Reconstruction after mastectomy and radiation; when are the right times for each?

Reconstruction after mastectomy and radiation; when are the right times for each?

An increasing number of women are undergoing mastectomy as a treatment for breast cancer or as a means of prevention. After breast cancer patients receive a mastectomy, a partial or full removal of the breast, often radiation therapy is required. Half of these women that go through the post or pre mastectomy radiation develop other complications, complications that place the patients back in the operating room much later for reconstructive procedures. However, the September issue of Archives of Surgery published by JAMA reports that radiation treatments do not seem related to the need for additional procedures pre or post mastectomy.

Studies suggest immediate reconstruction is safe and has potential psychological and aesthetic benefits. Today, many treatment facilities now offer the option of having breast reconstruction at the same time as mastectomy when previously; women went through a three step process: mastectomy, radiation/chemotherapy, reconstruction.

Dara Christante, M.D., and colleagues at Oregon Health & Science University Knight Cancer Institute, Portland, studied stage one, two and three patients to further examine the parameters of their studies. Between 2000 and 2008, 302 women were treated and identified via an institutional cancer registry. Of these, 152 had breast reconstructions, including 131 that were immediate post removal surgery.

The study found that:

Postmastectomy irradiation and immediate breast reconstruction were each indentified as strong independent predictors of complications. Postmastectomy irradiation tripled the risk for an unplanned return to the operating room and immediate breast reconstruction increased that risk eight-fold. The combination of immediate breast reconstruction and postmastectomy irradiation resulted in nearly one of two patients returning to the operating room with complications compared with 7 percent of patients who received postmastectomy irradiation but did not undergo reconstruction.

In most cases, reconstruction of the breasts right after mastectomy is avoided. However, Christante's study found that 20% who were considered low-risk enough to have immediate reconstruction actually required radiation exposure, after final reporting.

The authors continue:

Therefore, predicting postmastectomy irradiation more accurately would permit avoidance of immediate breast reconstruction and its postmastectomy irradiation-associated complications, potentially decreasing the rate of unplanned operations. Conversely, some women are unnecessarily directed away from immediate breast reconstruction because of an overestimation of their risk for postmastectomy irradiation. In this series, 12 of 22 patients (55%) who underwent delayed reconstruction did not undergo postmastectomy irradiation.

To be able to accurately prescribe radiation postmastectomy, knowing lymph node functional status is helpful. A sentinel lymph node biopsy (SLN) performed prior to mastectomy is recommended.

To this point:

Patients with a negative sentinel lymph node would be reassured that their risk with immediate breast reconstruction is low. Patients with a positive sentinel lymph node would be identified as having a higher, quantifiable risk of meeting postmastectomy irradiation indications.

In a follow up study, Anne Warren Peled, M.D., and colleagues at Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, followed 98 women that underwent chemotherapy either before or after their mastectomies 2005-2008. Fifty seven received chemotherapy before their surgery and 41 received chemotherapy afterwards, and all were followed for an average of 19.2 months to monitor potential side effects and complications.

It was found that 31% of patients had a complication requiring a return to the O.R. Interesting enough, this report was not based on when irradiation took place, before surgery, after or not at all.

Peled concludes:

Although systemic chemotherapy has been thought to increase wound-related complications, our study demonstrates that risk of non-infectious postoperative complications is not increased after mastectomy and immediate breast reconstruction among women who receive chemotherapy. Additionally, the timing of chemotherapy in relation to mastectomy did not have a significant impact on surgical outcomes. However, the wound infection rate was significantly higher in patients who had received adjuvant [postoperative] chemotherapy and in some cases resulted in delay of chemotherapy.

The final verdict? The UCSF doctor states:

These results suggest a possible benefit for pre-operative administration of chemotherapy in those patients who require chemotherapy, even in women who will undergo mastectomy, and they support the use of immediate reconstruction in this patient population.

"Using Complications Associated With Postmastectomy Radiation and Immediate Breast Reconstruction to Improve Surgical Decision Making"

Dara Christante, MD; SuEllen J. Pommier, PhD; Brian S. Diggs, PhD; Bethany T. Samuelson, BA; AiLien Truong, BS; Carol Marquez, MD; Juliana Hansen, MD; Arpana M. Naik, MD; John T. Vetto, MD; Rodney F. Pommier, MD

Arch Surg. 2010;145(9):873-878. doi:10.1001/archsurg.2010.170

Breast Reconstruction Surgery after Mastectomy: TRAM, DIEP, SIEA flaps. (Video Medical And Professional 2020).

Section Issues On Medicine: Women health