BREAST SURGERY
Considering the Optimal Timing of Breast Reconstruction With Abdominal Flaps With Adjuvant Irradiation in 370 Consecutive Pedicled Transverse Rectus Abdominis Myocutaneous Flap and Free Deep Inferior Epigastric Perforator Flap Performed in a Chinese Oncology Center Is There a Significant Difference Between Immediate and Delayed? Shanshan He, MD,* Jian Yin, MD, PhD,* Geoffrey L. Robb, MD, FACS,† Jingyan Sun, MD, PhD,* Xuehui Zhang, MD,* Haixin Li, PhD,‡ Jing Liu, MD,* and Chunyong Han, MD, PhD* Purpose: There is an ongoing debate on the optimal sequence of radiation and breast reconstruction. The purpose of this article was to (a) assess the impact of radiation on autologous breast reconstruction and (b) analyze the best timing for autologous breast reconstruction in the setting of radiation in a Chinese population. Methods: A retrospective review of patients undergoing breast reconstruction with autologous lower abdominal flaps between 2001 and 2014 in the Tianjin Medical University and Cancer Hospital was performed. Patients were grouped by their irradiation status (irradiated vs nonirradiated). The irradiated group was further stratified into 2 groups by the timing of irradiation (immediate breast reconstruction followed by radiation vs prior radiation and delayed breast reconstruction). The primary outcomes were early and late breast complications, secondary and revision surgeries to the reconstructed breast, whereas the secondary outcomes were aesthetic and psychological evaluations of the patients. Logistic regression was used to assess the potential association between irradiation, patient and treatment variables, and surgical outcomes. Results: Three hundred sixty patients with 370 reconstructed breasts were included in the study. Two hundred seventy-eight cases were nonirradiated, of which 158 were immediate and 120 were delayed. Ninety-two cases were irradiated, of which 61 were immediate, and 31 were delayed. Three hundred thirty-two cases underwent pedicled transverse rectus abdominis myocutaneous flap, 38 had deep inferior epigastric perforator flap. The irradiated group had a significant increase in secondary surgery due to fat necrosis (P < 0.001) and in late complications Received May 2, 2016, and accepted for publication, after revision August 26, 2016. From the *Department of Breast Reconstruction, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin, China; †Department of Plastic Surgery, MD Anderson Cancer Center, Houston, TX; and ‡Department of Epidemiology, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin, China. This study was supported by the fund of Tianjin Medical University Cancer Institute and Hospital (grant 1405) and the National Key Clinical Specialist Construction Programs of China. Conflicts of interest and sources of funding: none declared. Reprints: Jian Yin, MD, PhD, Department of Breast Reconstruction, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin, China. E-mail: [email protected]. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.annalsplasticsurgery.com). Copyright © 2016 The Author(s). Published by Wolters Kluwer Health, Inc. This is an open-access article distributed under the terms of the Creative Commons AttributionNon Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. ISSN: 0148-7043/17/7806–0633 DOI: 10.1097/SAP.0000000000000927
Annals of Plastic Surgery • Volume 78, Number 6, June 2017
(P = 0.011). A significant increase in flap contracture (P = 0.043) and an increasing trend in the severity of fat necrosis were observed when radiation was performed after breast reconstruction. However, radiation and its timing did not have an adverse impact on patients' aesthetic and psychological evaluations by the Breast-Q survey. Conclusions: Radiation administered to the reconstructed breast mound increased the rate of late complications and the need for secondary surgery with increased abdominal flap shrinkage and contracture and the severity of flap fat necrosis. Irradiation on the reconstructed breast did not lead to worse aesthetic outcomes due to the generally different expectation in the Chinese female patients in that they were more focused on the breast shape when clothed. Immediate breast reconstruction followed by irradiated was a generally successful treatment sequence in the Chinese module. Key Words: breast reconstruction, autologous, radiation, timing, Chinese population (Ann Plast Surg 2017;78: 633–640)
R
adiation therapy is an essential treatment parameter for breast cancer patients with large tumor and/or lymph node invasion reducing local recurrence and improving disease-free survival as well as overall survival.1,2 However, radiation treatment can have adverse effects on autologous tissues used in immediate breast reconstruction. Radiation can cause local edema, erythema, and desquamation in the short-term and significant tissue fibrosis and contracture in the long term.3,4 For patients who wish to have autologous breast reconstruction, the effect of radiation and its timing is still controversial.5–8 From an oncologic perspective, breast reconstruction before or after irradiation has similar survival benefits.9 Although the National Comprehensive Cancer Network guideline suggests delaying breast reconstruction until 6 months after the completion of postmastectomy irradiation due to aesthetic considerations, some surgeons have argued that immediate breast reconstruction followed by irradiation can still achieve satisfactory outcomes and avoid the mental stress of an absent breast mound during adjuvant therapies, while maintaining cost-effectiveness.10–13 In this study, we performed a retrospective review of patients who had autologous breast reconstruction in our clinical oncology center to illustrate the impact of radiation on autologous breast reconstruction and analyze the best timing in our practice for autologous breast reconstruction in the setting of postmastectomy radiation.
PATIENTS AND METHODS We retrospectively collected data of autologous breast reconstruction between May 2001 and June 2014 in Tianjin Cancer Hospital. www.annalsplasticsurgery.com
633
Annals of Plastic Surgery • Volume 78, Number 6, June 2017
He et al
TABLE 1. Patient Characteristics and Treatment Variables by Radiation Status
Age, y 30 Follow-up, mo Smoking status Comorbidities Diabetes mellitus Hypercoagulation Hyperlipidemia Others Pathology In situ Invasive Others Lymph node invasion Neoadjuvant chemotherapy Adjuvant chemotherapy Hormone therapy
Irradiated (n = 92)
Nonirradiated (n = 278)
36 (36.1%) 40 (43.5%) 16 (17.4%)
92 (33.1%) 151 (54.3%) 35 (12.6%)
P
0.178
Statistical Analysis 0.226
65 (79.1%) 25 (27.2%) 2 (2.2%) 31.51 ± 19.45 2 (2.2%)
220 (79.0%) 52 (18.8%) 6 (2.2%) 28.72 ± 18.29 3 (1.1%)
0 (0%) 7 (7.6%) 2 (2.2%) 2 (2.2%)
2 (0.7%) 9 (3.2%) 4 (1.4%) 8 (2.9%)
1 (1.1%) 90 (97.8%) 1 (1.1%) 73 (79.3%) 19 (20.7%) 85 (92.4%) 61 (71.8%)
29 (10.4%) 241 (86.7%) 8 (2.9%) 47 (16.9%) 14 (5.0%) 244 (87.8%) 161 (67.6%)
0.06 0.789 0.367
0.009*
0.05) (Table 5). Figures 1 to 4 demonstrated examples of patients from different groups who expressed satisfactory results.
Effects of Timing of Radiation on Surgical Outcomes To further investigate whether the timing of radiation has any effects on the reconstructed breasts, we evaluated the differences in surgical outcomes after patients were stratified by the sequence of radiation and breast reconstruction in the irradiated group. Patients in the IBR + XRT group had longer follow-up duration (34.03 ± 20.43 months vs 26.11 ± 16.19 months, P = 0.029), and fewer smokers (0% vs 6.5%, P = 0.035). Other patients’ characteristics and treatment variables were similar between the 2 subgroups (Supplementary Table 2, http:// links.lww.com/SAP/A199). The incidence of early breast complications and secondary surgery was not significant between the subgroups (P = 0.572, P = 0.475). However, a significant increase in flap contracture
TABLE 3. Early Breast Complications, Secondary Surgery, and Revision Surgery of the Reconstructed Breasts by Irradiation Status
Early breast complications Overall complications Impaired perfusion Partial necrosis Delayed wound healing Secondary surgery Fat necrosis related Non fat necrosis related Revision surgery
Irradiated (n = 92)
Nonirradiated (n = 278)
P
15 (16.3%) 8 (8.7%) 5 (5.4%) 9 (9.8%) 17 (18.5%) 16 (17.4%) 7 (7.6%) 4 (4.3%)
29 (10.4%) 17 (6.1%) 6 (2.2%) 16 (5.8%) 16 (5.8%) 11 (4.0%) 7 (2.5%) 13 (4.3%)
0.131 0.393 0.211 0.182 1 year postoperative Psychological evaluation
Irradiated (n = 86)
Nonirradiated (n = 242)
P
66.49 ± 16.40
66.68 ± 15.42
0.882
66.40 ± 17.47
67.88 ± 15.86
0.595
73.00 ± 25.20
76.44 ± 23.23
0.397
*Occurs when a P value of
Considering the Optimal Timing of Breast Reconstruction With Abdominal Flaps With Adjuvant Irradiation in 370 Consecutive Pedicled Transverse Rectus Abdominis Myocutaneous Flap and Free Deep Inferior Epigastric Perforator Flap Performed in a Chinese Oncology Center Is There a Significant Difference Between Immediate and Delayed? Shanshan He, MD,* Jian Yin, MD, PhD,* Geoffrey L. Robb, MD, FACS,† Jingyan Sun, MD, PhD,* Xuehui Zhang, MD,* Haixin Li, PhD,‡ Jing Liu, MD,* and Chunyong Han, MD, PhD* Purpose: There is an ongoing debate on the optimal sequence of radiation and breast reconstruction. The purpose of this article was to (a) assess the impact of radiation on autologous breast reconstruction and (b) analyze the best timing for autologous breast reconstruction in the setting of radiation in a Chinese population. Methods: A retrospective review of patients undergoing breast reconstruction with autologous lower abdominal flaps between 2001 and 2014 in the Tianjin Medical University and Cancer Hospital was performed. Patients were grouped by their irradiation status (irradiated vs nonirradiated). The irradiated group was further stratified into 2 groups by the timing of irradiation (immediate breast reconstruction followed by radiation vs prior radiation and delayed breast reconstruction). The primary outcomes were early and late breast complications, secondary and revision surgeries to the reconstructed breast, whereas the secondary outcomes were aesthetic and psychological evaluations of the patients. Logistic regression was used to assess the potential association between irradiation, patient and treatment variables, and surgical outcomes. Results: Three hundred sixty patients with 370 reconstructed breasts were included in the study. Two hundred seventy-eight cases were nonirradiated, of which 158 were immediate and 120 were delayed. Ninety-two cases were irradiated, of which 61 were immediate, and 31 were delayed. Three hundred thirty-two cases underwent pedicled transverse rectus abdominis myocutaneous flap, 38 had deep inferior epigastric perforator flap. The irradiated group had a significant increase in secondary surgery due to fat necrosis (P < 0.001) and in late complications Received May 2, 2016, and accepted for publication, after revision August 26, 2016. From the *Department of Breast Reconstruction, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin, China; †Department of Plastic Surgery, MD Anderson Cancer Center, Houston, TX; and ‡Department of Epidemiology, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin, China. This study was supported by the fund of Tianjin Medical University Cancer Institute and Hospital (grant 1405) and the National Key Clinical Specialist Construction Programs of China. Conflicts of interest and sources of funding: none declared. Reprints: Jian Yin, MD, PhD, Department of Breast Reconstruction, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin, China. E-mail: [email protected]. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.annalsplasticsurgery.com). Copyright © 2016 The Author(s). Published by Wolters Kluwer Health, Inc. This is an open-access article distributed under the terms of the Creative Commons AttributionNon Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. ISSN: 0148-7043/17/7806–0633 DOI: 10.1097/SAP.0000000000000927
Annals of Plastic Surgery • Volume 78, Number 6, June 2017
(P = 0.011). A significant increase in flap contracture (P = 0.043) and an increasing trend in the severity of fat necrosis were observed when radiation was performed after breast reconstruction. However, radiation and its timing did not have an adverse impact on patients' aesthetic and psychological evaluations by the Breast-Q survey. Conclusions: Radiation administered to the reconstructed breast mound increased the rate of late complications and the need for secondary surgery with increased abdominal flap shrinkage and contracture and the severity of flap fat necrosis. Irradiation on the reconstructed breast did not lead to worse aesthetic outcomes due to the generally different expectation in the Chinese female patients in that they were more focused on the breast shape when clothed. Immediate breast reconstruction followed by irradiated was a generally successful treatment sequence in the Chinese module. Key Words: breast reconstruction, autologous, radiation, timing, Chinese population (Ann Plast Surg 2017;78: 633–640)
R
adiation therapy is an essential treatment parameter for breast cancer patients with large tumor and/or lymph node invasion reducing local recurrence and improving disease-free survival as well as overall survival.1,2 However, radiation treatment can have adverse effects on autologous tissues used in immediate breast reconstruction. Radiation can cause local edema, erythema, and desquamation in the short-term and significant tissue fibrosis and contracture in the long term.3,4 For patients who wish to have autologous breast reconstruction, the effect of radiation and its timing is still controversial.5–8 From an oncologic perspective, breast reconstruction before or after irradiation has similar survival benefits.9 Although the National Comprehensive Cancer Network guideline suggests delaying breast reconstruction until 6 months after the completion of postmastectomy irradiation due to aesthetic considerations, some surgeons have argued that immediate breast reconstruction followed by irradiation can still achieve satisfactory outcomes and avoid the mental stress of an absent breast mound during adjuvant therapies, while maintaining cost-effectiveness.10–13 In this study, we performed a retrospective review of patients who had autologous breast reconstruction in our clinical oncology center to illustrate the impact of radiation on autologous breast reconstruction and analyze the best timing in our practice for autologous breast reconstruction in the setting of postmastectomy radiation.
PATIENTS AND METHODS We retrospectively collected data of autologous breast reconstruction between May 2001 and June 2014 in Tianjin Cancer Hospital. www.annalsplasticsurgery.com
633
Annals of Plastic Surgery • Volume 78, Number 6, June 2017
He et al
TABLE 1. Patient Characteristics and Treatment Variables by Radiation Status
Age, y 30 Follow-up, mo Smoking status Comorbidities Diabetes mellitus Hypercoagulation Hyperlipidemia Others Pathology In situ Invasive Others Lymph node invasion Neoadjuvant chemotherapy Adjuvant chemotherapy Hormone therapy
Irradiated (n = 92)
Nonirradiated (n = 278)
36 (36.1%) 40 (43.5%) 16 (17.4%)
92 (33.1%) 151 (54.3%) 35 (12.6%)
P
0.178
Statistical Analysis 0.226
65 (79.1%) 25 (27.2%) 2 (2.2%) 31.51 ± 19.45 2 (2.2%)
220 (79.0%) 52 (18.8%) 6 (2.2%) 28.72 ± 18.29 3 (1.1%)
0 (0%) 7 (7.6%) 2 (2.2%) 2 (2.2%)
2 (0.7%) 9 (3.2%) 4 (1.4%) 8 (2.9%)
1 (1.1%) 90 (97.8%) 1 (1.1%) 73 (79.3%) 19 (20.7%) 85 (92.4%) 61 (71.8%)
29 (10.4%) 241 (86.7%) 8 (2.9%) 47 (16.9%) 14 (5.0%) 244 (87.8%) 161 (67.6%)
0.06 0.789 0.367
0.009*
0.05) (Table 5). Figures 1 to 4 demonstrated examples of patients from different groups who expressed satisfactory results.
Effects of Timing of Radiation on Surgical Outcomes To further investigate whether the timing of radiation has any effects on the reconstructed breasts, we evaluated the differences in surgical outcomes after patients were stratified by the sequence of radiation and breast reconstruction in the irradiated group. Patients in the IBR + XRT group had longer follow-up duration (34.03 ± 20.43 months vs 26.11 ± 16.19 months, P = 0.029), and fewer smokers (0% vs 6.5%, P = 0.035). Other patients’ characteristics and treatment variables were similar between the 2 subgroups (Supplementary Table 2, http:// links.lww.com/SAP/A199). The incidence of early breast complications and secondary surgery was not significant between the subgroups (P = 0.572, P = 0.475). However, a significant increase in flap contracture
TABLE 3. Early Breast Complications, Secondary Surgery, and Revision Surgery of the Reconstructed Breasts by Irradiation Status
Early breast complications Overall complications Impaired perfusion Partial necrosis Delayed wound healing Secondary surgery Fat necrosis related Non fat necrosis related Revision surgery
Irradiated (n = 92)
Nonirradiated (n = 278)
P
15 (16.3%) 8 (8.7%) 5 (5.4%) 9 (9.8%) 17 (18.5%) 16 (17.4%) 7 (7.6%) 4 (4.3%)
29 (10.4%) 17 (6.1%) 6 (2.2%) 16 (5.8%) 16 (5.8%) 11 (4.0%) 7 (2.5%) 13 (4.3%)
0.131 0.393 0.211 0.182 1 year postoperative Psychological evaluation
Irradiated (n = 86)
Nonirradiated (n = 242)
P
66.49 ± 16.40
66.68 ± 15.42
0.882
66.40 ± 17.47
67.88 ± 15.86
0.595
73.00 ± 25.20
76.44 ± 23.23
0.397
*Occurs when a P value of
