Challenge of Breast Reconstruction in Patients Undergoing Radiotherapy

Timing remains an important challenge for breast reconstruction in patients undergoing radiation therapy and surgery for breast cancer, according to research discussed at the 34th Annual Miami Breast Cancer Conference, held March 9–12 in Miami Beach, Fla.

“I think that it is important to understand that this is not a uniform population,” noted Lloyd Gayle, MD, Chief, Division of Plastic Surgery, Maimonides Medical Center, in Brooklyn, NY. “Radiation therapy varies by institution, it varies by patient-there are clearly multiple factors that govern who is an appropriate candidate for reconstruction. […] Inter-institutional variability in radiation therapy delivery must be considered when evaluating results of reconstruction in the setting of radiation therapy.”

Timing is one key factor, Gayle noted; immediate reconstruction or delayed reconstruction, and the delivery of radiotherapy before or after reconstruction, can all affect patient outcomes.

Prior radiotherapy can adversely affect skin healing after mastectomy, for example. That can preclude skin-sparing mastectomy.

“Equally important is the impact surgery has on radiotherapy,” he noted. “Surgery with radiotherapy always has to be done in concert with radiation therapy planning.”

Patients with a prior history of radiotherapy adjuvant to lumpectomy who later require total mastectomy represent particularly challenging cases requiring “meticulous” planning, Gayle said.

“In the setting of either pre or postmastectomy radiation, there exists a significant risk of complication associated with the need for salvage flap revision,” for example, necessitating “careful preoperative discussions with patients,” he said. “But that does not preclude the use of implant reconstruction.”

The “evolving issue” of autologous or implant reconstruction also remains an important one, Gayle said. There is limited evidence about the optimal timing of reconstruction with expander or implants for patients who are treated with radiotherapy. There is reason to believe that expander or implant irradiation might increase the likelihood of postoperative complications, he noted.

Clinical trial follow-up periods might also be too short to definitively characterize long-term outcomes of reconstruction among patients who undergo radiotherapy.

“There is simply a paucity of data about when one should do radiation therapy relative to surgery,” Gayle noted. But despite that paucity of data, there’s “clearly been a significant uptick in the amount of reconstruction activity” in this setting, he added.

Immediate reconstruction rates in patients undergoing postmastectomy radiotherapy more than doubled between 2000 and 2010, for example, from 13.6% to 25%. During the same time, implant-only reconstruction climbed from 27% to 52% of patients and autologous tissue-only reconstruction dropped from 56% to 32%.

One study published in 2014 suggested that capsular contracture complications were more frequent in patients who underwent post than prereconstruction radiotherapy, though reconstruction completion and failure rates were comparable.

Capsular contracture can cause aesthetic problems and “significant amounts” of pain for patients, noted Gayle.

Patients receiving radiotherapy following immediate reconstruction with tissue expanders and implants expressed impressive rates of satisfaction with reconstruction, he noted (90% vs 97.5% among patients who underwent expander or implant reconstruction without radiotherapy).

For patients undergoing autologous tissue reconstruction and radiotherapy, flap shrinkage can occur, but this affects a “very small” proportion of patients.