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.

The incidence of complications was significant even in the absence of irradiation, but radiotherapy increased the risk of complications to less or more extent. When reconstruction was done with implant, the most common type of complication was Grade III-IV capsular contracture. In patients subjected to immediate reconstruction, the complication rates with or without radiotherapy were from 0% to 64% and from 0% to 12%, respectively. In women who underwent delayed reconstruction, the incidence of complications with or without irradiation was from 22% to 55%, and from 17% to 34%, respectively. The negative effect of radiotherapy was more significant with immediate than with delayed reconstruction. In patients who underwent reconstruction with skin-muscle flaps, the most common type of complication was skin necrosis. The incidence of complications with or without radiotherapy was from 12% to 39% and from 5% to 25%, respectively.

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.

Complications and patient satisfaction following expander/implant breast reconstruction with and without radiotherapy.

Krueger EA,  . Int J Radiat Oncol Biol Phys. 2001 Mar 1;49(3):713-21.

Department of Radiation Oncology, The University of Michigan Medical School,

PURPOSE: To compare the rates of complications and patient satisfaction among breast cancer patients treated with mastectomy and tissue expander/implant reconstruction with and without radiotherapy. METHODS AND MATERIALS: As part of the Michigan Breast Reconstruction Outcome Study (MBROS), breast cancer patients undergoing mastectomy with reconstruction were prospectively evaluated with respect to complications, general patient satisfaction with reconstruction, and esthetic satisfaction. Included in this study was a cohort of women who underwent breast reconstruction using an expander/implant (E/I). A subset of these patients also received radiotherapy (RT). At 1 and 2 years postoperatively, a survey was administered which included 7 items assessing both general satisfaction with their reconstruction and esthetic satisfaction. Complication data were also obtained at the same time points using hospital chart review. Radiotherapy patients identified in the University of Michigan Radiation Oncology database that underwent expander/implant reconstruction but not enrolled in the MBROS study were also added to the analysis. RESULTS: Eighty-one patients underwent mastectomy and E/I reconstruction. Nineteen patients received RT and 62 underwent reconstruction without RT. The median dose delivered to the reconstructed breast/chest wall, including boost, was 60.4 Gy (range, 50.0-66.0 Gy) in 1.8- to 2.0-Gy fractions. With a median follow-up of 31 months from the date of surgery, complications occurred in 68% (13/19) of the RT patients compared to 31% (19/62) in the no RT group (p = 0.006). Twelve of 81 patients (15%) had a breast reconstruction failure. Reconstruction failure was significantly associated with experiencing a complication (p = 0.0001) and the use of radiotherapy (p = 0.005). The observed reconstruction failure rates were 37% (7/19) and 8% (5/62) for patients treated with and without radiotherapy, respectively. Tamoxifen was associated with a borderline risk of complications (p = 0.07) and a significant risk of reconstruction failure (p = 0.01). Sixty-six patients of the study group completed the satisfaction survey; 15 patients did not. To offset potential bias for patients not completing the survey, we analyzed satisfaction data assuming "dissatisfaction" scores for surveys not completed. In the analysis of patients with unilateral E/I placement, reconstruction failure was significantly associated with a lower general satisfaction (p = 0.03). Ten percent of patients experiencing a reconstruction failure were generally satisfied compared to 23% who completed E/I reconstruction. In addition, tamoxifen use was associated with a significantly decreased esthetic satisfaction (p = 0.03). Radiotherapy was not associated with significantly decreased general or esthetic satisfaction. CONCLUSION: Irradiated patients had a higher rate of expander/implant reconstruction failure and complications than nonirradiated patients. Despite these differences, our pilot data suggest that both general satisfaction and patient esthetic satisfaction were not significantly different following radiotherapy compared to patients who did not receive RT. Although statistical power was limited in the present study and larger patient numbers are needed to validate these results, this study suggests comparable patient assessment of cosmetic outcome with or without radiotherapy in women who successfully complete expander/implant reconstruction.

Comparison of immediate and delayed free TRAM flap breast reconstruction in patients receiving postmastectomy radiation therapy.

Tran NV,   Plast Reconstr Surg. 2001 Jul;108(1):78-82.

Department of Plastic Surgery, The University of Texas M. D. Anderson Cancer Center

Tumor pathologic features and the extent of nodal involvement dictate whether radiation therapy is given after mastectomy for breast cancer. It is generally well accepted that radiation negatively influences the outcome of implant-based breast reconstruction. However, the long-term effect of radiation therapy on the outcome of breast reconstruction with the free transverse rectus abdominis myocutaneous (TRAM) flap is still unclear. For patients who need postmastectomy radiation therapy, the optimal timing of TRAM flap reconstruction is controversial. This study compares the outcome of immediate and delayed free TRAM flap breast reconstruction in patients who received postmastectomy radiation therapy.All patients at The University of Texas M. D. Anderson Cancer Center who received postmastectomy radiation therapy and who also underwent free TRAM flap breast reconstruction between January of 1988 and December of 1998 were included in the study. Patients who received radiation therapy before delayed TRAM flap reconstruction were compared with patients who underwent immediate TRAM flap reconstruction before radiation therapy. Early and late complications were compared between the two groups. Early complications included vessel thrombosis, partial or total flap loss, mastectomy skin flap necrosis, and local wound-healing problems, whereas late complications included fat necrosis, volume loss, and flap contracture of free TRAM breast mounds. Late complications were evaluated at least 1 year after the completion of radiation therapy for patients who had delayed reconstruction and at least 1 year after reconstruction for patients who had immediate reconstruction.During the study period, 32 patients had immediate TRAM flap reconstruction before radiation therapy and 70 patients had radiation therapy before TRAM flap reconstruction. Mean follow-up times for the immediate reconstruction and delayed reconstruction groups were 3 and 5 years, respectively. The mean radiation dose was 50 Gy in the immediate reconstruction group and 51 Gy in the delayed reconstruction group. One complete flap loss occurred in the delayed reconstruction group, and no flap loss occurred in the immediate reconstruction group. The incidence of early complications did not differ significantly between the two groups. However, the incidence of late complications was significantly higher in the immediate reconstruction group than in the delayed reconstruction group (87.5 percent versus 8.6 percent; p = 0.000). Nine patients (28 percent) in the immediate reconstruction group required an additional flap to correct the distorted contour from flap shrinkage and severe flap contraction.These findings indicate that, in patients who are candidates for free TRAM flap breast reconstruction and need postmastectomy radiation therapy, reconstruction should be delayed until radiation therapy is complete.

Morbidity of immediate breast reconstruction (IBR) after mastectomy by a subpectorally placed silicone prosthesis: the adverse effect of radiotherapy.

Contant CM,   Eur J Surg Oncol. 2000 Jun;26(4):344-50.

Department of Surgical Oncology, University Hospital Rotterdam/Daniel den Hoed Cancer Center, Rotterdam, The Netherlands.

AIMS: This study evaluates the incidence of local complications after immediate breast reconstruction (IBR) following mastectomy with a subpectorally placed silicone prosthesis, with emphasis on the effect of radiation treatment on IBR. METHODS: The medical records of 100 women, who underwent a mastectomy followed by IBR with a subpectorally placed silicone prosthesis at the University Hospital Rotterdam/Daniel den Hoed Cancer Center, between March 1990 and March 1995, were reviewed. Thirteen prostheses were implanted prior to radiation treatment, and 15 prostheses were implanted after irradiation of the chest wall. RESULTS: Early complications were seen in 15% of the IBR and were more often in irradiated women. At long-term follow-up, the most common complication was capsular contracture (21%). This occurred significantly more around prostheses placed in a previously irradiated area (P<0.0005), or which were irradiated after IBR (P=0.001). Loss of prosthesis was seen in 11 cases, and was significantly (P<0.005) more in irradiated women (n=5; 18%) compared to women who were not irradiated (n=6; 7%). CONCLUSIONS: Complications after IBR with a silicone prosthesis were more common in women who were treated with radiotherapy prior to or after IBR following mastectomy than in women who were not irradiated. In particular, capsular contracture around a prosthesis placed in a previously irradiated area was significantly increased. The use of musculocutaneous flaps, such as the transverse rectus abdominis muscle or latissimus dorsi flap, is preferable for reconstruction of previously irradiated breasts. There is no indication to remove the prosthesis before radiation therapy of the chest wall.

Irradiation after immediate tissue expander/implant breast reconstruction: outcomes, complications, aesthetic results, and satisfaction among 156 patients.

Cordeiro PG,  Plast Reconstr Surg. 2004 Mar;113(3):877-81.
Division of Plastic and Reconstructive Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY

Chest wall irradiation is becoming increasingly common for mastectomy patients who have opted for immediate breast reconstruction with tissue expanders and implants. The optimal approach for such patients has not yet been defined. This study assesses the outcomes of a reconstruction protocol for patients who require irradiation after tissue expander/implant reconstruction. The charts of all patients who underwent immediate tissue expander/implant reconstruction at Memorial Sloan-Kettering Cancer Center between January of 1995 and June of 2001 and who had not previously undergone irradiation were retrospectively reviewed. A subgroup of patients who required chest wall irradiation after mastectomy and reconstruction was identified. Those patients were treated according to the following treatment algorithm: (1) reconstruction with tissue expander placement at the time of mastectomy , (2) tissue expansion during postoperative chemotherapy, (3) exchange of the tissue expander for a permanent implant approximately 4 weeks after the completion of chemotherapy, and (4) chest wall irradiation beginning 4 weeks after the exchange. All irradiated patients with at least 1 year of follow-up monitoring after the completion of radiotherapy were evaluated with respect to aesthetic outcomes, capsular contracture, and patient satisfaction. A control group of nonirradiated patients was randomly selected from the cohort of patients treated during the study period. During the 5-year study period, a total of 687 patients underwent immediate reconstruction with tissue expanders. Eighty-one patients underwent postoperative irradiation after placement of the final implant. A total of 68 patients who received postoperative chest wall irradiation underwent at least 1 year of follow-up monitoring after the completion of radiotherapy, with a mean follow-up period of 34 months. Seventy-five nonirradiated patients were evaluated as a control group. Overall, 68 percent of the irradiated patients developed capsular contracture, compared with 40 percent in the nonirradiated group (p = 0.025). Eighty percent of the irradiated patients demonstrated acceptable (good to excellent) aesthetic results, compared with 88 percent in the nonirradiated group (p = not significant). Sixty-seven percent of the irradiated patients were satisfied with their reconstructions, compared with 88 percent of the nonirradiated patients (p = 0.004). Seventy-two percent of the irradiated patients stated that they would choose the same form of reconstruction again, compared with 85 percent of the nonirradiated patients. The results of this study suggest that tissue expander/implant reconstruction is an acceptable surgical option even when followed by postoperative radiotherapy and should be considered in the reconstruction algorithm for all patients, particularly those who may not be candidates for autogenous reconstruction.

Post-mastectomy radiotherapy after immediate autologous breast reconstruction in primary treatment of breast cancers.

Soong IS,  Clin Oncol (R Coll Radiol). 2004 Jun;16(4):283-9.

Department of Clinical Oncology, Pamela Youde Nethersole Eastern Hospital, Hong Kong, PR China.

AIM: To assess the clinical outcome of breast cancer patients with immediate autologous breast reconstruction and post-mastectomy radiotherapy (PMRT) as primary treatment. MATERIALS AND METHODS: Twenty-five women with breast cancer treated with immediate autologous breast reconstruction and post-mastectomy radiotherapy as primary treatment between 1995 and 2001 in Pamela Youde Nethersole Eastern Hospital of Hong Kong were retrospectively studied. Radiation doses of 50 Gy (in 2 Gy daily fraction) were given to the reconstructed breasts, except one who was given 45 Gy (in 1.8 Gy daily fraction). Nine women (36%) were treated without bolus, whereas the other 16 women (64%) were treated with 0.5 cm thick bolus on alternate days. The main outcome measures include local control, treatment complications and cosmetic outcome. RESULTS: Median follow-up was 3.7 years (range: 1.0-6.6 years). Two women (8%), who were treated without bolus, developed chest wall recurrences. The overall 5-year, actuarial, local failure-free rate and disease-specific survival rate were 89.8% and 77.9%, respectively. Apart from mild acute skin reactions, no significant acute radiotherapy side-effects were observed. No flap necrosis or flap loss was seen. The cosmesis of the reconstructed breasts were rated as good to excellent in 85% of the surviving patients. There was no observed adverse effect on cosmesis by adding bolus on alternate days. CONCLUSION: PMRT after immediate autologous tissue-flap breast reconstruction is well tolerated and is not associated with increased incidence of complications. Adding 0.5 cm bolus on alternate days might improve local control without causing adverse cosmetic effect. The concern of adverse effects of radiotherapy should not exclude the choice of immediate breast reconstruction in suitable patients.

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).

Radiotherapy and breast reconstruction: clinical results and dosimetry.

Kuske  Int J Radiat Oncol Biol Phys 1991 Jul;21(2):339-46

At Washington University, 70 breast cancers were irradiated in 66 patients following mastectomy with reconstruction (N = 61) or wide local excision of an augmented breast (N = 5). Two patients elected to have a second reconstruction after an unsatisfactory initial result. Thus, 72 breasts were evaluated after radiotherapy for tumor control, complications, cosmesis, and patient satisfaction. Locoregional failure occurred in only five patients, one following adjuvant radiotherapy after mastectomy with reconstruction and four following radiotherapy for recurrent breast cancer within a reconstructed breast. Grade 2 or 3 complications occurred in 34 patients (51%). The complication rate was highest in autologous tissue transfer reconstructions. Cosmetic results were evaluated good/excellent in 49% by physicians and 67% by patients. Immediate reconstructions had fewer good/excellent physician evaluations (32%) compared with reconstructions performed at least 6 weeks after radiotherapy (55%). Transverse rectus abdominis flaps had the best cosmesis scores, followed by permanent silicone prostheses, tissue expanders, latissimus dorsi, and gluteal flaps. Radiotherapy and reconstruction are not incompatible, but careful consideration of their relative timing and technique appear to be important in optimizing cosmesis while minimizing complications.

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.

Breast reconstruction in women treated with radiation therapy for breast cancer: cosmesis, complications, and tumor control.

Schuster Plast Reconstr Surg 1992 Sep;90(3):445-52; discussion 453-4

The records of 55 patients who had breast cancer treated by mastectomy, irradiation, and breast reconstruction were reviewed for cosmetic outcome, complications, and tumor control. Local control rates were 95 percent in patients treated for high risk factors or breast conservation and 85 percent in patients treated for recurrent breast cancer. Acceptable cosmetic results were obtained in only 42 percent of patients. The incidence of complications was 55 percent. Transverse rectus abdominis muscle (TRAM) reconstructions gave superior cosmetic results compared with all other types of reconstructions.

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.

Feasibility of postmastectomy radiation therapy after TRAM flap breast reconstruction.

Hunt Ann Surg Oncol 1997 Jul-Aug;4(5):377-84

Postoperative radiotherapy (PORT) has been shown to decrease locoregional failure rates in high-risk breast cancer patients following modified radical mastectomy. However, there had not been a study evaluating the effect of PORT in patients after transverse rectus abdominis myocutaneous (TRAM) flap breast reconstruction. The charts of patients who had undergone modified radical mastectomy with TRAM flap reconstruction and PORT at our institution were reviewed. Eighty-four percent of patients felt their overall cosmetic result was excellent or good; only one patient reported a poor cosmetic result. Local control was achieved in three of the four patients who received PORT for local recurrence. There was only one local recurrence among the 14 patients who received PORT because they were at high risk of local recurrence.

Breast reconstruction with myocutaneous flaps in previously irradiated patients.

Kroll Plast Reconstr Surg 1994 Mar;93(3):460-9; discussion 470-1

Breast reconstructions performed with latissimus dorsi and transverse rectus abdominis myocutaneous (TRAM) flaps in 82 patients with a history of previous chest-wall irradiation were compared with similar reconstructions in 202 nonirradiated patients to determine whether prior irradiation was associated with more frequent complications and to determine the success rate of breast reconstruction using distant flaps in irradiated patients. Complications in the reconstructed breast were more frequent in the irradiated patients (39 percent) than in the nonirradiated patients (25 percent. In the irradiated group, breast complications were more common in reconstructions performed with the latissimus dorsi flap (63 percent) than in those performed with the TRAM flap (33 percent; p = 0.063). Aesthetic outcomes also were slightly poorer in the irradiated patients. Although complications were more common and aesthetic outcomes not as good in previously irradiated patients, we do not consider such irradiation to be a contraindication to breast reconstruction.

The effects of radiation treatment after TRAM flap breast reconstruction.

Williams Plast Reconstr Surg 1997 Oct;100(5):1153-60

Nineteen patients from 1981 to 1994 receiving radiation therapy after a pedicled TRAM flap reconstruction were compared with 108 patients who received radiation prior to reconstruction and 572 patients who underwent breast reconstruction without radiation. 10 patients (52.6 percent) demonstrated postradiation changes in the TRAM flap reconstruction, and 6 required surgical intervention (31.6 percent). Overall complication rates were increased but were not found to be statistically significant between the radiated TRAM flap group and patients with preoperative radiation followed by TRAM flap reconstruction (31 versus 25 percent). Fibrosis was not found in patients with pre-TRAM flap radiation or in patients without radiation but was seen in 31.6 percent of patients who received radiation after the reconstruction. The complication rate does not change whether a patient receives radiation before or after her reconstruction; only the nature of the complication changes (fat necrosis to fibrosis).

Radiation tolerance of transverse rectus abdominis myocutaneous-free flaps used in immediate breast reconstruction.

Zimmerman Am J Clin Oncol 1998 Aug;21(4):381-5

The authors determine the effects of postoperative radiation therapy on flap and local control outcomes in patients who have undergone immediate transverse rectus abdominis myocutaneous (TRAM)-free flap reconstruction after modified radical mastectomy for locally advanced breast cancer. Cosmesis was rated as excellent by 60% of patients, good by 30%, and fair by the remaining 10%. Three patients thought that radiation had improved cosmesis, one noted worse cosmesis, and the remainder thought it had no effect on cosmesis. The local control rate was 86%. Postreconstruction irradiation of TRAM-free flaps used in immediate reconstruction for locally advanced breast cancer appears safe and cosmetically acceptable.