|Program and Abstracts
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The Impact of Hormonal Therapy on Outcomes of Total Skin-Sparing Mastectomy and Immediate Tissue Expander-Based Breast Reconstruction
Frederick Wang, MD, Anne Warren Peled, MD, Barbara Fowble, MD, Michael Alvarado, MD, Cheryl Ewing, MD, Laura Esserman, MD, MBA, Robert Foster, MD, Hani Sbitany, MD.
University of California, San Francisco, San Francisco, CA, USA.
Total skin-sparing mastectomy (TSSM) and nipple-sparing mastectomy (NSM) have increased in popularity for treatment of breast cancer. The majority of patients undergo tissue expander (TE)-implant reconstruction, and many will also receive adjuvant hormonal therapy for hormone receptor positive tumors. Prior studies have demonstrated a potential increased risk of implant loss with hormonal therapy in implant-based reconstruction. We aim to evaluate the impact of starting hormonal therapy prior to implant exchange in our TSSM cohort, focusing on postoperative complications associated with implant exchange.
We reviewed all TSSM cases from 2006 to 2013 with immediate TE reconstruction that had a minimum 3 months of follow-up after completing TE-implant exchange. Patient demographics, comorbidities, surgical characteristics, and postoperative complications were collected prospectively. Complications were evaluated based on perioperative exposure to hormonal therapy. A generalized estimating equation model for relative risks was developed to evaluate relative risks of complications by hormonal therapy and radiation therapy and their interaction.
We identified 332 cases (213 patients) with and 444 cases (276 patients) without perioperative hormonal therapy at time of implant exchange with overall median follow-up of 26 (IQR 10-48) months after implant exchange. Patients who received perioperative hormonal therapy were 2 years older on average (p=0.004) and were more likely to have had either neoadjuvant or adjuvant chemotherapy (p<0.001). Cases with perioperative hormonal therapy had higher presenting clinical stage (p<0.001). Radiation therapy had been administered in more cases with hormonal therapy than without (22% vs. 13%, p=0.001). There were no differences with regard to incision choice or method of tissue expander coverage with acellular dermal matrices between the groups. In unadjusted analysis, the risk of infections requiring oral antibiotics was 10% with hormonal therapy compared to 7% without (RR 1.5, 95% CI 0.9-2.4, p=0.081), but this was not statistically significant. We stratified cases by exposure to radiation therapy and found a borderline significant interaction between hormonal therapy and radiation on the risk of implant loss (p=0.07). In cases without radiation, those with hormonal therapy had 0.4 (95% CI 0.1-1.5, p=0.2) times the risk of implant loss. In cases with radiation, those with hormonal therapy had 1.7 (95% CI 0.7-4.1, p=0.3). In multivariate analysis, radiation therapy was associated with an increased risk of wound breakdown (RR 4.4, 95% CI 2.6-7.2, p<0.001), infections requiring oral antibiotics (RR 3.2, 95% CI 2.0-5.1, p<0.001), intravenous antibiotics (RR 6.9, 95% CI 4.1-11.5, p<0.001), infections requiring procedures (RR 11.7, 95% CI 5.8-23.8, p<0.001), implant exposure (RR 6.3, 95% CI 2.6-15.1, p<0.001), and implant loss (RR 3.9, 95% CI 1.5-10.1, p=0.006). In cases with radiation therapy, those with hormonal therapy had 4.0 (95% CI 0.9-18.3, p=0.071) times the risk of implant loss compared to those without hormonal therapy.
This is the first study evaluating the risk of hormonal therapy on outcomes of TSSM with immediate TE-implant based reconstruction. Patients who have had radiation therapy and are taking hormonal therapy at the time of implant exchange should be counseled regarding their potential increased risk of implant loss.
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