Post-Mastectomy Radiation Therapy…and Breast Reconstruction
Radiation therapy (RT) is a proven and well-accepted modality in treatment (or adjunct treatment) for breast cancer. It is almost always used following lumpectomy, as it significantly reduces the local recurrence rate.
Even following mastectomy, although a definitive procedure for the cancer, may be recommended RT following the mastectomy due to various pathologic findings. Classic indications are:
Certain (aggressive) types of tumors
Tumors 5cm or greater
4 or more positive lymph nodes
Positive (inadequate) margins on specimen
Others, and newer indications, are:
for tumors less than 5cm and 1-3 nodes (+) – include any 3 of the 4: 1-3 nodes (+), LVI, ER (-) tumors, or premenopusal or less than 40 years of age
for tumors less than 5cm and node (-) – include any 3 of the 4: margin less than 2mm, less than 40 years of age
Although a beneficial adjunct for breast cancer in several circumstances, it has also detriments to both the patient as well as plastic surgeon. Above all, treatment for cancer comes before the aesthetics of breast reconstruction, and the proven benefit outweighs the ill-effects of RT. The impact that RT has on the skin, as evidenced by the radiation dermatitis/radiation burn, angiofibrosis, contrcture/fibrosis of the skin, and soft tissue, as well as the healing/infection issues are not favorable.
From the plastic surgery standpoint, these effects are troublesome, especially when dealing with reconstruction. This should be discussed with your plastic surgeon, as it impacts the type of reconstruction you should have. Women undergoing lumpectomy are often told that most of their breast will be preserved and that radiation will be needed postoperatively. However, what is not conveyed, is that the above changes may occur and account for some of the breast asymmetry or contractures. Although a “breast conserving” therapy is performed, many women end up seeking a plastic surgeon to assist with these issues, which often times, include the same procedures as if a mastectomy was performed anyhow.
Implant-based reconstruction is not a recommended reconstructive procedure, as already noted in previous posts. The complication rates are markedly increased with often times, poor aesthetic results, let a lone the wound healing, infection, contracture/asymmetry rates, among others. This type of reconstruction usually fairs poorly following RT. There are several studies showing good results following implant-based reconstruction, however. Many times, RT is not known until final pathology returns several days later. If by chance a tissue expander reconstruction was chosen, and RT is later found to be needed for an indication above, I would opt to keep them in, quickly inflate to maximal expansion, then deflate for the RT. Immediately afterwards, quick expansion would be done (e.g., M.D. Anderson protocol). However, exchange for a flap-based reconstruction is always an option if any complications come about during this process.
Radiation after flap-based procedures are significantly better following RT. After a flap procedure (e.g., latissismus, TRAM, or DIEP flap, recruiting well-vascularized tissue from a remote area negates some of the ill-effects that RT has done. There still is a chance for the reconstructed breast to shrink or contract if followed by radiation, but it resists the effects much better than implants. Usually, performing this in a delayed fashion would allow your plastic surgeon to excise all of the affected tissue, and use the flap to reconstruct the defect. This is my preference after, or for known RT. The flap-based reconstructions (e.g., latissimus, TRAM, or notably the DIEP), are excellent options as discussed in previous posts. You may consider delaying your reconstruction for a later date if you know you will be receiving RT postoperatively.
Back to blog