PMRT can improve survival and local-regional control in selected patients with invasive breast cancer treated with mastectomy and systemic therapy. Local-regional and survival benefits of PMRT for patients with lymph node-positive disease. Survival advantage associated with PMRT was evident both for patients with 1-3 positive lymph nodes and those with 4 or more positive lymph nodes. Accordingly, the use of PMRT for patients with stage II breast cancer is increasing
Current Role of Reconstruction With a Latissimus Dorsi FlapStudies evaluating the outcomes of 2-stage breast reconstruction (placement of a tissue expander followed by placement of a permanent breast implant after PMRT) consistently reveal high rates of acute and chronic complications and poor aesthetic outcomes.Capsular contracture that results from PMRT can distort the appearance of the breast and cause potentially significant chronic chest wall pain and tightness.Many surgeons attribute the poor outcomes with implant-based breast reconstruction to older, less precise techniques of radiation delivery. However, even with modern radiation delivery techniques, complication rates with implant-based reconstruction are high.In addition, fibrotic changes around breast implants associated with PMRT can continue to evolve years after treatment; early results of new techniques often underestimate the true incidence of complications.
Effect of Immediate Implant-Based Breast Reconstruction on Radiation Treatment Field DesignEvans and colleagues found that the addition of the tissue flap -- either a transverse rectus abdominis myocutaneous (TRAM) flap or a latissimus dorsi myocutaneous flap -- did not appear to protect against capsular contracture, a common complication of PMRT.…………………………………………………………….In 2007, Spear and colleagues concluded that in patients with unsatisfactory outcomes after 2-stage implant-based reconstruction as a result of the adverse effects of radiation, breast contour can be improved by adding a latissimus dorsi flap, generally to the inferior pole of the breast.
This is something that truly needs to be considered in woman who need or may need post-mastectomy radiation therapy. The article has some nice visuals that help explain the physics for those interested.Not only can PMRT adversely affect the aesthetic outcome of immediate implant-based breast reconstruction, but there is increasing evidence that such reconstructions may interfere with the delivery of PMRT.Chest wall treatment in patients who have undergone reconstruction must be accomplished by using traditional, 2-beam tangential fields alone rather than the modern, 3-beam technique. As mentioned, this can deliver potentially harmful doses of radiation to the heart or lung.
Autologous Tissue Breast Reconstruction in Patients Receiving PMRT
Although the consensus in the literature is that autologous tissue is preferable to breast implants within an irradiated operative field, autologous tissue reconstructions may also be adversely affected by PMRT.However, autologous tissue reconstructions can interfere with the radiation field design and can also lead to adverse changes in the aesthetic reconstruction outcome.
Immediate reconstruction substantially compromised treatment of the internal mammary nodes and made it less possible to use a modern, 3-beam technique with a separate medial electron beam to treat this region. In patients with right-sided reconstructions, the chest wall and internal mammary chains were treated with deeper tangential beams (traditional, 2-beam tangential beam technique) at the expense of irradiation of more lung parenchyma. In patients with left-sided reconstructions (accounting for 67% of the compromised treatment plans), the heart and lung were spared at the expense of suboptimal coverage of the chest wall and internal mammary nodes. Sixty-five percent of patients with compromised internal mammary node coverage also had compromised coverage of the chest wall and suboptimal sparing of lung and epicardial heart structures (including the left anterior descending branch). Thus, even if the internal mammary nodes had not been treated, these patients' plans would not have been optimal.
Delayed-Immediate Breast Reconstruction
Integrating Radiation Therapy and Breast Reconstruction: Which Comes First?; Medscape Article, January 30, 2009; Thomas A. Buchholz, MD, FACR; Steven J. Kronowitz, MD, FACS
Related Blog Posts
Breast Reconstruction – Part I
Breast Reconstruction – Part II