
==== Front
Plast Reconstr Surg Glob Open
Plast Reconstr Surg Glob Open
GOX
Plastic and Reconstructive Surgery Global Open
2169-7574
Lippincott Williams & Wilkins Hagerstown, MD

GOX-D-24-00198
00074
10.1097/GOX.0000000000006121
3
Breast
Original Article
Immediate Breast Reconstruction Outcomes in Patients with Prior Mantle and Whole Breast Irradiation
Mullen Barbara L. MD *
Mazroua Muhammad S. MBBCh *
Murphy Brenna M. MD †
Boonipat Thanapoom MD *
Gao Robert W. MD ‡
Mrdutt Mary M. MD, MS §
Shumway Dean A. MD ‡
Degnim Amy C. MD §
Vijayasekaran Aparna MBBS *
From the * Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, Minn.
† Department of Internal Medicine, Stanford Health Care, Stanford, Calif.
‡ Department of Radiation Oncology, Mayo Clinic, Rochester, Minn.
§ Division of Surgical Oncology, Mayo Clinic, Rochester, Minn.
Aparna Vijayasekaran, MBBS, Division of Plastic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, E-mail: vijayasekaran_aparna@mayo.edu
9 2024
24 9 2024
12 9 e612120 2 2024
5 7 2024
Copyright © 2024 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

Background:

Limited studies have detailed the risk of mastectomy with immediate breast reconstruction among women who previously received mantle field radiation.

Methods:

A single institution retrospective review from 2010 to 2020 of patients previously treated with mantle field radiation (MF-RT) and subsequent mastectomy with immediate breast reconstruction was performed. Patients with prior whole breast irradiation (WBI) were also included as a reference group. Demographic, comorbidity, and surgical factors were collected. The primary outcome was major complications, defined as those requiring reoperation, intravenous antibiotics, or debridement.

Results:

Fourteen patients with prior MF-RT (27 breasts) and 129 with prior WBI (132 breasts) underwent mastectomy with immediate reconstruction. Prior MF-RT patients were significantly younger (43.8 versus 57.5, P < 0.001) and had significantly lower body mass index (23.6 versus 26.8, P = 0.004) compared with prior WBI patients. Nipple-sparing mastectomy was significantly more common in the mantle than in the WBI patients (78.6% versus 35.9%, P = 0.03). Most (13, 92.9%) prior mantle patients underwent tissue expander/implant-based reconstruction. Three (21.4%) prior MF-RT patients had major complications at any point, but none required an alternative type of reconstruction. On multiple variable analysis, there was no significant difference in major complication risk among prior MF-RT versus WBI patients (HR 0.74, confidence interval 0.20–2.70, P = 0.74).

Conclusion:

Immediate tissue expander/implant-based reconstruction in prior MF-RT patients seems safe, with a complication risk similar to that of prior WBI patients.

OPEN-ACCESSTRUE
COUNTRYUNITED STATES
SDCT
==== Body
pmcTakeaways

Question: What is the reconstructive risk with immediate breast reconstruction in patients with prior mantle radiation?

Findings: For those undergoing immediate breast reconstruction, prior mantle patients were significantly younger, had lower body mass indexes, had lower radiation dose, and had longer time from radiation completion to mastectomy than prior whole breast radiation patients. Mantle radiation patients did not have higher risk of major complications.

Meaning: Breast reconstruction in prior mantle radiation patients seems to be safe with similar risk to prior whole breast radiation patients.

INTRODUCTION

Mantle field radiation (MF-RT) was a previously common treatment for Hodgkin lymphoma.1 Although MF-RT targets mediastinal, supraclavicular, and axillary lymph nodes in the superior chest and neck, breast skin and underlying soft tissue are also included within the field (Fig. 1).2 Further, MF-RT has been associated with a higher rate of breast cancer than the general nonradiated population.3,4 Hodgkin lymphoma is a disease that primarily affects young adults,5 and the risk of secondary breast malignancy continues for decades following treatment.6 Although MF-RT began to fall out of favor around 2006 with the increased adoption of systemic therapies and involved site radiation, long-term sequelae of this treatment, including secondary breast cancer, remain a significant concern.

Fig. 1. Illustration of different radiation fields used in the treatment of Hodgkin lymphoma. A, Mantle field radiation. B, Mini-mantle field radiation. C, Modified-mantle field radiation. D, Combined mantle field and inverted “Y” field radiation. Created with BioRender.com.

Among those who develop secondary breast cancer, managing these patients’ oncologic care and reconstruction in the setting of prior radiation is important. For those who undergo mastectomy, reconstruction offers important aesthetic and psychological benefits to many patients.7,8 However, there are limited data on the risk of reconstruction complications in patients undergoing mastectomy with immediate breast reconstruction after previous MF-RT.9–11 Freniere et al captured the largest MF-RT cohort of 97 breasts, comparing implant-based and autologous reconstruction.9 Two other published studies have a small sample size and no comparison to other types of radiation exposure.8,9 Across studies, numbers are limited, restricting large-scale meta-analysis and broad practice recommendations for this unique group of patients.

We aimed to characterize our approach to immediate breast reconstruction in patients undergoing mastectomy with prior MF-RT. We offer a comparison to our experience with immediate reconstruction for patients with prior whole breast radiation as part of breast-conserving therapy.

METHODS

Overview

A retrospective chart review from 2010 to 2020 of patients who underwent a mastectomy and immediate breast reconstruction with a history of prior MF-RT or prior whole breast irradiation (WBI) was performed. Institutional review board approval was obtained from Mayo Clinic Minnesota.

Demographic information and medical comorbidities that could affect reconstruction outcomes were collected. Radiation history was gathered, including time from radiation completion to mastectomy, cumulative radiation dose, and re-irradiation following mastectomy. In patients receiving WBI with a boost, cumulative dose included the boost dose. Additional oncologic details [including any chemotherapy exposure (prior/remote history, neoadjuvant, or adjuvant), reason for mastectomy (risk-reducing, in situ carcinoma, or invasive carcinoma or malignancy), and nodal involvement] were recorded. Surgical factors were also gathered, including mastectomy type [nipple-sparing (NSM), skin-sparing (SSM)], axillary surgery, reconstruction type, reconstruction details (tissue expander fill, implant size, flap type, acellular dermal matrix use, when applicable, and fat grafting application), and SPY angiography use. Although axillary nodal surgery at the time of postradiation mastectomy and immediate reconstruction was tracked, patients at the time of breast-conserving therapy frequently had axillary lymph node biopsies and some axillary lymph node dissections. However, we do not have this data reliably reported within the electronic medical record. If prior axillary dissection was noted in chart, then it was included, but otherwise, prior axillary node procedures were not tracked. The last follow-up was recorded.

Cases of mini-MF-RT or modified MF-RT were included in the MF-RT group. Cases were excluded if they had previous non-MF-RT or non-WBI (eg, partial breast radiation, esophageal radiation). Cases were also excluded if they had outside postradiation mastectomy or reconstruction, no immediate reconstruction, or prior breast surgery. If initial breast conserving therapy (including partial mastectomy or lumpectomy) were at an outside institution, these patients were still included.

Outcomes

Complications were recorded for each breast, including hematoma, seroma, wound dehiscence, necrosis, infection, tissue expander/implant extrusion, and capsular contracture. Major complications were defined as those requiring reoperation, intravenous antibiotics, or debridement in the clinic as an intervention, whereas minor complications were those conservatively managed. Minor complications also included infections treated with oral antibiotics; hematomas/seromas managed with compression, aspiration, or IR-guided drain placement; wound dehiscence addressed with dressing changes; or any other previously listed complications that were monitored without intervention. Donor site complications in patients with autologous reconstruction were not included.

Major complications warranting conversion to an alternative reconstruction type (eg, tissue expander/implant to autologous reconstruction) or flat closure were recorded. Any change in the reconstruction approach due to complications was defined as a reconstruction failure.

Tissue expander/implant leak, deflation, or rupture were considered device failures and were thus excluded from analysis as a complication of radiation. Likewise, reoperations for a patient’s preference were also excluded from complication analysis (eg, cold sensation of implants prompting removal).

Statistical Analysis

For statistical analysis to maintain independent observations, factors and complications were analyzed for each patient rather than each breast. Therefore, averages were performed when differences in factors were present (eg, difference in tissue expander fill between each breast was reported as an average of the two breasts) and the first complication on either side for bilateral cases was recorded. Demographic, comorbidity, and surgical factors were compared between the prior MF-RT and the prior WBI groups using Kruskal-Wallis and Fisher exact tests. Additional analysis was performed, excluding patients who underwent autologous reconstruction given the higher percentage of autologous reconstruction among WBI versus MR-RT. Overall analysis of complications was for complications at any point in follow-up. Outcomes were estimated with the Kaplan-Meier method at 1 year after mastectomy. Additionally, Cox proportional hazard regression was used to compare various factors’ association with major complications. Analysis was performed using BlueSky Statistics v10.3.1-Pro. Any significance was determined by a P value less than 0.05.

RESULTS

Preoperative Factors

We identified 14 patients (27 breasts) with previous MF-RT who underwent mastectomy with immediate reconstruction. Their mean age was 43.8 (SD 9.6) years with a median body mass index (BMI) of 23.6 [interquartile range (IQR) 3.0]. Additional demographic details are shown in Table 1. Median follow-up after mastectomy was 3 years.

Table 1. Demographics and Comorbidities of MF-RT and WBI Patients

	MF-RT Group,
n = 14	WBI Group,
n = 129	P	
Age, y, mean (SD)	43.8 (9.6)	57.5 (9.8)	<0.001*	
BMI, median (IQR)	23.6 (3.0)	26.8 (6.5)	0.004*	
Diabetes, N (%)	1 (7.1)	6 (4.7)	0.52	
Hypertension, N (%)	2 (14.3)	51 (39.5)	0.08	
Hyperlipidemia, N (%)	3 (21.4)	50 (38.8)	0.25	
Coronary artery disease, N (%)	1 (7.1)	2 (1.6)	0.27	
Chronic obstructive pulmonary disease, n (%)	0 (0.0)	1 (0.8)
	1.00	
Smoking, n (%)			0.47	
 Current	0 (0.0)	2 (1.6)		
 Former	2 (14.3)	37 (28.7)		
Any chemotherapy exposure, N (%)	12 (85.7)	74 (57.4)	0.046*	
* Significant, P < 0.05.

Patients with MF-RT received a median dose of 36.1 (IQR 17.2) Gy, and the median time from radiation completion to mastectomy was 24.0 (IQR 14.5) years. The abdomen was included in the radiation field in five patients: spleen only in one; entire abdomen in one; inverted-Y field in one; spleen, liver, and para-aortic nodes in one; and para-aortic nodes in one. No patients in this cohort received re-irradiation.

Surgical Factors

NSM was the most common approach (78.6%) among patients with prior MF-RT. Among those with NSM, the mean weight of excised breast tissue was 281 g versus 702 g among those who had SSM. Almost all had mastectomy flap perfusion assessed with SPY angiography (92.9%).

For reconstruction, all MF-RT patients underwent immediate tissue expander placement: one with second-stage bilateral deep inferior epigastric artery perforator flaps, and the remaining 13 (92.9%) with second-stage implant-based reconstruction with an average implant size of 415 (IQR 95) mL. The median final tissue expander fill was 306 mL (IQR 114). Additional reconstruction details are shown in Table 2.

Table 2. Surgical and Reconstruction Factors in MF-RT and WBI Patients

	MF-RT Group,
n = 14	WBI Group,
n = 129	P	
Indication, N (%)			0.87	
 Risk-reducing	6 (42.9)	50 (38.8)		
 Carcinoma in situ	3 (21.4)	25 (19.4)		
 Invasive carcinoma or malignancy	5 (35.7)	54 (41.9)		
Mastectomy type, N (%)			0.03*	
 Nipple-sparing	11 (78.6)	46 (35.9)		
 Skin-sparing	3 (21.4)	68 (53.1)		
 Areolar	0 (0.0)	2 (1.6)		
 Total	0 (0.0)	12 (9.4)		
Axillary nodal surgery, N (%)			0.56	
 None	6 (42.9)	47 (36.4)		
 Sentinel lymph node biopsy	8 (57.1)	55 (42.6)		
 Sentinel lymph node biopsy and prior axillary node dissection	0 (0)
	5 (3.9)
		
 Axillary lymph node dissection	0 (0)	3 (2.3)		
 Prior axillary node dissection	0 (0)	19 (14.7)		
Positive nodes, N (%)	1 (7.1)	3 (2.3)	0.34	
Spy use, N (%)	13 (92.9)	72 (55.8)	0.008*	
Reconstruction type, N (%)			0.21	
 Tissue expander/implant	13 (92.9)	82 (63.6)		
 Autologous	1 (7.1)	39 (30.2)		
  Staged with tissue expander	1 (7.1)	15 (11.6)		
 Combined autologous/tissue expander/implant	0 (0.0)
	4 (3.1)
		
 Direct-to-implant	0 (0.0)	4 (3.1)		
Tissue expander fill, mL, median (IQR)	306 (114)	370 (245)	0.27	
Implant characteristics				
 Type, N (%)	n = 12	n = 71	1.00	
  Smooth	9 (75.0)	52 (73.2)		
  Textured	3 (25.0)	19 (26.8)		
 Size, mL, median (IQR)	415 (95)	440 (175)	0.65	
Autologous flaps used, N (%)	n = 1	n = 43	1	
 DIEP	1 (100)	16 (37.2)		
 ms-TRAM	0 (0.0)	6 (14.0)		
 pedicled/free TRAM	0 (0.0)	8 (18.6)		
 LD	0 (0.0)	12 (27.9)		
 Fat grafting only	0 (0.0)	1 (2.3)		
Fat grafting, N (%)		n = 128		
 During stage 1 or 2	11 (78.6)	73 (57.0)	0.16	
 Interim or delayed	5 (35.7)	46 (35.7)	1.00	
Acellular dermal matrices, N (%)	12 (85.7)	92 (71.3)	0.35	
* Significant, P < 0.05.

WBI Cohort Comparison

One hundred twenty-nine patients (132 breasts) with prior WBI underwent mastectomy with immediate breast reconstruction. These WBI patients were significantly older (mean age 57.5, P < 0.001) and had higher median BMI (26.8, P = 0.004) than the MF-RT group. Of note, more MF-RT patients had chemotherapy exposure (85.7%) versus the WBI group (57.4%, P = 0.046), which widened when excluding autologous reconstruction patients (P = 0.013). (See table, Supplemental Digital Content 1, which displays the demographics and comorbidities of mantle RT and WBI patients, excluding autologous reconstruction. http://links.lww.com/PRSGO/D468.). The average follow-up for WBI was shorter than MF-RT at 1.8 years (P = 0.047; Table 1).

Compared with the MF-RT cohort, the WBI cohort received a higher median dose [60.0 (IQR 10.4) Gy, P < 0.001] with a shorter median time from radiation completion to mastectomy [9.0 (IQR 9) years, P < 0.001]. When excluding those with autologous reconstruction, the WBI cohort still received significantly higher median dose [60 (IQR 10.1) Gy, P < 0.001] and shorter median time from radiation completion to mastectomy [8.0 (IQR 8) years, P < 0.001]. Re-irradiation was seen in seven (5.4%) WBI patients.

A greater proportion of WBI patients underwent SSM (53.1%, P = 0.03) and fewer had SPY assessment of mastectomy flap perfusion (55.8%, P = 0.008). When excluding patients with autologous reconstruction, the difference in mastectomy type was even more significant (P = 0.002), though SPY use was no longer significantly different (P = 0.055). (See table, Supplemental Digital Content 2, which displays the surgical and reconstruction factors in MF-RT and WBI patients, excluding autologous reconstruction. http://links.lww.com/PRSGO/D469.)

Outcomes

Major complications at any point during follow-up were seen in three of 14 (21.4%) prior MF-RT patients versus 35 of 129 (27.1%) WBI patients (P = 0.44). Major complications among MF-RT patients were necrosis and capsular contracture. They were managed with surgical intervention, and none required implant removal or a different type of reconstruction. Major complications were only seen in the implant-based reconstruction patients, whereas the autologous reconstruction MF-RT patient case was complicated by minor hematoma. Among the 35 WBI patients with major complications, the most frequent were infection and necrosis. Thirteen major complications required a different type of reconstruction, of which six necessitated flat closure. When excluding patients with autologous reconstruction, there remained no significant difference in major complications between the MF-RT (3/13, 27.9%) and WBI groups (24/86, 27.9%, P = 1.00).

Minor complications affected 28.6% and 27.9% of patients with prior MF-RT and WBI, respectively. Table 3 details major and minor complications at different time points.

Table 3. Complications for Mantle and WBI Patients

	Mantle RT Group	WBI Group	P	
Major Complication, Any Time, n (%)	3 (21.4)
	35 (27.1)
	0.76	
 Infection	0 (0.0)	12 (34.3)		
 Necrosis	2 (66.7)	6 (17.1)		
 Seroma	0 (0.0)	1 (2.9)		
 Extrusion	0 (0.0)	2 (5.7)		
 Capsular contracture	1 (33.3)	5 (14.3)		
 Hematoma	0 (0.0)	3 (8.6)		
 Dehiscence	0 (0.0)	2 (5.7)		
 Other	0 (0.0)	4 (11.4)		
Major complication within 90-days of mastectomy, n (%)	2 (14.3)	13 (10.1)	0.64	
Major complication within 1-year of mastectomy, n (%)	2 (14.3)	24 (18.6)	1.00	
Minor complication, any time, n (%)	4 (28.6)	36 (27.9)	1.00	

Factors Associated with Major Complications

On single variable analysis, there was no significant difference in major complications at any point between the prior MF-RT and WBI groups [HR 0.63, 95% confidence interval (CI) 0.19-2.06, P = 0.44]. Single variable analysis was also performed using factors that were significantly different between the prior MF-RT and WBI groups. Increasing BMI (HR per kg/m2 1.06, 95% CI, 1.006–1.12, P = 0.03) and any chemotherapy exposure (HR 2.09, 95% CI, 1.01–4.32, P = 0.046) were the only factors associated with a higher rate of major complications at any point, whereas age (HR 1.004, 95% CI, 0.97–1.03, P = 0.82), total radiation dose (HR 1.00, 95% CI, 1.00–1.00, P = 0.41), time from radiation completion to mastectomy (HR 0.98, 95% CI, 0.94–1.02, P = 0.36), mastectomy type, and SPY use (HR 0.55, 95% CI, 0.29–1.06, P = 0.07) were not significantly associated with major complications.

On multiple variable Cox regression (Table 4), higher BMI remained significantly associated with major complications at any point (HR per kg/m2 1.06, 95% CI, 1.003–1.11, P = 0.04) after adjusting for age and type of radiation, but not when adjusting for any chemotherapy exposure (HR per kg/m2 1.05, 95% CI, 1.00–1.11, P = 0.053) or excluding autologous reconstruction cases (HR per kg/m2 1.06, 95% CI, 0.61–1.50, P = 0.85). On multiple variable analysis, any chemotherapy exposure remained significantly associated with major complications (HR 2.26, 95% CI, 1.08-4.75, P = 0.038). There was still no significant difference in major complications among the prior MF-RT versus WBI groups (HR 0.74, 95% CI, 0.20-2.70, P = 0.74). The Kaplan-Meier curve in Figure 2 showed no significant difference in major complications between MF-RT and WBI groups at 1 year (P = 0.72).

Table 4. Multiple Variable Analysis Cox Hazard Regression Analysis

	Hazard Ratio	CI	P	
Age per year	0.997	0.96–1.03	0.84	
BMI per unit	1.06	1.003–1.11*	0.04*	
Type of radiation (MF-RT versus WBI)	0.74	0.20–2.70	0.65	
BMI per unit	1.05	0.9992–1.11	0.053	
Any chemotherapy exposure	2.26	1.08–4.75*	0.03*	
Type of radiation (MF-RT versus WBI)	0.58	0.16-2.02	0.39	
* Significant.

Fig. 2. Kazplan-Meier curve of 1-year major complication rate between mantle and WBI groups (P = 0.72).

DISCUSSION

Overall, 21.4% of prior MF-RT patients had major complications with immediate breast reconstruction at the time of mastectomy. This is similar to the study by Freniere et al, which found an unplanned reoperation rate of 31% in prior MF-RT patients.9 There was no significant difference in major complications between the prior MF-RT and WBI patients, with 27.1% of prior WBI patients experiencing major complications. Kearney et al, in examination of multiple breast radiation cohorts, found an 11% major complication rate among the no prior breast radiation group with 30% in prior breast and 24% in postmastectomy radiation exposures.12 Despite the elevated risk relative to no radiation exposure, no MF-RT patients had reconstruction failure, suggesting our reconstructive approach was successful for these patients.

Notably, our population tended to be younger with lower BMIs than other prior radiation groups in our practice, suggesting they may be at lower baseline risk for major complications. Although higher BMI can increase risks for complications, lower BMI may present a different set of challenges, such as thinner mastectomy flaps with subsequently higher concerns for exposure or flap necrosis as well as more prominent implants and subsequent cosmetic difficulties. Further, the MF-RT population, broadly as a group with a higher risk of breast cancer and, in turn, potentially younger age of diagnosis given their exposure, may be a more favorable reconstruction population from a demographics perspective. Additionally, this is also reflected in their radiation exposure from a dose and time elapsed from treatment perspective. Although these weren’t significant on multiple variable analysis, possible dose- and time-dependent effects of radiation on tissue may reduce this population’s risk. We did find that on MVA only, chemotherapy exposure was significantly associated with major complications across both populations. However, many of these exposures were remote (eg, at the time of breast-conserving therapy or Hodgkin lymphoma treatment) without the anticipated longevity of impact on reconstruction that would be seen with prior radiation exposure. Further, we suspect this significance likely does not reflect a true risk, but is likely the result of an unidentified confounder. Two notable differences were observed in our practice of this radiation population relative to the traditional prior WBI patients: (1) predominance of bilateral NSM in combination with implant-based reconstruction and (2) use of SPY angiography intraoperatively.

Most MF-RT patients had NSM. Broadly, the use of NSM is often limited by the proximity of cancers to the nipple and breast size in addition to patient preference for maintenance of nipple-areolar complex (NAC). Though implant size among MF-RT patients was not significantly different from that seen in WBI, those who underwent SSM in the MF-RT group had the highest weights of excised breast tissue at 703 g (along with preoperative breast size of DD) versus those receiving NSM at an average weight of 281 g. Thus, the high frequency of NSM was likely secondary to breast size. Still, in our surgeon experience, postreconstruction NAC symmetry is more attainable in a bilateral symmetrically radiated field versus asymmetric exposure. These asymmetries may also have been noted on preoperative evaluation for WBI patients, who did not have significantly different tissue expander fills or implant sizes (a surrogate for breast size), leading to favoring the SSM approach. Additionally, the popularity of NAC tattooing has grown at our institution, which may have proven a more reliable alternative for patients lacking symmetry of radiation exposure.

Almost all prior MF-RT patients had two-stage implant-based reconstruction. Of note, our practicing surgeons typically opt for a staged approach to reconstruction with placement of TE at the time of mastectomy, then autologous or implant-based reconstruction rather than direct-to-implant or direct autologous reconstruction, even among patients who do not have radiation exposure. Although autologous reconstruction has lower complication rates13 and better patient-reported outcomes14 following postmastectomy radiation, Freniere et al found that the reoperation rate for MF-RT patients was higher for autologous compared with implant-based reconstruction.9 Likewise, when Disa et al examined the risks of premature tissue expander removal, they did not find an association with prior MF-RT.15 Another important consideration is the use of inverted-Y extended MF-RT in some patients. This region involves the abdomen and excludes the patient’s candidacy for abdominally based flaps.1 Our findings suggest implant-based reconstruction is a safe approach in this patient population. Our sample was too small (with only one autologous reconstruction patient) to compare the reconstructive technique and conclude if one approach should be selected over the other.

The majority of prior MF-RT patients in our study underwent bilateral mastectomy. This aligns with the increased risk of breast cancer conferred by MF-RT.3,4 King et al found that MF-RT and BRCA mutations were factors associated with an increased rate of contralateral prophylactic mastectomy.16 Likewise, the consensus statement by Wright et al suggested prophylactic contralateral mastectomy in the setting of unilateral breast cancer in this population.17

SPY angiography is often used intraoperatively to assess mastectomy flap or NAC perfusion when there is a concern. Given the retraction required in NSM, SPY is more frequently used in these cases. Even with this difference, all patients with NSM and prior MF-RT had SPY used, whereas just over 60% with NSM and prior WBI had it used. This suggests that in MF-RT reconstruction, greater concern for skin flap perfusion may exist. Notably, this significant difference in SPY use was not seen when patients undergoing autologous reconstruction were excluded. It is difficult to speculate whether this concern is driven purely by intraoperative factors (such as thinner flaps or greater retraction) or differences in radiation-induced skin changes that could be assessed preoperatively.

Anecdotally, surgeons at our institution have felt that reconstruction among patients with MF-RT is more challenging than among prior breast radiation patients, even though no significant difference in major complications was found. Still, these groups were significantly different from a demographic, radiation, and operative technique perspective, as detailed above. Further, individualized counseling and surgical planning for these groups despite the shared remote history of radiation is recommended. Likewise, we did not assess patient-reported or aesthetic outcomes of these reconstructions to compare between groups. We plan to assess preoperative radiation changes and aesthetic outcomes in the future with these cohorts.

Future populations of Hodgkin lymphoma survivors will have differential radiation exposure and, in turn, a lower risk of secondary breast malignancy, as the practice has shifted from the large MF-RT to targeted nodal treatment.2,18 This approach is predicted to reduce breast cancer risk among this population in a dose-dependent manner.19 Likewise, an anticipated change in major complication risk with reconstruction may also exist and requires assessment in future studies.

This study was limited to a small sample size, as is seen in previous studies. With this limited sample size, our principal form of reconstruction amongst these patients was implant-based reconstruction, limiting conclusions that can be generalized to those seeking autologous reconstruction. Still, we add to the number of patients undergoing immediate breast reconstruction after MF-RT for future larger-scale analyses of this distinct population. Additionally, because radiation treatments have changed, understanding the impact of targeted nodal radiation on later mastectomy with immediate reconstruction outcomes will become increasingly important. However, our data suggest that implant-based reconstruction is successful with a reasonable degree of complications in the setting of prior MF-RT.

DISCLOSURE

The authors have no financial interest to declare in relation to the content of this article.

Supplementary Material

Disclosure statements are at the end of this article, following the correspondence information.

Related Digital Media are available in the full-text version of the article on www.PRSGlobalOpen.com.
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