title: Outcomes of breast reconstruction in breast cancer patients with a history of mantle radiation for Hodgkin lymphoma.
abstract: BACKGROUND
  Although mantle radiation (ie, extended field radiation) represented the standard of care in the past for Hodgkin disease, contemporary treatment of lymphoma consists of a multimodal approach with chemotherapy. Patients who were exposed to mantle radiation have a higher risk of breast cancer and are more susceptible to postoperative complications after breast reconstruction due to radiation. In this study, we present postoperative outcomes in patients with a history of mantle radiation who underwent mastectomy and breast reconstruction.
  
  
  METHODS
  All patients at Stanford University Medical Center between January 2006 and December 2012 with a history of Hodgkin lymphoma treated with mantle radiation who received breast reconstruction were identified. A retrospective chart review was conducted analyzing patient demographics, history of Hodgkin treatment, type of reconstruction, follow-up, and complications. Complications were further classified into medical complications, donor-site complications, and recipient-site complications.
  
  
  RESULTS
  Sixteen patients with a history of Hodgkin disease and mantle radiation received breast reconstruction. The average age of the patients at their mastectomy was 46 (33-60) years, with the average age at the time of their mantle radiation of 20.5 (10-33) years with an average interval of radiation to breast cancer treatment of 24.8 (16-38) years. There were five unilateral and 11 bilateral reconstructions. All patients had immediate reconstruction with tissue expanders (14 patients) or autologous tissue (one muscle-sparing transverse rectus abdominis myocutaneous and one transverse upper gracilis flap). Eleven (69%) patients had postoperative complications. In the patients who had tissue expander reconstruction, there was an overall complication rate of 64%, which included capsular contracture (n=5, 56%), mastectomy flap necrosis (n=5, 56%), cellulitis (n=4, 44%), seroma (n=3, 33%), hematoma (n=1, 11%), and chronic pain (n=1, 11%). Three (two unilateral and one bilateral) tissue expander infections required removal of the expander and delayed reconstruction with a latissimus dorsi flap, whereas one patient with chronic pain and capsular contracture required a muscle-sparing transverse rectus abdominis myocutaneous for a unilateral implant failure.
  
  
  CONCLUSIONS
  Although the risk of complications associated with preoperative radiation is well documented, physicians and patients should be cognizant of the increased risk of complications after mantle radiation as it represents a unique modality of radiation exposure.
authors.affiliation: From the Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University Medical Center, Stanford, CA.
authors.forename: Ryan K
authors.initials: RK
authors.lastname: Wong
authors.forename: Shane D
authors.initials: SD
authors.lastname: Morrison
authors.forename: Arash
authors.initials: A
authors.lastname: Momeni
authors.forename: Matthew
authors.initials: M
authors.lastname: Nykiel
authors.forename: Gordon K
authors.initials: GK
authors.lastname: Lee
mesh_terms: D000328:Adult; D001943:Breast Neoplasms / Q000209:etiology* / Q000601:surgery; D005260:Female; D005500:Follow-Up Studies; D006689:Hodgkin Disease / Q000532:radiotherapy*; D006801:Humans; D016462:Mammaplasty / Q000379:methods*; D008408:Mastectomy; D008875:Middle Aged; D009381:Neoplasms, Radiation-Induced / Q000601:surgery*; D011183:Postoperative Complications; D012189:Retrospective Studies; D013524:Surgical Flaps; D015626:Tissue Expansion; D016896:Treatment Outcome