Morbidity associated with autologous breast reconstruction before and after exposure to radiotherapy

Literature “Radiation has a deleterious effect on autologous flap reconstruction. delayed reconstruction seems to be a safe option in most of the cases.” “Autologous breast reconstruction can be performed safely regardless of preoperative or postoperative radiation therapy.” “Primary reconstruction with DIEP flaps can be performed successfully in patients who require PMRT.” “Postmastectomy radiation therapy can result in volume loss and fat necrosis.” Consensus?

‘Should autologous reconstructions be delayed if there is a probability of radiation therapy in the post-operative period?’

Radiotherapy Indications T3 T4 Positive LN Lymphovascular invasion Positive margins Triple negative tumors  Pathology report?

Radiotherapy Impact on breast reconstruction? • Early changes Erythema, desquamation, edema • Late changes Contracture, loss of volume and distortion Progressive! 3-5y “Pathofysiology of irradiated skin and breast” int. J. Radiation Oncology Biol. Phys. 1995

Influence of radiotherapy on the timing of reconstructions Influence is dual Oncological safety Effects of RT on outcome of reconstruction Delayed Immediate ME + IR Adjuvent therapy ME Adjuvent therapy DR

Matter of debate Studies are contradictory Perforator flaps Literature? Only three studies

“Radiation effects on breast reconstruction with the deep inferior epigastric perforator flap” Nicole E. Rogers, Robert J. Allen PLASTIC AND RECONSTRUCTIVE SURGERY? MAY 2002 30 patients IR and PMRT 30 matched patients without PMRT Structural changes Esthetic outcome Result: significant higher rate of fat necrosis, fibrosis and flap contracture in the irradiated group

“Effect of postoperative radiotherapy on autologous deep inferior epigastric perforator flap volume after immediate breast reconstruction” J. S. Chatterjee, A. Lee, W. Anderson, L. Baker, J. H. Stevenson, J. A. Dewar and A. M. Thompson Br J Surg. ocT 2009 22 patients with IR and PMRT Measurement of flap-volume intra-operative Measurement breast volume with Morris-mammometer Result: reduction of 65ml in irradiated group, no volume change in other group.

“Comparison of Irradiated Versus Nonirradiated DIEP Flaps in Patients Undergoing Immediate Bilateral DIEP Reconstruction with Unilateral Postmastectomy Radiation Therapy (PMRT)” Emily M. Clarke-Pearson? Manjeet Chadha? Erez Dayan, Joseph H. Dayan, William Samson? Mark R. Sultan, Mark L. Smith Annals of plastic surgery, 2003 11 patients with immediate bilateral DIEP-flap and unilateral PMRT minor complications no clinically significant fat necrosis satisfactory esthetic outcome

Conclusion of literature Limited study population Follow-up time Lack of objective measurements Subjective parameter? Comparison between radiotherapy before and after reconstruction

Lack of good quality studies Timing remains controversial Need for more investigation Consensus Develop guidelines

UZ Leuven Retrospective single-centre study IR and PMRT PMRT and DR

Patients and methods August 1997- October 2013 : 1547 patients Inclusion criteria: Follow-up: >3y Unilateral Radiation therapy chest wall 20 patients with IR and PMRT 40 matched patients with PMRT and DR

Outcomes measured 1) Structural chances 2) Patients satisfaction Infection Wound dehiscence Fat necrosis Fibrosis/contracture Revision Flap failure Secondary procedures Contralateral procedures 2) Patients satisfaction BREAST-Q questionnaire: QoL, satisfaction and expectations 3) Photographs

Patients characteristics IR DR No of patients 20 40 Age, y - Mean 46,25 46,08 - Range 35-62 32-62 BMI 22,9 21,5 17-33,1 19-34,2 Type flap - DIEP 18 37 - SGAP 1 - SIAE 2 Chemotherapy - Yes 15 29 - No 5 11 Smoking 2 4 18 36 RT: 50 Gy, 25 sessions 20 40

Results structural changes Variable Statistic Cases Controls P-value infection   n/N (%) 16/20 ( 80.00%) 38/40 ( 95.00%) 0.089 1 4/20 ( 20.00%) 2/40 ( 5.00%) wound dehiscence 17/20 ( 85.00%) 36/40 ( 90.00%) 0.676 3/20 ( 15.00%) 4/40 ( 10.00%) fat necrosis 8/20 ( 40.00%) 35/40 ( 87.50%) <.001 12/20 ( 60.00%) 5/40 ( 12.50%) fibrosis/contracture 39/40 ( 97.50%) 1/40 ( 2.50%) flap revision 20/20 (100.00%) 0.548 0/20 ( 0.00%) flap failure 40/40 (100.00%) Variables are analyzed using a Fishers Exact test. All reported p-values are two-sided.

Variable Statistic Cases Controls P-value secondary procedures N 20 40 0.432   Mean 1.9 1.4 Std 1.79 1.37 Median 2.0 IQR (0.0; 2.5) (0.0; 2.0) Range (0.0; 5.0) contralateral procedures 0.658 0.6 0.7 0.94 0.0 Variables are analysed using a Mann-Whitney U test. All reported p-values are two-sided.

Interpretation Significantly higher rates of fat necrosis and fibrosis/contracture are observed among IR with PMRT than DR A trend towards higher infection rate among IR is observed No evidence is found for differences between both groups regarding other complications

Patient 1 Age: 37y BMI: 20,76 Chemo: / Non-smoker Contracture Lipofilling Patient 1

Patient 2 Age: 64y BMI: 29,40 Chemo: / Non-smoker Fat necrosis and contracture Lipofilling Patient 2

Randomising Factors predicting outcome? Delayed-immediate? Conclusion Randomising Factors predicting outcome? Delayed-immediate?

Delayed-immediate? 2-staged approach Stage 1: mastectomy + tissue expander Stage 2: definitive reconstruction Stage 2 depends on pathologic report: when no PMRT is needed: stage 2 is performed after several days PMRT is needed: stage 2 is performed after 3 months Delayed-immediate?

Conclusion Randomising Factors predicting outcome Immediate-delayed? First results in favor of delaying…