Eén operatie Reconstructie zal nooit originele borst kunnen vervangen Mogelijkheid tot huidsparende mastectomie Minder littekens

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1 RECONSTRUCTIE BIJ INVASIEF CARCINOMA: ONMIDDELLIJK OF DELAYED dr. Marc Vandevoort Plastische, Reconstructieve en Esthetische Chirurgie, UZ Leuven Onmiddellijk Eén operatie Reconstructie zal nooit originele borst kunnen vervangen Mogelijkheid tot huidsparende mastectomie Minder littekens Delayed Twee ingrepen Reconstructie wordt steeds positief bekeken Adjuvante behandeling werd toegediend Meer uitgesproken littekens Wanneer welke reconstructievorm en waarom Literatuur 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. 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. Consensus? 1

2 Dienen autologe reconstructies te worden uitgesteld indien er een mogelijkheid bestaat op adjuvante radiotherapy Indications Radiotherapie T3 T4 Positive LN Lymphovascular invasion Positive margins Triple negative tumors Pathology report? Radiotherapie Impact on breast reconstruction Early changes Erythema, desquamation, edema Late changes Contracture, loss of volume and distortion Progressive! 3-5y Pathofysiology of irradiated skin and breast int. J. Radiation Oncology Biol. Phys Influence of radiotherapy on the timing of reconstructions Influence is dual Oncological safety Effects of RT on outcome of reconstruction -Delayed -Immediate ME + IR ME Adjuvant therapy Adjuvant therapy DR Matter of debate Studies are contradictory Perforator flaps Literature? Only three studies Radiation effects on breast reconstruction with the deep inferior epigastric perforator flap Nicole E. Rogers, Robert J. Allen PLASTIC AND RECONSTRUCTIVE SURGERY? MAY 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 2

3 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 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. 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, patients with immediate bilateral DIEP-flap and unilateral PMRT minor complications no clinically significant fat necrosis satisfactory esthetic outcome 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 UZ Leuven Retrospective single-centre study IR and PMRT PMRT and DR 3

4 Patients and methods Outcomes measured Patients characteristics August 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 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 4

5 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 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? Randomising Factors predicting outcome Immediate-delayed? Welke vragen dienen we ons te stellen? First results in favor of delaying 5

6 Indien expander welk soort expander? Externe valve? Geïntegreerde valve Wat met RT velden? Patiënten die de uitdrukkelijke wens hebben voor onmiddellijke reconstructie Op het hart drukken wat de gevolgen kunnen zijn 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 Lipofilling van rigide borst is zeer moeizaam? Aanvankelijk enkel versoepeling, pas na enkele sessies volumewinst, vaak frustrerend voor zowel patiënt als arts. 6