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      Influence of Radiation Dose to Reconstructed Breast Following Mastectomy on Complication in Breast Cancer Patients Undergoing Two-Stage Prosthetic Breast Reconstruction

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          Abstract

          Purpose: This study investigated the association between radiation dose and complication rate in patients who underwent breast reconstruction to understand the role of radiation hypofractionated regimen, boost radiation therapy (RT), and RT techniques.

          Methods: We retrospectively evaluated 75 patients treated with post-mastectomy adjuvant RT for breast cancer in the setting of two-stage prosthetic breast reconstruction. Near maximum radiation dose (D max) in the 2 or 0.03 cc of reconstructed breast or overlying breast skin was obtained from dose-volume histograms.

          Results: Post-RT complications occurred in 22.7% of patients. Receiver operating characteristic analysis showed that all near D max parameters were able to predict complication risk, which retained statistical significance after adjusting other variables (odds ratio 1.12 per Gy, 95% confidence interval 1.02–1.23) with positive dose-response relationship. In multiple linear regression model ( R 2 = 0.92), conventional fractionation (β = 11.7) and 16 fractions in 2.66 Gy regimen (β = 3.9) were the major determinants of near D max compared with 15 fractions in 2.66 Gy regimen, followed by utilization of boost RT (β = 3.2). The effect of bolus and dose inhomogeneity seemed minor ( P > 0.05). The location of hot spot was not close to the high density metal area of the expander, but close to the surrounding areas of partially deflated expander bag.

          Conclusions: This study is the first to demonstrate a dose-response relationship between risk of complications and near D max, where hypofractionated regimen or boost RT can play an important role. Rigorous RT-quality assurance program and modification of dose constraints could be considered as a critically important component for ongoing trials of hypofractionation. Based on our findings, we initiated a multi-center retrospective study (KROG 18-04) and a prospective study (NCT03523078) to validate our findings.

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          Trends and variation in use of breast reconstruction in patients with breast cancer undergoing mastectomy in the United States.

          Concerns exist regarding breast cancer patients' access to breast reconstruction, which provides important psychosocial benefits. Using the MarketScan database, a claims-based data set of US patients with employment-based insurance, we identified 20,560 women undergoing mastectomy for breast cancer from 1998 to 2007. We evaluated time trends using the Cochran-Armitage test and correlated reconstruction use with plastic-surgery workforce density and other treatments using multivariable regression. Median age of our sample was 51 years. Reconstruction use increased from 46% in 1998 to 63% in 2007 (P < .001), with increased use of implants and decreased use of autologous techniques over time (P < .001). Receipt of bilateral mastectomy also increased: from 3% in 1998 to 18% in 2007 (P < .001). Patients receiving bilateral mastectomy were more likely to receive reconstruction (odds ratio [OR], 2.3; P < .001) and patients receiving radiation were less likely to receive reconstruction (OR, 0.44; P < .001). Rates of reconstruction receipt varied dramatically by geographic region, with associations with plastic surgeon density in each state and county-level income. Autologous techniques were more often used in patients who received both reconstruction and radiation (OR, 1.8; P < .001) and less frequently used in patients with capitated insurance (OR, 0.7; P < .001), patients undergoing bilateral mastectomy (OR, 0.5; P < .001), or patients in the highest income quartile (OR, 0.7; P = .006). Delayed reconstruction was performed in 21% of patients who underwent reconstruction. Breast reconstruction has increased over time, but it has wide geographic variability. Receipt of other treatments correlates with the use of and approaches toward reconstruction. Further research and interventions are needed to ensure equitable access to this important component of multidisciplinary treatment of breast cancer.
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            Capsular contractures: a systematic review.

            The aim of this article was to review the current literature on capsular contractures, focusing in particular on the epidemiology, risk factors, cause, and treatment modalities, to provide the plastic surgeon with an up-to-date review of the current available evidence. A literature search was undertaken of the MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials databases. The search strategy was conducted using three groups of key words, with the first relating to the organ involved (breast), the second relating to the surgical procedure performed and related technical issues, and the third relating to the surgical complications. Potentially relevant articles were identified by means of the title and the abstract, and full articles were obtained and assessed in detail. Only a few studies have included large enough sample sizes, were conducted in a prospective manner, were adequately randomized, and achieved adequate follow-up periods to obtain a true measure of rates of capsular contraction occurrence. Recent advances in molecular biology, microbiology, immunology, and basic pathology have outlined some of the mechanisms that underlie this phenomenon. Revision surgery remains the only effective treatment option available but is limited by its high associated risk of recurrences. No adequate preventative measures exist in practice, beyond the avoidance of risk factors. Although a great deal of progress has been made over the past few decades, the exact nature and contribution of molecular, immunologic, and microbiological factors remain unclear. It is hoped that future studies will focus on attempting to resolve some of the issues highlighted in this review.
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              Complications After Mastectomy and Immediate Breast Reconstruction for Breast Cancer: A Claims-Based Analysis.

              To evaluate complications after postmastectomy breast reconstruction, particularly in the setting of adjuvant radiotherapy.
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                Author and article information

                Contributors
                Journal
                Front Oncol
                Front Oncol
                Front. Oncol.
                Frontiers in Oncology
                Frontiers Media S.A.
                2234-943X
                09 April 2019
                2019
                : 9
                : 243
                Affiliations
                [1] 1Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine , Seoul, South Korea
                [2] 2Department of Plastic and Reconstructive Surgery, Severance Hospital, Yonsei University College of Medicine , Seoul, South Korea
                [3] 3Department of Plastic and Reconstructive Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine , Seoul, South Korea
                Author notes

                Edited by: William Small Jr., Stritch School of Medicine, United States

                Reviewed by: Jaroslaw T. Hepel, Rhode Island Hospital, United States; Sonali Rudra, MedStar Georgetown University Hospital, United States

                *Correspondence: Dong Won Lee xyphoss@ 123456yuhs.ac

                This article was submitted to Radiation Oncology, a section of the journal Frontiers in Oncology

                †These authors have contributed equally to this work

                Article
                10.3389/fonc.2019.00243
                6465567
                31024845
                f6327dc1-04ea-45b6-bb64-8c040e2beddf
                Copyright © 2019 Chang, Song, Oh, Lew, Roh, Kim, Keum, Lee and Kim.

                This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

                History
                : 13 October 2018
                : 18 March 2019
                Page count
                Figures: 4, Tables: 3, Equations: 0, References: 29, Pages: 9, Words: 6505
                Funding
                Funded by: Korean Foundation for Cancer Research 10.13039/501100004082
                Award ID: 2017-B-3
                Categories
                Oncology
                Original Research

                Oncology & Radiotherapy
                breast reconstruction,mastectomy,implant,radiation dose,hypofractionated rt,dosimetric analysis

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