Botulinum Toxin A (Botox) in Tissue Expander Breast Reconstruction

This study is currently recruiting participants. (see Contacts and Locations)
Verified February 2014 by Mayo Clinic
Sponsor:
Information provided by (Responsible Party):
Valerie Lemaine, Mayo Clinic
ClinicalTrials.gov Identifier:
NCT01591746
First received: April 13, 2012
Last updated: February 17, 2014
Last verified: February 2014
  Purpose

Each year, the number of breast cancer survivors who choose post-mastectomy breast reconstruction keeps rising. Among women who elect to pursue breast reconstruction, approximately 75% will choose prosthetic breast reconstruction. Implant-based breast reconstruction is frequently achieved in two-stages. The first stage consists of the placement of a tissue expander after mastectomy. This is followed by a period of weekly tissue expansions that can last several months. In the second stage, the tissue expander is removed in a surgical procedure and replaced with a permanent breast implant. Tissue expansion is a well-established breast reconstruction technique characterized by high success rates and high patient satisfaction. Despite the well-recognized advantages of this successful breast reconstruction technique, the subpectoral placement of a tissue expander is associated with significant pain and discomfort in the immediate post-operative period and during the phase of tissue expansion. Pectoralis major muscle spasm is a frequently reported problem during tissue expansion. Legeby et al. recently showed that women who underwent prosthetic breast reconstruction had higher pain scores and took more analgesics that those who did not choose post-mastectomy reconstruction.

In the past 10 years, publications on the use of BTX-A for pain relief in a wide array of clinical conditions have increased tremendously. BTX-A is one of the neurotoxins produced by Clostridium botulinum bacteria. By reversibly inhibiting neurotransmitter release, BTX-A has both analgesic and paralytic properties. The analgesic action of BTX-A was initially thought to be related to its effects on muscular contraction. However, a recent in vitro study of embryonic rat dorsal neurons did confirm that BTX-A inhibits release of substance P, a neurotransmitter associated with pain and inflammatory reactions. The presence of analgesic properties of BTX-A is increasingly supported by several clinical observations: pain relief with BTX-A injections has been reported for migraine headaches, chronic pelvic, chronic tennis elbow, and post-operative pain control for lower limb lengthening correction, among others.

This aspect has never been studied in breast cancer survivors who elect to pursue breast reconstruction with tissue expanders. Furthermore, physical function outcomes are important to consider with BTX-A use because the link between temporary muscle paralysis and improvements in participation in daily activities is not a given.

The investigators propose to complete a double-blinded prospective randomized controlled trial of women undergoing unilateral and bilateral mastectomies with immediate placement of tissue expanders, to establish the efficacy and safety of BTX-A in alleviating pain and in improving physical well-being during the expansion period.


Condition Intervention Phase
Breast Cancer
Pain, Postoperative
BRCA1 Mutation
BRCA2 Mutation
Breast Diseases
Neoplasms
Drug: Botulinum Toxin Type A
Drug: Sodium Chloride Solution
Phase 3

Study Type: Interventional
Study Design: Allocation: Randomized
Endpoint Classification: Safety/Efficacy Study
Intervention Model: Parallel Assignment
Masking: Double Blind (Subject, Caregiver, Investigator, Outcomes Assessor)
Primary Purpose: Supportive Care
Official Title: Botulinum Toxin A in Tissue Expander Breast Reconstruction: A Double-Blinded Randomized Controlled Trial

Resource links provided by NLM:


Further study details as provided by Mayo Clinic:

Primary Outcome Measures:
  • Change from Baseline in average pain scores using a numeric pain intensity scale [ Time Frame: Pre-operative visit, first post-opeartive visit, each expansion visit, preoperative listing visit for the second stage surgery. ] [ Designated as safety issue: No ]
    The numeric pain intensity scale (NPIS) will be completed at various time frames. The NPIS is a visual analog scale commonly used to assess clinical pain.

  • Change from Baseline in Physical Well-Being using the BREAST-Q Physical Well-Being scale [ Time Frame: Pre-operative visit, first post-opeartive visit, each expansion visit, preoperative lisiting visit for second stage surgery. ] [ Designated as safety issue: No ]
    The Physical Well-Being scale of the BREAST-Q, reconstruction module, will be used for this purpose. The BREAST-Q is a validated patient-reported outcome measure to accurately assess quality of life and patient satisfaction.


Secondary Outcome Measures:
  • Initial percent volume expansion intra-operatively [ Time Frame: Single intra-operative measurement at first surgery ] [ Designated as safety issue: No ]
    The amount of initial intraoperative fill volume in the tissue expander at the time of surgery divided by the manufacturers recommended total tissue expander volume will be measured.

  • Rate of tissue expansion [ Time Frame: Up to 24 weeks ] [ Designated as safety issue: No ]
    Measurement of expansion volume at each tissue expansion and number of tissue expansions completed.

  • Rate of reconstruction failure [ Time Frame: At 6 months after first surgery ] [ Designated as safety issue: Yes ]
    Determine the rate of tissue expander removal.

  • Incidence of side effects attributable to the injection of BTX-A at doses of 100 units and 200 units. [ Time Frame: First 30 days postoperatively ] [ Designated as safety issue: Yes ]
    All serious adverse events will be recorded and reported. Minor adverse events and unusual complications encountered during the postoperative period will be carefully recorded.


Estimated Enrollment: 200
Study Start Date: August 2012
Estimated Study Completion Date: August 2015
Estimated Primary Completion Date: August 2015 (Final data collection date for primary outcome measure)
Arms Assigned Interventions
Experimental: Group A
Botulinum Toxin A
Drug: Botulinum Toxin Type A
100 Units of Botulinum toxin A diluted in 5 mL 0.9% Sodium Chloride in the pectoralis major muscle in each operated breast.
Other Name: BOTOX
Placebo Comparator: Group B
Placebo
Drug: Sodium Chloride Solution
5 mL 0.9% NaCl injection to the pectoralis major muscle in each operated breast.

Detailed Description:

Consecutively enrolled eligible women will be randomized into one of two different treatment groups: 1) Group receiving BTX-A, and 2) Group receiving a placebo. All consenting subjects will be randomized to receive either a single injection of 100 units of BTX-A, or a placebo (saline water), during surgery in the pectoralis major muscle on the operated side once the mastectomy and the breast reconstruction have been completed. Expected duration of subject participation is up to 12 months, depending on the number of tissue expansion visits necessary to fill the tissue expander to its final desired volume.

  Eligibility

Ages Eligible for Study:   18 Years and older
Genders Eligible for Study:   Female
Accepts Healthy Volunteers:   Yes
Criteria

Inclusion:

  1. Women at least 18 years of age, who will undergo immediate unilateral or bilateral tissue expander breast reconstruction following therapeutic skin-sparing or nipple-sparing mastectomy.
  2. Women at least 18 years of age, who will undergo immediate bilateral tissue expanders breast reconstruction following risk-reduction (prophylactic) skin-sparing or nipple-sparing mastectomy.

Exclusion:

  1. Subjects who are unable to read or speak English.
  2. Breast reconstruction using the latissimus dorsi flap combined with a tissue expander.
  3. Documented diagnosis of chronic pain, upper limb spasticity, cervical dystonia, axillary hyperhidrosis, strabismus or blepharospasm;
  4. Hypersensitivity to any botulinum toxin preparation or to any of the components in the formulation.
  5. Infection at the proposed site of injection.
  6. Pre-existing neuromuscular disorders (including diagnosed myasthenia gravis, Eaton-Lambert syndrome, or amyotrophic lateral sclerosis).
  7. Aminoglycosides intake at the time of surgery (these antibiotics can potentiate the effect of BTX-A).
  8. Women who are pregnant or breast feeding.
  9. Presence of submuscular implants from previous breast surgery.
  10. Reported use of Botox within 4 months prior to planned surgical date.
  Contacts and Locations
Choosing to participate in a study is an important personal decision. Talk with your doctor and family members or friends about deciding to join a study. To learn more about this study, you or your doctor may contact the study research staff using the Contacts provided below. For general information, see Learn About Clinical Studies.

Please refer to this study by its ClinicalTrials.gov identifier: NCT01591746

Contacts
Contact: Valerie Lemaine, MD 507-284-2736 lemaine.valerie@mayo.edu

Locations
United States, Arizona
Mayo Clinic Recruiting
Scottsdale, Arizona, United States, 85259
Contact: Alanna M Rebecca, M.D.    480-342-2976    Rebecca.Alanna@mayo.edu   
United States, Florida
Mayo Clinic Recruiting
Jacksonville, Florida, United States, 32224
Contact: Galen Perdikis, M.D.    904-953-2073    Perdikis.Galen@mayo.edu   
United States, Minnesota
Mayo Clinic Recruiting
Rochester, Minnesota, United States, 55905
Contact: Valerie Lemaine, MD, MPH       lemaine.valerie@mayo.edu   
Sponsors and Collaborators
Mayo Clinic
Investigators
Principal Investigator: Valerie Lemaine, MD Mayo Clinic
  More Information

No publications provided

Responsible Party: Valerie Lemaine, Principal Investigator, Mayo Clinic
ClinicalTrials.gov Identifier: NCT01591746     History of Changes
Other Study ID Numbers: 11-001687
Study First Received: April 13, 2012
Last Updated: February 17, 2014
Health Authority: United States: Food and Drug Administration

Keywords provided by Mayo Clinic:
Mastectomy
Mammaplasty
Breast reconstruction
Tissue expansion
Botulinum toxins, Type A
Quality of Life
Acellular dermal matrix

Additional relevant MeSH terms:
Botulinum Toxins, Type A
Botulinum Toxins
Breast Neoplasms
Breast Diseases
Neoplasms
Pain, Postoperative
Neoplasms by Site
Skin Diseases
Postoperative Complications
Pathologic Processes
Pain
Signs and Symptoms
Neuromuscular Agents
Peripheral Nervous System Agents
Physiological Effects of Drugs
Pharmacologic Actions
Anti-Dyskinesia Agents
Central Nervous System Agents
Therapeutic Uses

ClinicalTrials.gov processed this record on July 23, 2014