13/10/2015
RECONSTRUCTIE BIJ INVASIEF CARCINOMA: ONMIDDELLIJK OF DELAYED dr. Marc Vandevoort Plastische, Reconstructieve en Esthetische Chirurgie, UZ Leuven
Onmiddellijk
Delayed
Eén operatie Reconstructie zal nooit originele borst kunnen vervangen Mogelijkheid tot huidsparende mastectomie Minder littekens
Twee ingrepen Reconstructie wordt steeds positief bekeken Adjuvante behandeling werd toegediend Meer uitgesproken littekens
Literatuur Wanneer welke reconstructievorm en waarom
“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.”
Consensus?
“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.”
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Radiotherapie Dienen autologe reconstructies te worden uitgesteld indien er een mogelijkheid bestaat op adjuvante radiotherapy
Indications
Radiotherapie Impact on breast reconstruction
•T3
•Early changes
•T4 •Positive
Erythema, desquamation, edema
LN
•Lymphovascular •Positive
•Triple
invasion
•Late changes Contracture, loss of volume and distortion Progressive! 3-5y
margins
negative tumors
“Pathofysiology of irradiated skin and breast”
Pathology report?
Influence of radiotherapy on the timing of reconstructions ME + IR
Influence is dual
Matter of debate Studies are contradictory
Oncological safety Adjuvant therapy
Effects of RT on outcome of reconstruction -Delayed -Immediate
ME
DR
Perforator flaps Literature? Only three studies
int. J. Radiation Oncology Biol. Phys. 1995
“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
Adjuvant therapy
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“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.
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
•“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
UZ Leuven Retrospective single-centre study IR and PMRT
PMRT and DR
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Patients and methods
Outcomes measured
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
1) Structural chances Infection Wound dehiscence Fat necrosis Fibrosis/contracture Revision Flap failure Secondary procedures Contralateral procedures
Patients characteristics 2) Patients satisfaction BREAST-Q questionnaire: QoL, satisfaction and expectations 3) Photographs
Results structural changes
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
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• • • • • •
Age: 37y BMI: 20,76 Chemo: / Non-smoker Contracture Lipofilling
• • • • •
Age: 37y BMI: 20,76 Chemo: / Non-smoker Contracture Lipofilling
Age: 64y BMI: 29,40 Chemo: / Non-smoker Fat necrosis and contracture • Lipofilling
• Randomising • Factors predicting outcome • Immediate-delayed?
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?
Welke vragen dienen we ons te stellen?
• First results in favor of delaying…
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Indien expander welk soort expander? Externe valve? Geïntegreerde valve
Patiënten die de uitdrukkelijke wens hebben voor onmiddellijke reconstructie
Te reconstrueren borst iets groter maken…om toekomstig krimpen en rigider worden te kunnen incalculeren
Liposuctie van bestraalde, te grote, rigide borst kan nefast aflopen Op het hart drukken wat de gevolgen kunnen zijn
Wat met RT velden?
Lipofilling van rigide borst is zeer moeizaam? Aanvankelijk enkel versoepeling, pas na enkele sessies volumewinst, vaak frustrerend voor zowel patiënt als arts.
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