Prosthetic Breast Reconstruction Outcomes in Hodgkin's Lymphoma Survivors
Jacquelyn Withers, B.S., Abdl-Rawf Al-Nowaylati, M.D., Hani Sbitany, M.D..
University of California, San Francisco, San Francisco, CA, USA.
Purpose: It is well known that survivors of Hodgkin's lymphoma who have received mantle radiation are at significantly higher risk of secondary breast cancer. However, there are few studies in the literature assessing breast reconstruction outcomes in this unique patient population. We aimed to compare outcomes of this cohort to those treated for breast cancer at UCSF without a history of radiation, to assess long-term effects of mantle radiation on breast reconstruction.
Methods: We performed a retrospective double cohort study. Our case group included all breast cancer patients with a history of mantle radiation for Hodgkin's lymphoma who underwent implant based breast reconstruction at UCSF. We chose a 1:6 ratio of cases to historical controls, selecting controls from patients who underwent implant based reconstruction following either prophylactic or oncologic mastectomy. Because no Hodgkin's patients received further radiation for breast cancer treatment, we excluded controls who had any radiation treatment for breast cancer. Additionally, controls were matched to cases within 5 years of age, on chemotherapy history, and based on bilateral versus unilateral reconstruction. Data was collected on demographic factors, breast cancer and reconstruction treatment details, and short and long-term post-operative outcomes. Major breast complications were defined as those requiring reoperation or readmission, and included: infection, dehiscence, hematoma, seroma, fat necrosis, capsular contracture, implant extrusion, and partial or complete flap loss.
Results: We identified 13 breast cancer patients with a history of mantle radiation for Hodgkin's lymphoma, and selected 78 matched controls. In Hodgkin's patients, mantle radiation preceded breast reconstruction by an average of 25 years. Hodgkin's patients had a significantly higher rate of prior abdominal surgery at 85% versus 56%, primarily due to history of staging laparotomy for Hodgkin's treatment (p=0.05). All patients except for one in the Hodgkin's group had two-stage reconstructions. Two cases and 12 controls had unilateral reconstructions, whereas 11 cases and 66 controls had bilateral reconstructions. One (8%) patient in the Hodgkin's group converted to autologous reconstruction, versus 4 (5%) in the control group. Four (5%) additional patients in the control group had their implants removed. There was higher overall rate of major breast complications in the Hodgkin's group at 54%, compared to 29% in the control group (p=0.08). In particular, significantly more Hodgkin's patients developed capsular contracture than did controls - 38% (n=5) versus 10% (n=8) (p=0.01). Hodgkin's patients also had a higher rate of readmissions for complications at 31% compared to 10% (p=0.04).
Conclusions: Patients with a remote history of mantle radiation are at higher risk of breast complications and readmissions following implant-based breast reconstruction compared to patients not receiving breast radiation. In particular, these patients are at a higher risk for developing capsular contracture. Autologous reconstruction may be preferable for these patients, although abdominally based flaps may not be possible, given their frequent history of abdominal staging laparotomy.
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