee GK, Langstein HN et al (2006) The impact of immediate breast reconstruction on the technical delivery of postmastectomy radiotherapy. Int J Radiat Oncol Biol Phys 66:76–82
Overgaard M, Hansen PS, Overgaard J, Rose C, Andersson M, Bach F et al (1997) Postoperative radiotherapy in high-risk premenopausal women with breast cancer who receive adjuvant chemotherapy. Danish Breast Cancer Cooperative Group 82b Trial. N Engl J Med 337:949–955
Overgaard M, Jensen MB, Overgaard J, Hansen PS, Rose C, Andersson M 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 353:1641–1648
Ragaz J, Jackson SM, Le N, Plenderleith IH, Spinelli JJ, Basco VE et al (1997) Adjuvant radiotherapy and chemotherapy in node-positive premenopausal women with breast cancer. N Engl J Med 337:956–962
Ringberg A, Tengrup I, Aspegren K, Palmer B (1999) Immediate breast reconstruction after mastectomy for cancer. Eur J Surg Oncol 25:470–476
Spear SL, Baker JL Jr (1995) Classification of capsular contracture after prosthetic breast reconstruction. Plast Reconstr Surg 96:1119–1123 discussion 1124
Spear SL, Majidian A (1998) Immediate breast reconstruction in two stages using textured, integrated-valve tissue expanders and breast implants: a retrospective review of 171 consecutive breast reconstructions from 1989 to 1996. Plast Reconstr Surg 101:53–63
Tallet AV, Salem N, Moutardier V, Ananian P, Braud AC, Zalta R 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 57:136–142
Vandeweyer E, Deraemaecker R (2000) Radiation therapy after immediate breast reconstruction with implants. Plast Reconstr Surg 106:56–58 discussion 59–60
Wazer DE, Morr J, Erban JK, Schmid CH, Ruthazer R, Schmidt-Ullrich RK (1997) The effects of postradiation treatment with tamoxifen on local control and cosmetic outcome in the conservatively treated breast. Cancer 80:732–740
Whitfield GA, Horan G, Irwin MS, Malata CM, Wishart GC, Wilson CB (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 90:141–147
Wright JL, Cordeiro PG, Ben-Porat L, Van Zee KJ, Hudis C, Beal K (2008) Mastectomy with immediate expander-implant reconstruction, adjuvant chemotherapy, and radiation for stage II-III breast cancer: treatment intervals and clinical outcomes. Int J Radiat Oncol Biol Phys 70:43–50
Conflict of interest
None.
Author information
Authors and Affiliations
Corresponding author
Additional information
This study was conducted on behalf of the CORS (Cercle des Oncologues Radiothérapeutes du Sud).
An invited commentary to this article can be found at doi:10.1007/s10549-010-0878-z.
Rights and permissions
About this article
Cite this article
Cowen, D., Gross, E., Rouannet, P. et al. Immediate post-mastectomy breast reconstruction followed by radiotherapy: risk factors for complications. Breast Cancer Res Treat 121, 627–634 (2010). https://doi.org/10.1007/s10549-010-0791-5
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10549-010-0791-5