What Is the Optimum Timing of Postmastectomy Radiotherapy in Two-Stage Prosthetic Reconstruction: Radiation to the Tissue Expander or Permanent Implant?
BACKGROUND
Postmastectomy radiotherapy is increasingly common for patients with advanced breast cancer. The optimal timing and sequence of mastectomy, reconstruction, and radiotherapy remains unresolved for patients choosing immediate two-stage prosthetic reconstruction.


METHODS
Long-term outcomes were compared for all patients with prosthetic-based reconstruction without radiation, radiation to the tissue expander, or to the permanent implant from 2003 to 2012 performed by the senior author (P.G.C.). Surgeon-evaluated outcomes included reconstructive failure, aesthetic results, and capsular contracture. Odds of failure with radiotherapy at different times were evaluated with logistic regression and Kaplan-Meier analysis. Patient-reported outcomes were assessed using the BREAST-Q.


RESULTS
A total of 1486 reconstructions without radiation, 94 reconstructions with tissue expander radiation, and 210 reconstructions with permanent implant radiation were included. Six-year predicted failure rates were greater for patients with tissue expander radiation than for patients with permanent implant radiation (32 percent versus 16.4 percent; p < 0.01). Patients undergoing radiation to the tissue expander had a greater proportion of very good to excellent aesthetic results compared to patients with permanent implant radiation (75.0 percent versus 67.6 percent; p < 0.01) and lower rates of grade IV capsular contracture (p < 0.01). BREAST-Q scores were similar for patients with the different radiation timings.


CONCLUSIONS
Although the risk of reconstructive failure is significantly higher for patients with tissue expander radiation compared to patients with permanent implant radiation, the aesthetic results and capsular contracture rates are slightly better. Patient reported outcomes do not differ between patients with tissue expander or permanent implant radiation.


METHODS
Therapeutic, III.
New York, N.Y. From the Plastic and Reconstructive Surgical Service, Radiation Oncology, Breast Cancer Medical Service, and Breast Surgical Service, Memorial Sloan Kettering Cancer Center.
Peter G
PG
Cordeiro
Claudia R
CR
Albornoz
Beryl
B
McCormick
Clifford A
CA
Hudis
Qunying
Q
Hu
Alexandra
A
Heerdt
Evan
E
Matros
D000368:Aged; D000704:Analysis of Variance; D019928:Breast Implantation / Q000009:adverse effects / Q000379:methods*; D018427:Breast Implants; D001943:Breast Neoplasms / Q000473:pathology / Q000532:radiotherapy* / Q000601:surgery; D002173:Cancer Care Facilities; D016009:Chi-Square Distribution; D015331:Cohort Studies; D004954:Esthetics; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D053208:Kaplan-Meier Estimate; D016015:Logistic Models; D008408:Mastectomy / Q000379:methods; D008875:Middle Aged; D009519:New York City; D016017:Odds Ratio; D011237:Predictive Value of Tests; D011475:Prosthesis Failure / Q000528:radiation effects*; D018714:Radiotherapy, Adjuvant; D012086:Reoperation / Q000379:methods; D012189:Retrospective Studies; D018570:Risk Assessment; D013997:Time Factors; D015625:Tissue Expansion Devices; D016896:Treatment Outcome