Long-Term Outcomes in Breast Cancer
Patients Undergoing Immediate 2-Stage
Expander/Implant Reconstruction and
Alice Ho, MD1; Peter Cordeiro, MD2; Joseph Disa, MD2; Babak Mehrara, MD2; Jean Wright, MD3;
Kimberly J. Van Zee, MS, MD2; Clifford Hudis, MD4; Amanda McLane, BA1; Joanne Chou, MPH5; Zhigang Zhang, PhD5;
Simon Powell, MD, PhD1; and Beryl McCormick, MD1
BACKGROUND: Breast reconstruction with tissue expander (TE)/permanent implant (PI) followed by postmastec-
tomy radiation (PMRT) is an increasingly popular treatment for breast cancer patients. The long-term rates of perma-
nent implant removal or replacement (PIRR) and clinical outcomes in patients treated with a uniform reconstructive
surgery and radiation regimen were evaluated. METHODS: Between 1996 and 2006, 1639 patients with stage II-III
breast cancer received modified radical mastectomy (MRM) at Memorial Sloan-Kettering Cancer Center. A total of
751 received TE placement at the time of mastectomy. Of these, 151 patients went on to receive chemotherapy and
exchange of the TE for a permanent implant, followed by PMRT. Clinical outcomes and PIRR-free rates were esti-
mated by Kaplan-Meier methods. Cox regression model was used to examine patient, disease, and treatment charac-
teristics associated with PIRR. RESULTS: Median follow-up was 86 months (range, 11-161 months). The 7-year PIRR-
free rate was 71% (38 PIRRs in 35 patients). The 7-year rate of PI replacement was 17.1% (21), and removal was 13.3%
(17). Reasons for PIRR included infection (15); implant extrusion, shift, leak, or rupture (4); patient request (1), or mul-
tifactorial (17). On univariate analysis, no factor was significantly associated with PIRR. Two patients experienced local
recurrence in the chest wall, both after 7 years. The 7-year distant metastasis–free survival rate was 81% and overall
survival 93%. CONCLUSIONS: Favorable 7-year PIRR rates and clinical outcomes were achieved in a sizable cohort of
patients treated with homogeneous sequencing, radiation, and reconstructive surgery and lengthy follow-up. Factors
predictive for high risk of PIRR were not identifiable in this population. Cancer 2012;118:2552-9. V
C 2011 American
KEYWORDS: postmastectomy, radiation, immediate reconstruction, implant, outcomes.
Postmastectomy radiation in patients with 4 or more positive lymph nodes is widely accepted as an essential
element of treatment for locally advanced breast cancer. An update of the seminal Early Breast Cancer Collaborative Tria-
plicable to a subset with 1 to 3 positive lymph nodes.1Consequently, increasing use of PMRT in breast cancer patients
withlymphnode-positivedisease is anticipated.
Enhancing quality of life is also an important goal for breast cancer survivors. Breast reconstruction offers aesthetic
and psychological advantages that contribute significantly to patient satisfaction and quality of life.2Many mastectomy
patients are opting to receive implant-based breast reconstruction; a 2-stage tissue expander (TE)/permanent implant (PI)
approach constituted 2/3 of the breast-reconstructive surgeries performed in the United States between 2008 and 2009.3
Knowledge of long-term oncologic outcomes and surgical complication rates is therefore relevant to thousands of women
whoarefaced withthe decisiontoreceive implantreconstruction priortoradiation.
DOI: 10.1002/cncr.26521, Received: June 1, 2011; Revised: July 21, 2011; Accepted: August 5, 2011, Published online September 14, 2011 in Wiley Online
Corresponding author: Alice Ho, MD, Radiation Oncology, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10065; Fax: (212)
1Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York;2Department of Surgery, Memorial Sloan-Kettering Cancer
Center, New York, New York;3University of Miami School of Medicine, Miami, Florida;4Department of Medicine, Memorial Sloan-Kettering Cancer Center, New
York, New York;5Department of Epidemiology-Biostatistics, Memorial Sloan-Kettering Cancer Center, New York, New York.
May 1, 2012
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May 1, 2012