Breast conserving surgery followed by radiation therapy is a good option for women with early-stage breast cancer who have breast implants, according to a study presented October 16, 2005, at the American Society for Therapeutic Radiology and Oncology’s 47 th Annual Meeting in Denver.

The new findings challenge past studies that showed delivering radiation to a breast with an implant in place causes significant problems in the implant, resulting in poor cosmetic results.

“ Past research was based on a small sample of patients and older radiation techniques,” said Rosalyn Morrell, M.D., lead author of this Mayo Clinic study. “Therefore, we investigated a larger group of women treated with radiation using newer techniques that refuted the reports of poor cosmetic outcome among patients.”

Most women with early-stage breast cancer are able to undergo breast conservation surgery to keep their breast after treatment. Typically, this means that they first have surgery to remove the cancer (a lumpectomy), followed by a course of radiation therapy to kill any cancer cells that may remain. This approach is just as effective as a mastectomy in treating the cancer and is preferred by many women.

More women today are opting to have cosmetic breast implants. As women age, their risk of breast cancer increases, so a fraction of these women will eventually develop breast cancer. These are the patients who would be most interested in preserving their breasts and avoiding mastectomy.

Between 1994 and 2004, researchers reviewed the records of 26 breast cancer patients with previously augmented breasts who were treated with breast conservation surgery and radiation at the Mayo Clinic. All patients had their implants in place before their breast cancer diagnosis. Eighty-five percent of patients followed over a three-year period had favorable cosmetic results following radiation therapy. None of the patients in the study suffered a relapse of their cancer.

Breast-conserving therapy and sentinel lymph node biopsy are feasible in cancer patients with previous implant breast augmentation.

Gray RJ,  .Am J Surg. 2004 Aug;188(2):122-5

Department of Surgery, Mayo Clinic,

Breast-conserving therapy (BCT) is reported to result in a significant rate of complications and local recurrences in patients with prior implant breast augmentation. The role of sentinel lymph node (SLN) biopsy in these patients is unknown. METHODS: Retrospective review of patients with prior breast augmentation treated with BCT or SLN biopsy. RESULTS: Nineteen breast cancers were treated with BCT. Of 17 breasts undergoing adjuvant radiotherapy, 11 (64.7%) retained favorable aesthetic results. Of 9 subpectoral implants, capsular contracture developed in only 1 (11.1%). During follow-up (median 3 years), 1 local recurrence (5.3%) occurred in a patient who refused adjuvant radiotherapy and systemic therapy. Eleven patients underwent SLN biopsy with an identification rate of 100% and a false-negative rate of 0%. CONCLUSIONS: Breast-conserving therapy inclusive of radiotherapy after implant breast augmentation produced acceptable cosmetic results in nearly two-thirds of patients. Sentinel lymph node mapping in the setting of prior implant augmentation was highly successful and accurate.

Radiotherapy and breast reconstruction: the issue of compatibility

Fodor J, Orv Hetil. 2003 Mar 23;144(12):549-55

Orszagos Onkologiai Intezet Sugarterapias Osztaly, Budapest.

Cancer, developing after cosmetic augmentation mammaplasty in the breast, can be treated with lumpectomy and radiotherapy without removal of the implant. In series with this method of treatment the incidence of complications (mainly capsular contracture) was from 0% to 65%. The use of moderate dose (45-50 Gy), wedge filters, and no use of bolus application decreased the risk of complications. CONCLUSIONS: Radiotherapy and breast reconstruction are not incompatible, but careful consideration of their relative timing and technique is important. Plastic surgeons should counsel patients before starting their cancer disease treatment, and those who choose to have reconstruction need to be informed about risks for specific complications associated with the procedure. Results of the studies debating this issue are controversial. Longer follow-up time, larger patient material and better specified parameters are needed to validate results.

Radiation therapy of cancer in prosthetically augmented or reconstructed breasts.

Chu. Radiology 1992 Nov;185(2):429-33

The authors review the literature and report their experience with radiation treatment of 39 prosthetically augmented or reconstructed breasts in 37 patients with primary or recurrent breast cancer. Group 1 consisted of 10 patients (12 primary breast cancers), of whom six had undergone previous breast augmentation and were later treated with lumpectomy and radiation therapy. Four patients were treated with mastectomy, reconstruction, and postoperative irradiation. Local tumor control was achieved in all patients. Excellent or good cosmetic results were achieved in all but two patients. Group 2 consisted of 27 patients with recurrent breast cancer after mastectomy and reconstruction. Local tumor control was achieved in 78% (21 of 27), with a mean duration of 34 months. Excellent or good cosmetic results were achieved in 93% (25 of 27).

Breast-conserving surgery and radiation after augmentation mammoplasty.

Guenther. Cancer 1994 May 15;73(10):2613-8

20 women in whom breast cancer developed after augmentation mammoplasty (14 subcutaneous implants and 6 retromuscular implants). After surgery, six patients received systemic chemotherapy, and all patients received 4500-5000 cGy of tangential photon radiation delivered to the whole breast, plus a 1400-2100 cGy boost delivered to the tumor site using photon radiation, electron radiation, or iridium 192 implantation. there were no local recurrences; however, in two patients distant metastases developed. Seventeen (85%) of the twenty patients had good or excellent cosmetic results as determined by the degree of capsular contracture, breast shape and appearance, and the presence of skin changes.

Irradiation of prosthetically augmented breasts: a retrospective study on toxicity and cosmetic results.

Halpern. Int J Radiat Oncol Biol Phys 1990 Jan;18(1):189-91

Eleven patients with subcutaneous prosthetic breast implants were followed 3-16 years after mammary irradiation. Radiation doses ranged between 45 Gy and 50 Gy to the whole breast, supplemented in five cases with 10-21 Gy scar boost. Evaluation of the cosmetic results revealed a good score in three patients, moderate to fair in three, and poor in five. Of the five patients who had poor postirradiation cosmesis, three had fibrotic changes and encapsulation of the prostheses prior to the irradiation, and two received their irradiation 1 month after the reconstruction. Three observations could be made: (a) when the implanted breast was free of fibrotic changes, radiotherapy produced acceptable results, (b) whenever feasible, 45 Gy/5 weeks seemed preferable over higher doses, (c) irradiation immediately after the reconstructive surgery appeared to produce poorer cosmetic results.

Breast conservation therapy after augmentation mammaplasty: is it appropriate?

Handel. Plast Reconstr Surg 1996 Dec;98(7):1216-24

Between 1981 and 1994, we treated 33 augmented patients with breast conservation therapy. Among 26 individuals for whom complete follow-up data were available, 17 (65 percent) developed significant capsular contracture on the irradiated side. Thus far 8 patients with radiation-induced contracture have undergone corrective surgery. In our experience, augmented breast cancer patients treated with breast conservation therapy have less satisfactory cosmetic results than nonaugmented women. On the basis of these considerations, breast conservation therapy may be less than optimal in augmented cancer patients unless explantation is performed before treatment.

Treatment outcome with radiation therapy after breast augmentation or reconstruction in patients with primary breast carcinoma.

Victor  Cancer 1998 Apr 1;82(7):1303-9

Twenty-one newly diagnosed breast carcinoma patients with prosthetically augmented or reconstructed breasts were treated with external beam RT. With a median follow-up of 32 months, good/excellent cosmetic results were observed in 71% of patients (100% in those with augmented breasts and 54% in those with reconstructed breasts). Four patients (19%) with fair/poor cosmetic outcomes required implant removal and/or revision. Two patients developed an isolated local recurrence within the augmented breast. CONCLUSIONS: Patients with prosthetically augmented breasts can undergo RT and expect good/excellent cosmetic results. Patients with reconstructed breasts are at a significantly greater risk for cosmetic failure.

Radiation therapy after breast augmentation or reconstruction in early or recurrent breast cancer.

Ryu . Cancer 1990 Sep 1;66(5):844-7

Fourteen patients whose augmented or reconstructed breasts were treated with radiation therapy were analyzed. Silicone gel implants were used in 13 patients and free-injected silicone in one patient. Three patients developed documented implant encapsulation, although the majority retained good to excellent cosmesis. In summary, when breast carcinoma arises in the augmented or reconstructed breast, conservative management (i.e., limited surgery and definitive irradiation) is feasible without compromising the therapy or the cosmetic result.

Capsular contracture after lumpectomy and radiation therapy in patients who have undergone uncomplicated bilateral augmentation mammoplasty.

Mark  Radiology 1996 Sep;200(3):621-5

Twenty-one patients with breast cancer who had previously undergone bilateral breast augmentation without complications underwent ipsilateral lumpectomy and radiation therapy. Twelve patients had capsular contracture (57%).  Twelve patients (57%) reported fair to poor cosmesis. Lumpectomy and radiation therapy in patients with breast cancer who have previously undergone augmentation mammoplasty result in a high prevalence of capsular contracture and suboptimal cosmesis.

Breast irradiation following silicone gel implants.

Jacobson. Int J Radiat Oncol Biol Phys 1986 May;12(5):835-8

From November 1970 to October 1984, we treated ten patients with silicone gel prostheses with external radiation for recurrent disease, or as primary therapy. The majority of patients had excellent cosmetic results with minimal late skin changes and no fibrosis or contracture. We conclude that, with proper surgical and radiotherapeutic techniques, good cosmetic results can be obtained in these patients, without compromising their therapy.

Preservation of augmented breasts in patients with breast cancer.

Krishnan. Radiographics 1993 Jul;13(4):831-9

 If the patient chooses breast conservation treatment, the concerns that need to be addressed are whether the breast prosthesis should be removed before irradiation and whether the presence of the prosthesis would impair local control of the tumor or cosmetic results. This article presents the feasibility of breast conservation treatment without impairing the augmentation. Five patients underwent lumpectomy, perioperative placement of interstitial catheters in the tumor bed for immediate postoperative boost brachytherapy, and external beam irradiation to the entire breast. Results of follow-up examinations for a median of 60 months revealed successful local control and satisfactory cosmetic results. No long-term effects of radiation therapy on the breast prostheses have been observed.