Delaying implant-based mammary reconstruction after radiotherapy does not decrease capsular contracture: An in vitro study.

The most common complications of irradiated implant-based mammary reconstruction are fibrosis and capsular contracture. The indications for postmastectomy adjuvant radiotherapy have considerably broadened. Facing an increased number of patients who will require radiotherapy, most guidelines recommend delaying reconstruction after radiotherapy to prevent long-term fibrotic complications. Does radiotherapy permanently alter cellular properties which will adversely affect implant-based reconstruction? If so, is there a benefit in delaying reconstruction after radiotherapy? Our in vitro model simulates two implant-based mammary reconstruction approaches: the irradiated implant and the delayed implant reconstructions by using an implant inset beneath healthy non-irradiated tissue post radiotherapy. We performed cell culture of fibroblasts and endothelial cells to simulate these two surgical conditions. Irradiated fibroblasts simulate the capsular tissue seen around the breast implant. The delayed reconstruction approach is simulated by non-irradiated fibroblasts conditioned with supernatant culture media obtained from irradiated endothelial cells. Irradiation induced fibrosis through fibroblast differentiation into myofibroblasts, as demonstrated by increased α-smooth-muscle actin levels in fibroblasts. This constitutes the basis for scar tissue contraction observed in irradiated implant-based breast reconstruction. Irradiation of endothelial cells induced irreversible cell cycle arrest known as senescence and secretion of the profibrotic connective tissue growth factor. Non-irradiated fibroblasts conditioned with culture media obtained from irradiated endothelial cells exhibited myofibroblast differentiation and the expression of fibrotic phenotype akin to capsular contracture. Our results demonstrate that radiotherapy causes irreversible cellular changes, which permanently alter the microenvironment in favor of fibrosis. Given that these changes are permanent, delaying reconstruction does not present an advantage in preventing capsular contracture.

Grau de satisfação após mastectomia com reconstrução mamária

Introdução: A reconstrução mamária imediata ou tardia após tratamento cirúrgico do câncer de mama já esta bem estabelecida na literatura. Não altera o prognostico da paciente e pode ser realizado imediatamentena maioria dos casos. Objetivo: avaliar a qualidade de vida de pacientesoperadas de câncer de mama que se submeteram a reconstruçãomamaria. Pacientes e Métodos: Foram avaliadas, retrospectivamente,51 mulheres com câncer de mama que submeteram- se a mastectomia ou tratamento conservador e reconstrução da mama. A avaliação foi realizada através de um questionário qualitativo desenvolvido para avaliar os sentimentos destas mulheres em relação ao procedimento reconstrutivo e o impacto sobre a qualidade de suas vidas e auto-estima. Os questionários foram oferecidos durante consultas de retorno para reavaliação e puderam ser respondidos em casa e depois devolvidos se assim desejassem. Foram colhidas informações gerais como idade, ocupação, estado civil e nível de atividade física. O grau de satisfação foi avaliado em vários quesitos com numeração de 1 (plenamente insatisfeita) até 5 (completamente satisfeita) do questionário. O protocolo do presenteestudo foi encaminhado e aprovado pelo Comitê de Ética em Pesquisa do Hospital São Marcos. Resultados: As pacientes apresentam como características gerais uma média de idade de 50,5 anos, 43,1% se autodeclararam empregadas e 31,3% sedentárias. Entre os principais índices o de maior positividade foi o de pacientes que optariam plenamente pela reconstrução secom 92% de plena satisfação, 90% nunca se arrependeram pela decisão da reconstrução, 91,8% acreditam queo procedimento ajuda a enfrentar o câncer de mama, 68% sentem o corpo completamente normal. Conclusão: A auto-avaliação estética das pacientes pós-cirurgia reconstrutora foi positivo o que ressalta a importância deste procedimento para melhoria da qualidade de vida das pacientes.

Introduction: Immediate or late breast reconstruction after breast cancer surgical treatment is already wellestablished in the literature. It doesn?t change patient?s prognosis and can be performed immediately in mostcases. Objectives: To assess life quality of breast cancer operated patients who underwent breast reconstruction. Patientes and Methods: There were retrospectively studied 51 women with breast cancer who underwent mastectomy or conservative treatment and breast reconstruction. The evaluation was conducted through a qualitativequestionnaire designed to assess the feelings of these women regarding the reconstructive procedure and the impact on the quality of their lives and their self-esteem. The questionnaires were offered during return consults and they could be answered at home and then returnedif so desired. There were collected general information such as age, occupation, marital status and of physical activity level. The satisfaction level was assessed in secom veral questions of the questionnaire, with numbering from 1 (fully unsatisfied) to 5 (completely satisfied). This study?s protocol was submitted and approved by the Ethics Committee of São Marcos Hospital. Results: The patients presented, as general characteristics, 50.5 year-old average age, 43.1% self-reportedemployees and 31.3% sedentary ones. Among the main indices, the most positive was that of patients who opt for reconstruction with 92% of full satisfaction, besides 90% never regretted the decision of the reconstruction, 91.8% believe that the procedure helps to address breastcancer, 68% feel the body completely normal. Conclusion: The aesthetic self-assessment of patients after reconstructive surgery was positive, which highlights the importance of this procedure to improve theirlife quality.

Síndrome de Poland / Poland syndrome

A síndrome de Poland é uma rara anomalia congênita, não hereditária, que se manifesta em adolescentes pela ausência ou deficiência do desenvolvimento de uma das mamas. Pode estar associada também a falhas no desenvolvimento dos músculos grande e pequeno peitoral, assim como de outros músculos adjacentes. Antes do desenvolvimento puberal, nota-se assimetria na região torácica pela ausência dos músculos peitoral maior e menor. Apresenta-se um caso de síndrome de Poland, cuja amastia foi tratada com retalho miocutâneo do músculo grande dorsal e prótese de silicone.

Poland syndrome is a rare, non-inherited, congenital anomaly which manifests itself in adolescence by the absence or deficit of the development of a breast. It can also be linked to failures in the development of pectoralis minor and pectoralis major muscles, as well as other adjacent ones. Before the pubertal development, there is an asymmetry at the thoracic region due to the absence of those muscles. We present a Poland's syndrome case whose amastia was treated with a myocutaneous flap of the latissimus dorsi muscle and with a silicone prosthesis.

Uso del colgajo del músculo recto anterior del abdomen (tram) en reconstrucción mamaria inmediata / Use of the flap of the rectus abdominis (tram) in immediate mammary econstruction

Estudio realizado en el hospital oncológico “Dr. Juan Tanca Marengo” (SOLCA) en pacientes sometidas a reconstrucción mamaria inmediata (RMI). Tipo de estudio: retrospectivo, analítico, descriptivo. Objetivos: describir y analizar diferentes técnicas quirúrgicas empleadas en reconstrucción mamaria postmastectomía. Comparar distintos procedimientos de RM según el material usado en cuanto a complicaciones y resultado estético. Determinar el método reconstructivo más adecuado y aceptado por la paciente. Resultados: de 112 pacientes sometidas a RMI postmastectomía por cáncer de mama, en el hospital oncológico “Dr. Juan Tanca Marengo” (SOLCA) durante 1994 - 2004, 12 fueron excluídas al ser mastectomizadas por otro motivo o por falta de seguimiento postquirúrgico. Además, la práctica inmediata de reconstrucción mamaria fue la más frecuente, siendo los tejidos autólogos (TRAM), la técnica más utilizada (79.8) ya que sus complicaciones (36.5), fueron menores que con agentes heterólogos, 69 sea con implantes y/o expansores. En cuanto al resultado estético con TRAM fue evaluado como excelente por la misma paciente (56) y médico encargado (52). Conclusión: estos resultados demuestran la importancia de capacitar y entrenar a los cirujanos en RM para brindarles a las mujeres mastectomizadas una nueva opción con buenos resultados.

Study carried out in the oncologic hospital “Dr. Juan Tanca Marengo” (SOLCA) inpatients subjected to immediate mammary reconstruction (IMR). Study type: retrospective, analytical, descriptive. Objectives: describe and analyze different surgical techniques used in post-mastectomy. Mammary reconstruction. Compare different procedures of MR according to the material used regarding complications and esthetic result. Determine the most appropriate and accepted by the patient reconstructive method. Results: 12 patients out of 112 subjected to post-mastectomy IMR due to mammary cancer in the oncologic hospital “Dr. Juan Tanca Marengo” (SOLCA) from 1994 to 2004, were excluded because they had mastectomy for other reasons or lack of post-surgical follow up. Additionally, the immediate mammary reconstruction was the most frequent, and the most used technique the autologous tissues –TRAM - (79.8), since its complications (36.5) were lesser than with heterologous agents (69), be it with implanting and/or expanders. Regarding the estheticresult with TRAM, it was evaluated as excellent by the patient herself (56) and doctor in charge (52). Conclusion: these results prove the importance of preparing and training RM surgeons to offer to women that had mastectomy a new option with good results.