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What is the Optimum Timing of Post-mastectomy Radiotherapy in Two-stage Prosthetic Reconstruction: Radiation to the Tissue Expander or Permanent Implant?
Peter G. Cordeiro, MD, Claudia R. Albornoz, MD, Beryl McCormick, MD, Clifford A. Hudis, MD, Heerdt Alexandra, MD MPH, Evan Matros, MD MMSc.
Memorial Sloan Kettering Cancer Center, New York, NY, USA.

PURPOSE:
Post-mastectomy 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 (non-XRT), radiation to the tissue expander (TE-XRT) or radiation to the permanent implant (implant-XRT) from 2003 to 2012 by the senior author (PGC). Surgeon-evaluated outcomes included reconstructive failure, aesthetic results, and capsular contracture. Odds of failure with different radiotherapy timing were evaluated with logistic regression and Kaplan-Meier analysis. Patient-reported outcomes were assessed using the BREAST-Q©.
RESULTS:
A total of 1,486 non-XRT, 94 TE-XRT, and 210 implant-XRT reconstructions were included. Reconstructive failure was more likely for TE-XRT and implant-XRT compared to non-XRT patients (OR=5.75 and 5.19 respectively, p<0.01). Six-year predicted failure rates were greater for TE-XRT than implant-XRT patients (32% vs.16.4%, p<0.01). TE-XRT patients had a greater proportion of very good to excellent aesthetic results compared to implant-XRT (75.0% vs. 67.6%, p<0.01) and lower rates of capsular contracture grade IV (1.2% vs.6.3% respectively, p<0.01).BREAST-Q© scores were significantly lower for TE-XRT and implant-XRT compared to non-XRT patients (p<0.01), but without a minimal important difference between TE-XRT and implant-XRT patients.
CONCLUSION:
Although the risk of reconstructive failure is significantly higher for TE-XRT compared to implant-XRT patients, the aesthetic results and capsular contracture rates are slightly better. Patient reported health-related quality of life and satisfaction do not differ between TE-XRT and implant-XRT patients.


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