Impact of Postoperative Radiation Therapy on Postmastectomy Breast Reconstruction
Many women are now offered immediate reconstruction after mastectomy, which in many cases is followed by radiation therapy. Reconstructions are most commonly performed in one of two ways: an autologous (self) tissue flap using either the transverse rectum abdominal muscle (TRAM) or the latissimus dorsi (LD); or a permanent implant (PI). When using permanent implants, the initial use of tissue expanders (TE) is generally necessary. This study was done to look at complications and cosmetic outcome from radiation therapy after reconstruction.
The study was a review of 73 women’s records, ages 24-79 (median 47), 71 of whom had mastectomy with reconstruction. The researchers looked at any additional therapy received (chemotherapy), reconstruction method, radiation techniques, and other health issues. These were then evaluated to see how they correlated with acute radiation toxicity (skin burn) and other complications, including fat necrosis, lymphedema, telangiectasias (blood vessels that appear prominent on the skin surface), and need for revision of reconstruction.
Reconstruction was performed with TRAM flap in 37 patients, TE in 25 patients, LD flap in 4 patients, and a combination of TE and LD in 7 patients. Cosmesis before and after radiation did not differ significantly between reconstruction types. Radiation techniques did not correlate with cosmetic outcome either.
Median * time from reconstruction to radiation therapy (RT) was 7.6 months (range 2 months – 14 years), and time to reconstruction was not correlated with cosmetic outcome or rate of reconstruction revisions. Revisions of breast reconstruction were performed for 9 patients before beginning RT. Of these, 3 had infection, 3 had skin necrosis, 3 had capsular contracture, and 1 had poor cosmesis. Revisions of breast reconstruction were performed for 13 patients after completion of RT. Of these, 2 had infection, 1 had skin necrosis, 1 had implant leakage, and 9 had poor cosmesis. TRAM flap was less likely than TE to require revision after RT (9% versus 35%).
There was a trend towards those women receiving chemotherapy requiring more revisions, but this was not statistically significant. High blood pressure (hypertension), diabetes, alcohol use, and smoking did not correlate with cosmetic outcomes or revision rates. All women experienced skin burn during RT, but this did not correlate with cosmetic outcome or revision rates.
Based on the results of this study, most women who undergo RT after breast reconstruction have good or excellent cosmetic results at the completion of treatment. Patients who received chemotherapy were more likely to require revision, and were less likely to have good or excellent cosmetic results. This may be due to the impact of chemotherapy itself, but may also reflect the fact that patients with larger breast cancers and perhaps more extensive axillary surgical treatment (lymph node dissection) had worse cosmetic outcomes and required chemotherapy.
Patients may be advised that need for revision of reconstruction might be slightly higher for patients who undergo reconstruction with TE versus those who have a TRAM flap reconstruction, and that the need for chemotherapy may impact on ultimate cosmetic outcome. However, other factors, including radiation technique, time to radiation, acute radiation toxicity, and associated patient health issues, do not appear to affect cosmetic or reconstructive outcomes. This data demonstrates that patients and physicians should for the most part make treatment decisions independently of the details of reconstruction, as the majority of patients do achieve good or excellent cosmetic results following PMRT after breast reconstruction.
* The median is the "middle of the pack", where half of the patients have had more years since treatment and half have less. For instance, if the patients were 2, 4, 6, 10.8, 12, 12 and 14 years since treatment, 10.8 is the mid point, or the median. It is different from the mean, which would be the average time since treatment.
Partially funded by an unrestricted educational grant from Bristol-Myers Squibb.