Managing BRCA Mutation Carriers by Anees B. Chagpar

Author:Anees B. Chagpar
Language: eng
Format: epub
Publisher: Springer International Publishing, Cham

Breast Reconstruction Considerations

Planning for breast reconstruction, immediate or delayed, must consider the impact of post-mastectomy radiotherapy (PMRT) . The two main issues which raise concern are compromised delivery of RT by the reconstructed breast and the impact of RT on the long-term cosmetic result of the reconstruction [55]. Cosmesis and symmetry issues may be more evident in the setting of bilateral mastectomy with immediate reconstruction, followed by unilateral PMRT .

Historically, patients requiring PMRT have been encouraged to have delayed breast reconstruction, based on concern that the reconstruction would compromise the delivery of PMRT [56–59]. Specific concerns include compromised delivery to the internal mammary nodes, non-uniform delivery, underdosing of the chest wall, and increased dose to normal tissues [55], but the evidence for these concerns is conflicting. Motwani et al. [59] reported compromised delivery of RT in 52% of patients who had undergone immediate reconstruction, compared with 7% of controls. Koutcher et al. [60] found no compromise in PMRT for most patients, with a 30-month loco-regional control rate of 97%. Surgeons at the University of Texas MD Anderson Cancer Center have advocated an “delayed–immediate” reconstruction algorithm for patients who need to receive PMRT [61]. A tissue expander is placed at the time of mastectomy, deflated during adjuvant RT, expanded post-RT, and followed by autologous flap reconstruction 4–6 months later [62]. They report low complication rates, tissue expander loss in 14% of patients, and local recurrence at 32 months’ follow-up of 3% [63]. They suggest that the complication rate with a “delayed–immediate” approach and subsequent flap reconstruction may be lower than that for a standard delayed flap reconstruction (26 vs. 38%, p = 0.4) [62], but many others have reported acceptable cosmetic and oncologic outcomes with immediate reconstruction followed by PMRT [60]. In an analysis of 191 patients requiring PMRT who underwent TRAM flap reconstruction, the risk of loco-regional recurrence at 40 months’ follow-up did not significantly differ between immediate and delayed procedures (3.7 vs. 1.8%, p = 0.65) [64]. In a more recent report from the same authors, among 492 patients with stage II–III disease who received mastectomy, chemotherapy, and PMRT, at a median follow-up of 7.2 years, there was no difference in local recurrence, disease-free survival, or overall survival, between immediate and delayed flap reconstruction [65]. Similarly, Wright et al. [66] reported on 104 patients with tissue expander reconstruction who underwent exchange to a permanent implant prior to PMRT . Local control rates were excellent, and immediate breast reconstruction was not associated with increased risk of distant metastases or death. In contrast, Nahabedian et al. [67] retrospectively analyzed 146 patients who underwent immediate or delayed reconstruction after PMRT, finding that loco-regional recurrence rates were higher in patients who underwent immediate versus delayed reconstruction (27 vs. 15%, p = 0.04). These data should be interpreted with caution based on the surprisingly high rates of recurrence [67, 68]. Since randomized trials are unlikely, the safety of breast reconstruction prior to PMRT remains controversial.

Regarding cosmesis and PMRT , the data favor delayed breast reconstruction.

Download

Copyright Disclaimer:
This site does not store any files on its server. We only index and link to content provided by other sites. Please contact the content providers to delete copyright contents if any and email us, we'll remove relevant links or contents immediately.