about half of those getting mastectomy w immed reconst have complicn reqrng2ndsurgery

[Lani]

and 30% of those who have mastectomy with immediate reconstruction followed by radiation therapy have an infection (which does not require return to the operating room)

Food for thought for those thinking about getting immediate reconstruction. Hadn't seen facts and figures on this before.

Studies identify complications in women undergoing mastectomy and immediate breast reconstruction
[Eureka News Service]
About half of women who require radiation therapy after they have had a mastectomy and immediate breast reconstruction develop complications that necessitate a return to the operating room, but pre- or post-mastectomy chemotherapy does not appear to be associated with the need for additional procedures, according to two reports in the September issue of Archives of Surgery, one of the JAMA/Archives journals.

An increasing number of women are undergoing mastectomy as a treatment for breast cancer or as a means to prevent cancer if they have a genetic predisposition, according to background information in the articles. Previously, most women underwent mastectomy and then radiation or chemotherapy, followed by a second procedure for breast reconstruction after completing therapy. However, many treatment facilities now offer the option of having breast reconstruction at the same time as mastectomy. Studies suggest immediate reconstruction is safe and has potential psychological and aesthetic benefits.

Rates of radiation therapy after mastectomy are also increasing. In one article, Dara Christante, M.D., and colleagues at Oregon Health & Science University Knight Cancer Institute, Portland, studied 302 mastectomy patients with stage I to III breast cancer treated between 2000 and 2008, identified via an institutional cancer registry. Of the 302 women, 152 had breast reconstructions, including 131 that were immediate; 183 (60 percent) underwent biopsies to detect malignancy in their lymph nodes, of whom 108 (59 percent) had a negative finding; and 100 underwent postmastectomy irradiation to the chest wall.

"Postmastectomy irradiation and immediate breast reconstruction were each indentified as strong independent predictors of complications," the authors write. "Postmastectomy irradiation tripled the risk for an unplanned return to the operating room and immediate breast reconstruction increased that risk eight-fold. The combination of immediate breast reconstruction and postmastectomy irradiation resulted in nearly one of two patients returning to the operating room with complications compared with 7 percent of patients who received postmastectomy irradiation but did not undergo reconstruction."

Patients are typically counseled to avoid immediate breast reconstruction if they may be at risk of needing radiation therapy, the authors note. However, among patients in the current study, seven of 39 (20 percent) who were considered low-risk enough to have immediate reconstruction required irradiation after final pathology reports were available.

"Therefore, predicting postmastectomy irradiation more accurately would permit avoidance of immediate breast reconstruction and its postmastectomy irradiation-associated complications, potentially decreasing the rate of unplanned operations," the authors write. "Conversely, some women are unnecessarily directed away from immediate breast reconstruction because of an overestimation of their risk for postmastectomy irradiation. In this series, 12 of 22 patients (55 percent) who underwent delayed reconstruction did not undergo postmastectomy irradiation."

Knowledge of lymph node status significantly contributed to the ability to predict postmastectomy irradiation, the authors note. Therefore, women considering immediate breast reconstruction might wish to have a sentinel lymph node biopsy performed prior to mastectomy. "Patients with a negative sentinel lymph node would be reassured that their risk with immediate breast reconstruction is low," the authors conclude. "Patients with a positive sentinel lymph node would be identified as having a higher, quantifiable risk of meeting postmastectomy irradiation indications."

In another article, Anne Warren Peled, M.D., and colleagues at Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, studied 163 women who underwent mastectomy and immediate breast reconstruction between 2005 and 2007. Of these, 57 received chemotherapy before their surgery and 41 received chemotherapy post-operatively; all were followed for an average of 19.2 months to monitor postoperative complications.

Overall, 31 percent of patients had a complication requiring a return to the operating room. This rate did not differ based on whether women received chemotherapy before surgery, after or not at all. Postoperative infections developed in 18 patients (44 percent) who received chemotherapy after surgery, compared with 13 patients (23 percent) who received chemotherapy before surgery and 16 patients (25 percent) who did not receive any chemotherapy.

"Although systemic chemotherapy has been thought to increase wound-related complications, our study demonstrates that risk of non-infectious postoperative complications is not increased after mastectomy and immediate breast reconstruction among women who receive chemotherapy," the authors conclude. "Additionally, the timing of chemotherapy in relation to mastectomy did not have a significant impact on surgical outcomes. However, the wound infection rate was significantly higher in patients who had received adjuvant [postoperative] chemotherapy and in some cases resulted in delay of chemotherapy."

"These results suggest a possible benefit for pre-operative administration of chemotherapy in those patients who require chemotherapy, even in women who will undergo mastectomy, and they support the use of immediate reconstruction in this patient population."

ABSTRACT: Using Complications Associated With Postmastectomy Radiation and Immediate Breast Reconstruction to Improve Surgical Decision Making
[Archives of Surgery]
Objectives: To identify factors independently associated with surgical complications in oncologic and reconstructive surgery and to examine sentinel lymph node (SLN) biopsy data, along with variables that are typically known prior to definitive resection, for their ability to impact the prediction of need for postmastectomy irradiation (PMRT).

Design: Retrospective review.

Setting: University hospital.

Patients: Mastectomy patients with stage I to III breast cancer treated in 2000 to 2008.

Main Outcome Measures: Complication rates of oncologic and reconstructive surgery requiring reoperation and clinicopathologic variables that independently predict complications and/or PMRT administration by multivariate analysis.

Results: Among 100 of 302 mastectomy patients who underwent PMRT, complications occurred in 44% who underwent immediate breast reconstruction (IBR) and 7% who did not (P < .001). Postmastectomy irradiation independently predicted the occurrence of a complication (odds ratio, 3.3; P < .001). Implants were removed in 31% of patients who underwent PMRT and 6% of patients who did not (P = .005). Three percent of patients with T2 or smaller tumors and zero positive SLN required PMRT. Among those with T2 tumors, 49% with a positive axilla lymph node underwent PMRT. Independent predictors of PMRT need were T2 vs T1 tumors, positive axillary lymph node status, and the number of positive SLNs, with odds ratios of 5.8 (P < .001), 14.5 (P < .001), and 2.1 (P = .001), respectively.

Conclusions: Postmastectomy irradiation was associated with a high rate of surgical complications and implant loss among patients who underwent IBR. Determining the number of positive SLNs prior to definitive resection and reconstructive operations may reduce complications and implant loss by guiding surgical decision making. Patients with a negative SLN are unlikely to require PMRT. Those with positive SLN(s) are high-risk IBR candidates with a quantifiable PMRT risk.

ABSTRACT: Impact of Chemotherapy on Postoperative Complications After Mastectomy and Immediate Breast Reconstruction
[Archives of Surgery]
Objectives: To determine the impact of chemotherapy and the timing of chemotherapy on postoperative outcomes after mastectomy and immediate breast reconstruction.

Design: Retrospective review.

Setting: University tertiary care institution.

Patients: One hundred sixty-three consecutive patients undergoing mastectomy and immediate breast reconstruction.

Intervention: Systemic chemotherapy for breast cancer.

Main Outcome Measures: Postoperative complications following mastectomy and immediate breast reconstruction.

Results: One hundred sixty-three patients underwent mastectomy and immediate breast reconstruction during the study period, with a mean postoperative follow-up of 19.2 months. Sixty-six percent of the patients had expander/implant reconstruction, while 33% underwent autologous reconstruction. Fifty-seven patients received neoadjuvant chemotherapy and 41 received postoperative chemotherapy. Eighteen patients (44%) in the adjuvant chemotherapy cohort developed postoperative infections, compared with 13 patients (23%) in the neoadjuvant chemotherapy group and 16 patients (25%) who did not receive any chemotherapy (P = .05). Overall, 31% of patients had a complication requiring an unplanned return to the operating room; this rate did not differ between groups (P = .79). Of patients who underwent expander/implant reconstruction, 8 women (26%) in the neoadjuvant chemotherapy cohort, 7 women (22%) in the adjuvant chemotherapy cohort, and 8 women (18%) without chemotherapy required expander or implant removal (P = .70).

Conclusions: Although the highest rate of surgical site infections was in the adjuvant chemotherapy group, there were no differences between groups with respect to unplanned return to the operating room, expander loss, and donor-site complications. Neither the inclusion of chemotherapy nor the timing of its administration significantly affected the complication rates after mastectomy and immediate breast reconstruction in this population.