Postmastectomy radiation therapy (PMRT) can improve survival and locoregional control in patients with invasive breast cancer. The optimal timing and technique of breast reconstruction in patients requiring PMRT is controversial. The purpose of this chapter is to examine the most recent literature on breast reconstruction in patients receiving PMRT to help breast reconstructive surgeons make the best treatment decisions.
With an increasing number of patients receiving PMRT, the decision of whether to offer implant-based or autologous tissue breast reconstruction has never been so relevant. Recent studies indicate that implant-based breast reconstruction in patients receiving PMRT is problematic.
Outcomes of Implant-Based Reconstruction with Modern Radiation Delivery Techniques
Studies evaluating the outcomes of 2-stage breast reconstruction, with placement of a tissue expander followed by placement of a permanent breast implant after PMRT, consistently reveal high rates of acute and chronic complications and poor aesthetic outcomes.1 Capsular contracture that results from PMRT not only distorts the appearance of the breast, but also causes chronic chest wall pain and tightness that can be crippling. Many surgeons attribute the poor outcomes with implant-based breast reconstruction to older, less precise techniques of radiation delivery. However, even with modern radiation delivery techniques, complication rates with implant-based reconstruction are high.
Ascherman and colleagues2 recently evaluated the complications and aesthetic outcomes of 104 patients who underwent 2-stage implant-based reconstruction. Twenty-seven patients also underwent radiation therapy, either before mastectomy (patients who were undergoing salvage mastectomy after lumpectomy and radiation therapy) or after mastectomy. In all 27 of these patients, radiation therapy was completed before the tissue expander was exchanged for a permanent breast implant or before the expander port was removed. Despite use of the latest prosthetic materials and modern radiation delivery techniques, the overall complication rates for the irradiated and nonirradiated breasts were 40.7% and 16.7%, respectively (p ≤ 0.01). Complications that resulted in removal or replacement of the prosthesis occurred in 18.5% of the irradiated and only 4.2% of the nonirradiated breasts (p ≤ 0.025). In addition, the extrusion rate was higher for implants in irradiated breasts (14.8% vs 0%; p ≤ 0.001). Breast symmetry scores were significantly higher in the patients who did not receive radiation therapy (p < 0.01). Despite the retrospective study design, these findings are important because they represent the experience of a single surgeon who evaluated patients treated using the latest prosthetic devices with total submuscular coverage and modern radiation therapy techniques.
In another recent study, Benediktsson and Perbeck3 used applanation tonometry to prospectively evaluate rates of capsular contracture around saline-filled, textured implants in 107 patients who underwent mastectomy with immediate breast reconstruction. Twenty-four of the patients received PMRT. Radiation was delivered using a modern, 3-beam technique with a combination of photons and electrons, and reconstruction was accomplished using the latest prosthetic devices. The rate of capsular contracture was significantly higher for irradiated breasts than for nonirradiated breasts (41.7% vs 14.5%; p = 0.01). The difference in contracture rates was not evident during the first 6 months, but was highly significant thereafter, even 5 years later.
In 2006, Behranwala and colleagues4 published ...