Clinical investigation
Breast
The impact of immediate breast reconstruction on the technical delivery of postmastectomy radiotherapy

Presented at the Forty-Seventh Annual Meeting of the American Society of Therapeutic Radiology and Oncology (ASTRO), Denver, CO, October 18, 2005.
https://doi.org/10.1016/j.ijrobp.2006.03.040Get rights and content

Purpose: To quantify the impact of immediate breast reconstruction on postmastectomy radiation therapy (PMRT) planning.

Methods: A total of 110 patients (112 treatment plans) who had mastectomy with immediate reconstruction followed by radiotherapy were compared with contemporaneous stage-matched patients who had undergone mastectomy without intervening reconstruction. A scoring system was used to assess optimal radiotherapy planning using four parameters: breadth of chest wall coverage, treatment of the ipsilateral internal mammary chain, minimization of lung, and avoidance of heart. An “optimal” plan achieved all objectives or a minor 0.5 point deduction; “moderately” compromised treatment plans had 1.0 or 1.5 point deductions; and “major” compromised plans had ≥2.0 point deductions.

Results: Of the 112 PMRT plans scored after reconstruction, 52% had compromises compared with 7% of matched controls (p < 0.0001). Of the compromised plans after reconstruction, 33% were considered to be moderately compromised plans and 19% were major compromised treatment plans. Optimal chest wall coverage, treatment of the ipsilateral internal mammary chain, lung minimization, and heart avoidance was achieved in 79%, 45%, 84%, and 84% of the plans in the group undergoing immediate reconstruction, compared respectively with 100%, 93%, 97%, and 92% of the plans in the control group (p < 0.0001, p < 0.0001, p = 0.0015, and p = 0.1435). In patients with reconstructions, 67% of the “major” compromised radiotherapy plans were left-sided (p < 0.16).

Conclusions: Radiation treatment planning after immediate breast reconstruction was compromised in more than half of the patients (52%), with the largest compromises observed in those with left-sided cancers. For patients with locally advanced breast cancer, the potential for compromised PMRT planning should be considered when deciding between immediate and delayed reconstruction.

Introduction

Immediate breast reconstruction offers patients undergoing mastectomy several advantages over delayed reconstruction approaches. It is an oncologically safe approach in early-stage disease, improves the quality of life of women with breast cancer and can be done contemporaneously as mastectomy (1). It lowers psychosocial morbidity by eliminating the need to experience deformity after mastectomy (2). Other advantages to this approach are superior cosmetic results, decreased surgical morbidity, and lower cost (3). In patients with intermediate and advanced stage disease, postmastectomy radiation therapy (PMRT) is required to secure acceptable rates of locoregional control, and PMRT has a favorable impact on survival in these patients (4).

Unfortunately, immediate breast reconstruction and postmastectomy radiation therapy can interact unfavorably with one another. Reconstructions that are subsequently irradiated have poorer esthetic outcomes and higher complication rates (5). These patients can require additional surgeries to correct for asymmetry and volume loss. We previously described the possibility that immediate reconstruction could affect the technical delivery of radiation therapy (6). The purpose of this study was to quantify the frequency and magnitude of this impact of immediate breast reconstruction and postmastectomy radiation therapy planning.

Section snippets

Methods and materials

Between 1989 and 2003, a total of 1,311 patients underwent flap reconstruction of the breast at The University of Texas M.D. Anderson Cancer Center (MDACC). Of those patients, 195 (15%) also received external beam radiation therapy at this institution. Among these 195 patients, 118 were identified as having had immediate breast reconstruction before their radiotherapy. Two of these women had bilateral reconstructions and received bilateral irradiation for a total of 120 evaluable events. Two

Results

Of the 112 PMRT plans scored after reconstruction, 48% (54/112) of the plans had “optimal scores” (0 or 0.5 point deduction). In comparison, of the 106 plans in stage- and year-matched controls, but without immediate reconstruction, 93% (99/106) received an optimal score (p < 0.001). Of the less-than-optimal plans (52%) in patients with reconstruction, 33% (37/112) had moderate compromises (1 or 1.5 point deductions) and 19% (21/112) had major compromises (2 or more point deductions). Of

Discussion

This is the first study to measure the potentially deleterious effect of immediate breast reconstruction and the technical delivery of postmastectomy radiotherapy. Combining distinct treatment components to obtain an optimal comprehensive plan has been a challenge ever since the implementation of multimodality care. Although immediate breast reconstruction may be preferred over other reconstructive surgeries because of superior cosmetic outcomes, decreased psychosocial morbidity, and greater

Conclusion

In this study, radiation treatment planning was altered in more than half (52%) of the patients who underwent immediate breast reconstruction compared with 7% of matched controls. Major compromises occurred more commonly in left-sided cancers (65%). Immediate breast reconstruction poses challenges for the treatment planning of postmastectomy radiation therapy, both in covering all regions at risk for residual disease and in protecting adjacent normal structures. A preoperative discussion with

Acknowledgments

The authors thank Lawrence B. Levy (Radiation Oncology) for statistical assistance and Marie Turner (Radiation Oncology) for preparation of the manuscript.

References (23)

  • S.J. Kronowitz et al.

    Breast reconstruction with postmastectomy radiation therapyCurrent issues

    Plast Reconstr Surg

    (2004)
  • Cited by (196)

    • Chances and challenges—analysis of trends in breast reconstruction

      2022, Journal of Plastic, Reconstructive and Aesthetic Surgery
    • Helical tomotherapy for post-mastectomy radiation therapy with or without breast implant: a single institution experience

      2022, Clinical and Translational Radiation Oncology
      Citation Excerpt :

      US population-based studies have reported an increase in the number of PMRT patients undergoing immediate breast reconstructions, particularly with implant-based techniques [3,5]. However, a number of reports have indicated that radiotherapy plans with breast implants are compromised in greater than one half of this particular patient group [6,7]. Whether IBR actually impedes the optimization of radiation treatment (RT) remains controversial as it coincides with the emergence of novel techniques which are able to deliver RT more precisely [8].

    View all citing articles on Scopus

    Supported by a generous grant from the Stanford and Joan Alexander Foundation.

    View full text