Monday, July 20, 2009

The Impact of Partial Breast Reconstruction on Postoperative Cancer Surveillance – an Article Review

Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active. and it was easier than checking each one. 

I wanted to share this article (1st reference below) with you.  I feel it is important as we continue to improve the treatment of breast cancer.  Our surgical treatments can change the surveillance.
The authors begin their article by pointing out breast conservation therapy has grown in popularity and scope.  In saving the majority of the breast tissue, some of the reconstructive procedures significantly alter the architecture of the breasts.  How does this affect surveillance postoperatively?  The article’s stated purpose was to look at this question.
The purpose of this review was to evaluate long-term postoperative cancer surveillance techniques in a group of patients with breast cancer who underwent partial breast reconstruction using reduction techniques. We were interested in determining whether mammographic screening remained a sensitive tool following oncoplastic reduction and whether the observed changes and diagnostic testing differed in this patient group.
We hypothesized that patients undergoing the reduction techniques might have additional qualitative mammographic changes compared with patients undergoing breast conservation therapy alone, with longer time to stability.
We further hypothesized that the mammographic changes and clinical concerns in the oncoplastic group would result in more diagnostic testing (mammograms, ultrasound, and magnetic resonance imaging) and in the need for additional tissue sampling events.

The authors did a retrospective look at charts of all patients who underwent partial breast reconstruction using reduction techniques (breast conservation therapy with reduction) at Emory University Hospital before 2004.   Their control group (breast conservation therapy alone) included women who underwent breast conservation therapy without reconstruction during the same time period.  Data points included follow-up and the number and type of breast-imaging techniques (mammogram, ultrasound, or magnetic resonance imaging).  They found 34 patients who met their criteria, 17 in each group. 
The average age in the control group was 61 years (range, 44 to 81 years).   Most in this group had diagnosis of either infiltrating ductal carcinoma or infiltrating ductal carcinoma and ductal carcinoma-in-situ. Four in this group had positive lymph nodes.  The average weight of the biopsy specimen was 71 gm.
The average age in the reconstructive group was 52 years (range, 38 to 72 years).  Two in this group had positive lymph nodes. The average weight of the biopsy specimen was 291 gm. 
Negative margins were established in all patients before radiation therapy. All patients underwent postoperative radiation therapy.  Average follow-up time was 5.9 years in the control group and 6.3 years in the study group.  The local recurrence rate in each group was 6 percent (one of 17). 

The available tools for postoperative cancer surveillance include (1) physical examination, (2) radiological imaging, and (3) tissue sampling. When local recurrence is detected, it is usually in the form of a mass, calcifications, or both.
Tumor recurrence is typically found at the lumpectomy bed (true recurrence), adjacent to it (marginal miss), or elsewhere in the treated breast.  The greatest emphasis on surveillance is in the first 5 years, as this is when the risk of recurrence is the highest; however, the risk does persist.

When breast reduction techniques are used in reconstruction, there is the potential for  additional scarring, epidermal inclusion cysts, and fat necrosis.  All these may make surveillance potentially more difficult.  In addition, breast reduction surgery displaced breast parenchyma from it’s original location. 

The authors make the point that currently there is no consensus regarding appropriate radiographic imaging protocols following oncoplastic procedures.
The main objectives are to (1) exclude residual disease, (2) rule out recurrence, (3) establish a new baseline, and (4) evaluate for metachronous disease, while minimizing misinterpretation.
Mammography following breast conservation therapy has been shown to be sensitive in about 55 to 68 percent of breast conservation patients.  Mendelson followed the mammographic changes over time following breast conservation, with the most frequent findings being skin thickening and breast edema in almost 100 percent of patients.
Other findings at 6 months after treatment include scarring and fibrosis (50 percent), fluid collections/seromas (40 percent), and dystrophic calcifications (10 percent). Skin thickening, edema, and seromas did tend to resolve with time and likely represent the changes associated with radiation dermatitis. These conditions will often peak at about 6 months after radiation therapy and resolve over 2 to 3 years in most patients.

The authors noted that it takes longer to achieve mamographic stabilization in the study group.
Since the 95 percent confidence interval for stability in the oncoplastic group was 20.5 to 30.7 months, we believe that, based on these data, biannual mammographic screening should be extended until the third postoperative year in patients who undergo partial breast reconstruction to confirm stability, and that it should be performed on an annual basis thereafter.
Accurate interpretation of postoperative images requires familiarity with these temporal changes following partial breast reconstruction. Establishing a new baseline is important and will avoid unnecessary biopsies, because many of the posttreatment mammographic findings can mimic radiographic signs of malignancy.

Even though the study is retrospective and small, it is heartening to see that with good radiologists who are aware of the surgical breast changes, surveillance and detection is possible.  Surgeons and patients can feel assured that the reconstruction procedure is not hampering follow up care.

The Impact of Partial Breast Reconstruction Using Reduction Techniques on Postoperative Cancer Surveillance; Plast Reconstr Surg. July 2009 - Volume 124 - Issue 1 - pp 9-17; Losken, Albert M.D.; Schaefer, Timothy G. M.D.; Newell, Mary M.D.; Styblo, Toncred M. M.D.
Management Algorithm and Outcome Evaluation of Partial Mastectomy Defects Treated Using Reduction or Mastopexy Techniques;  Ann Plast Surg. 2007;3:235; Losken A, Styblo TM, Carlson GW, Jones G, Amerson B.
Critical Analysis of Reduction Mammaplasty Techniques in Combination with Conservative Breast Surgery for Early Breast Cancer Treatment;  Plast Reconstr Surg. 2006;117:1091-1103; Munhoz AM, Montag E, Arruda E, et al.

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