Immediate Breast Reconstruction May Complicate Postmastectomy Radiotherapy
Immediate Breast Reconstruction May Complicate Postmastectomy Radiotherapy
Abstract & Commentary
By William B. Ershler, MD, Editor, INOVA Fairfax Hospital Cancer Center, Fairfax, VA; Director, Institute for Advanced Studies in Aging, Washington, DC.
Synopsis: Immediate breast reconstruction after mastectomy has intuitive appeal, but concern has been raised that such an approach hinders postmastectomy radiotherapy. In a retrospective review of 110 breast cancer patients who had immediate breast reconstruction this concern was quantified. Optimal therapy was achieved in approximately 50% of patients, falling far short of that achieved in a similar cohort who had not received immediate reconstruction (> 90%). Thus, for those who are considering breast reconstruction but for whom postmastectomy radiation is indicated, the findings from this study would suggest that delayed reconstruction would be the optimal. The findings, however, are derived from a single institution and by retrospective analysis. A similar approach examined in a multi-site prospective trial with clinical outcomes such as the incidence of local recurrence and overall survival would be valuable to establish the standards for which patients' immediate reconstruction is offered.
Source: Motwani SB, et al. The impact of immediate breast reconstruction on the technical delivery of postmastectomy radiotherapy. Int J Radiat Oncology Biol Phys. 2006;66:76-82.
As reconstructive techniques are being perfected, many women are choosing to have immediate breast reconstructive surgery after mastectomy. This option has the advantages of superior cosmetic results, decreased surgical complications and cost, and a shorter combined recuperation time with one compared to two surgical procedures. In addition, there are psychological considerations inasmuch as it does not involve complete removal of the breast. Despite the appeal of this approach, there are concerns for those women for whom post-surgical radiation is planned.
In the current study, 110 breast cancer patients who were to undergo immediate breast reconstruction followed by radiotherapy at M.D. Anderson Cancer Center between 1989 and 2003 were compared to contemporaneous stage-matched controls (n = 106) who had mastectomy without immediate reconstruction. A scoring system was used to assess optimal radiotherapy incorporating four parameters (one point each): breadth of chest wall coverage, treatment of the ipsilateral internal mammary chain, minimization of exposed lung, and avoidance of heart. An "optimal" plan achieved all objectives or a minor point deduction; "moderately" compromised treatment plans had 1.0 or 1.5 point deductions; and "major" had 2 or more point deductions.
In the immediate reconstruction group, due to anatomic considerations created by the surgical approach, changes in the radiation treatment protocol were required. In the current series, treatment plans were altered in 52% (33% moderately compromised, 19% severely compromised) compared to only 7% of the matched controls. In those who underwent immediate reconstructions, only 41 percent of the right-sided breast cancers and 51 percent of the left-sided cancers were considered to have optimal treatment compared with 92 percent of the right-sided and 94 percent of the left-sided cancers for the patients who had mastectomy without immediate reconstruction.
Furthermore, the immediate reconstruction with radiation group was found to have less satisfactory esthetic results, higher complication rates, and increase requirement for subsequent corrective surgeries.
Commentary
Despite the intuitive value of immediate reconstruction, there appears to be a significant downside, particularly for those requiring postoperative radiation for optimal management. This report, although retrospective and not perfectly controlled, clearly demonstrates less than optimal treatment received by those who underwent immediate reconstruction compared to those who didn't. Presumably, this may affect local regional control and/or survival rates, although this remains to be demonstrated. The differences in achieving optimal treatment were so striking in this analysis that it is likely that detectable differences in clinical outcomes will become apparent with time. In the meantime, for patients with locally advanced breast cancer, the potential for compromised postmastectomy radiation treatment should be considered when deciding between immediate and delayed reconstruction.
Immediate breast reconstruction after mastectomy has intuitive appeal, but concern has been raised that such an approach hinders postmastectomy radiotherapy.Subscribe Now for Access
You have reached your article limit for the month. We hope you found our articles both enjoyable and insightful. For information on new subscriptions, product trials, alternative billing arrangements or group and site discounts please call 800-688-2421. We look forward to having you as a long-term member of the Relias Media community.