B2 Augmented or Reconstructed Breast Appearance

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Breast cancer patients who receive radiation to an augmented breast following lumpec-tomy or a reconstructed breast following mastectomy have a higher risk of cosmetic failure.

Augmentation

Breast augmentation preceding the diagnosis and treatment of a breast cancer can create a clinical conundrum. The appearance of the breasts is, typically, particularly important in this patient group; yet, their risk for cosmetic failure following breast conservation therapy is higher in some studies. Table 9 lists the rate of excellent or good cosmetic results in multiple studies demonstrating a wide range of outcomes.58-63 Three studies demonstrate acceptable rates of 85-100% excellent/good cosmesis, but in the other 3, only 27-45% of patients achieved this result. Fairly uniform radiation techniques were used among these studies with the augmented breast receiving on average a range of 45-50 Gy with cobalt, 4 or 6 MV photons and subsequent boosts of 10-20 Gy delivered in most cases. The primary cause of cosmetic failure in irradiated augmented breasts is capsular contracture, which has been demonstrated to occur in 57-65% of cases.59-62 The average time interval for onset of capsular contracture was reported at 22 weeks.62 Mark et al. reported that the capsular contracture seemed related to the type of the implant (silicone 64% and saline 40%) and was more likely with sub-muscular (64%)

Table 9. Cosmetic outcome following lumpectomy and breast irradiation in women with previous breast augmentation

Mean follow-up % Excellent/good or % Bakers

Institution (author) N (mo.s) 1-2* cosmetic outcome

Beaumont (Victor)56 8 32 1 00

Van Nuys (Handel)59 26 NA 27*

John Wayne Cancer 20 45 85 Institute (Guenther)63

*66% ultimate after one patient had surgical revision for capsular contracture. NA means not available.

versus sub-glandular (50%) placement.62 Baker's classification provides an assessment of capsular contracture. Baker I is a soft breast or implant with no deformity, II—the implant has a slightly thickened consistency with slight deformation, III—the implant is firm to hard and moderate deformity of the breast is noted, and IV—the implant is hard and there is severe breast deformity. There is an inherent risk of capsular contracture from breast implants in general unrelated to radiation. The overall incidence of capsular contracture after cosmetic breast augmentation with implants is 12% and is significantly greater for breast reconstruction following mastectomy for cancer treatment (34%) or cancer prophylaxis (30%).64

Surgical revision can improve the cosmetic outcome from capsular contracture in an augmented breast in some cases. At Memorial Sloan Kettering, Ryu reported that 2 patients underwent surgical revision with a subsequent excellent result.60 Eight patients in the Van Nuys experience underwent revision surgeries after capsular contracture. Five patients had a capsulectomy and a new implant placed and 4 (80%) subsequently had an excellent cosmetic outcome.59

Reconstruction

An increasing percentage of breast cancer patients who are ineligible for breast conserving therapy or who have more locally advanced breast cancer are seeking reconstruction of the breast following mastectomy.65 The options for breast reconstruction are tissue expansion with subsequent prosthetic implant placement or autologous tissue reconstruction. Immediate breast reconstruction during the same surgical period as the mastectomy provides the psychological benefit of waking-up post-procedure with a breast mound in place. However, a dilemma has emerged in that there is clinical evidence that breast reconstructions that undergo radiation have a higher risk of cosmetic failure,58-62'66-71 while even a larger percentage of mastectomy patients may now be considered candidates for treatment since publication of a survival advantage in a subset of women who receive post-mastectomy RT.72'73

Table 10 lists the cosmetic outcome from immediate expander/implant breast reconstruction that underwent a course of post-mastectomy irradiation. In three of these studies, there was a low rate of acceptable cosmetic outcome.58'60'66 The radiation treatment was similar in these studies with the chest wall/reconstructed breast receiving

Table 10. Cosmetic outcome following mastectomy with implant reconstruction and subsequent irradiation for primary or recurrent breast cancer

Mean follow-up % Excellent/good cosmetic Institution (author) N Cancer (months) outcome

Beaumont (Victor) 58 13 Primary 32 54

Cornell (Chu)61 27 Recurrent 30 93

Washington U. (Kuske)66 6 5 68% Primary 48 45

Memorial SK (Ryu)60 11 Recurrent 24 56 Memorial SK (Cordeiro)67

RT 68 Primary 34 80

on average of 50 Gy with cobalt, 4 or 6 MV photons, standard fractionation, and an electron boost to the chest wall was used for many. A similar radiation technique was used at MD Anderson Cancer Center for 12 patients, 6 post-mastectomy with implant reconstruction, and 6 cancers arising in a previously augmented breast.68 Comparable results were noted with no excellent, 33% good, and 42% poor cosmetic outcomes. In two studies,58'66 the use of bolus application during radiation was associated with a significantly worse cosmetic outcome. At Beaumont Hospital,58 87% of patients who were treated without bolus application had a good to excellent result compared to 37% who were treated with bolus application (P = 0.016). Similarly, Kuske et al.66 from Washington University reported that the use of a bolus layer was the only radiotherapy factor found to influence cosmetic results: 81% of patients with no bolus had an excellent/good cosmetic result versus 37% of patients for whom bolus was used during radiation (P = 0.003). In this study, the use ofbolus also resulted in a higher complication rate (51% vs. 23%, P = 0.048). The use of compensators or wedges was associated with a lower complication rate but did not have a significant effect on cosmesis. Eight of 70 reconstructed breasts in this study were treated without a compensator or wedge and all of these patients experienced complications (P = 0.036).

Two studies in Table 10 reported a high rate of acceptable cosmetic outcome from irradiation of expander/implant reconstructions.61'67 Chu et al. from New York Hospital, Cornell University Medical Center, reported a 93% excellent/good and 7% fair/poor cosmetic result in 27 patients with recurrent breast cancer 1 month to 10 years following mastectomy and silicone implant reconstruction.61 Nine patients in this study received "wide-local field technique" and were not treated to the entire reconstructed breast.

The other study with acceptable cosmetic results was recently reported from Memorial Sloan Kettering and looked at 687 breast cancer patients who underwent immediate tissue expander/implant reconstruction following mastectomy.67 At this institution, patients underwent mastectomy with placement of the tissue expander. Tissue expansion was continued during chemotherapy; and then 4 weeks following the completion of chemotherapy, the tissue expander was exchanged for the permanent implant. Post-mastectomy radiation began 4 weeks after this exchange. Eleven percent of 81 irradiated implants were subsequently removed versus 6% of 542 non-irradiated cases. The ultimate success rate for implant reconstruction was 90% versus 99% for irradiated and non-irradiated cases, respectively (P = 0.001). The 81 irradiated cases were matched to 75 non-irradiated control cases. There was an 80% excellent/good cosmetic result after post-mastectomy radiation that was not statistically different from the 88% noted in the non-irradiated cases.67 Non-irradiated cases did have a higher rate of very-good/excellent cosmetic result. Overall, 68% of the irradiated patients developed a capsular contracture compared with 40% of those non-irradiated (P = 0.006). Irradiated patients were more likely to develop a Baker's grade III contracture (33.3% vs. 9.3%), but there was no significant increase in grade IV or severe contracture. Sixty-seven percent of irradiated patients were satisfied with their reconstructions and 72% stated that they would choose the same form of reconstruction again. The authors concluded that although irradiation increased the incidence of implant complication and contracture, the rates of reconstructive success and patient satisfaction remained high.

The long-term cosmetic consequences of irradiation following an autologous breast reconstruction have been contradictory. Kuske et al. reported that cosmetic results in 8 patients who underwent PMR after immediate transverse rectus abdominis myocu-taneous (TRAM) flap reconstruction were good/excellent in 87% despite a 63% complication rate.66 Similarly, a study by Zimmerman et al. from UCLA, reported 90% patient-rated good/excellent cosmesis in 21 patients who underwent radiation following immediate free TRAM flap breast reconstruction and had a mean follow-up interval of 19 months.69 Other series have demonstrated worse complication rates from radiation after TRAM flap reconstruction.71 This inconsistency is illustrated by two reports with similar outcomes but different conclusions. Nineteen patients who received radiation after pedicled TRAM flap reconstruction were compared to 108 patients who underwent radiation prior to a similar reconstruction at Emory University.70 Thirteen or 68% of the 19 cases irradiated post-TRAM reconstruction had local recurrence of cancer requiring radiation. There was no significant difference in the rate of complication for an irradiated TRAM (31%) versus radiation pre-TRAM (25%) flap reconstruction. There was a 17% complication rate for 572 non-irradiated TRAM flap reconstructions at the institution overall. The authors concluded that the complication rate does not change whether a patient receives radiation before or after her TRAM flap reconstruction, only the nature of the complication changes (fat necrosis instead of fibrosis). A similar retrospective study from MD Anderson Cancer Hospital also compared the complication rate for post-mastectomy radiation after (n = 32) and before (n = 70) free TRAM flap breast reconstruction.71 The delayed reconstruction was performed an average of 43 months post-completion of radiation. There was no difference in the rates of early complications (vessel thrombosis, partial flap loss, total flap loss, and mastectomy flap necrosis) between the two groups. There were significantly more late complications (fat necrosis 43.8%, flaps with volume loss 87.5%, and flaps with contracture 75%) in the immediate reconstruction group compared to the group that underwent reconstruction after completion of radiation (fat necrosis 8.6%, flaps with volume loss 0%, and flaps with contracture 0%). Twenty-eight percent of the 32 flaps that were irradiated required additional flap or an external prosthesis to correct the volume loss. On the basis of this experience, the authors concluded that patients who are candidates for free TRAM flap breast reconstruction and need post-mastectomy radiation, reconstruction should be delayed until radiation therapy is complete. Unfortunately, neither of these studies provided physician- or patient-rated cosmetic data or patient satisfaction scores.

An interesting study from the Michigan Breast Reconstruction Outcome Study evaluated factors that influenced complication rates in a prospective cohort of 326 women who underwent breast reconstruction after mastectomy from 1994 to 1998. Twenty-three plastic surgeons from 12 centers in Michigan, Pennsylvania, Louisiana, and Ontario contributed patients to the survey.74 Sixty-four percent were immediate reconstructions and 24% were expander/implant, 55% were pedicle tram flap, and 21% were free TRAM flap reconstructions. No significant differences were observed across procedure types with regard to patient demographics or comorbidities. Complication data were collected 2 years after reconstruction. Overall, there were no complications in 54.6%, 1 complication in 29.1%, and 2 complications in 16.3%. Twenty-three percent had one major complication, and 8% had 2-3. Multivariate analysis to assess the effect of reconstruction type and timing while controlling for patient age, body mass index, smoking, chemotherapy, and radiation demonstrated that only immediate reconstruction and body mass index were significantly associated with higher total complication rates. For TRAM flap reconstructions, the major complication rates were 36% in the immediate group and 18% in the delayed group (P = 0.002). Trends for higher complication rates were noted with radiation therapy and chemotherapy in separate analyses. Radiation before or after surgery for an expander/implant reconstruction was associated with higher overall complication (P = 0.08) and major complication (P = 0.07) rates. Chemotherapy was associated with significantly higher major complications in TRAM flap procedures (P = 0.03).

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