International Journal of Radiation Oncology*Biology*Physics
Clinical investigationBreastThe impact of immediate breast reconstruction on the technical delivery of postmastectomy radiotherapy
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.
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Supported by a generous grant from the Stanford and Joan Alexander Foundation.