Post-mastectomy Breast Reconstruction after Previous Lumpectomy and Radiation Therapy: Analysis of Complications and Satisfaction
Ibrahim Khansa, BS, Salih Colakoglu, MD, Michael S. Curtis, MD, Janet H. Yueh, MD, Adeyemi Ogunleye, MD, Adam M. Tobias, MD, Bernard T. Lee, MD.
Beth Israel Deaconess Medical Center/ Harvard Medical School, Boston, MA, USA.
Surgical treatment options for early-stage breast cancer include breast-conservation therapy (BCT) and mastectomy. While the NSABP found equivalent survival between the two options, lumpectomy and radiation still carries a 14.3% cumulative recurrence rate over 25 years. In the event of a recurrence, the primary surgical option is salvage mastectomy, possibly followed by breast reconstruction. Most of these patients undergoing reconstruction have therefore had previous radiation therapy to the chest wall. Radiation is known to have deleterious long-term effects on tissue healing, and may thus increase complications and decrease satisfaction with subsequent breast reconstruction.
There is a wide discrepancy among studies analyzing outcomes in breast reconstruction after radiation therapy. Few studies have looked specifically at the effect of prior radiation in the setting of failed breast-conserving therapy on complications and satisfaction with breast reconstruction after salvage mastectomy. In particular, very few studies have looked at this relationship in autologous reconstructions. This study examines whether breast reconstruction in the setting of prior BCT carries an increased risk of complications and dissatisfaction compared to reconstruction without prior BCT.
All women at an academic institution undergoing initial breast reconstruction between January 1999 and December 2006 were identified. Among this patient population, women who had undergone prior lumpectomy and radiation were identified, and compared to a control group consisting of women having breast reconstruction in the same time period, without a prior history of BCT. A validated questionnaire adapted from the Michigan Breast Reconstruction Outcomes Survey was administered examining general and aesthetic satisfaction. Rates of complications, as well as general and aesthetic satisfaction, were compared between the two groups. The groups were substratified based on the type of reconstruction performed (autologous, autologous and implant, implant alone) and the length of time between BCT and mastectomy/reconstruction.
Overall, 532 women underwent 802 reconstructions, of which 113 women (137 reconstructions) had prior BCT. Patients undergoing reconstruction after BCT had significantly more complications than women undergoing reconstruction without prior BCT (36.50% vs 27.97%, p=0.046). However, there was no significant difference in satisfaction between the two groups (General satisfaction: 66.67% vs 66.77%, p=0.98; Aesthetic satisfaction: 63.33% vs 66.45%, p=0.58). Among the various types of reconstructions, autologous and implant-based reconstructions both had increased rates of complications when done after BCT, although this was not statistically significant. In patients undergoing reconstruction after BCT, the length of time between BCT and mastectomy/reconstruction did not affect complication and satisfaction rates.
The long-term deleterious effects of radiation on tissue healing may lead to an increased rate of complications with subsequent reconstruction. The finding that patients with prior BCT undergoing mastectomy and reconstruction are satisfied with their breast reconstruction despite the increased rate of complications is important, as it attests to the appropriateness of reconstructing a breast that has been previously irradiated in the setting of BCT.
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