Babak J. Mehrara, MD
Chier, Plastic and Reconstructive
Peter G. Cordeiro Endowed Chair in Plastic and Reconstructive Surgery
Memorial Sloan Kettering Cancer Center
New York, New York
Radiation can have major deleterious effects on the cosmetic outcomes of reconstructive procedures.1
As a result, the timing of reconstruction in women who may require postmastectomy radiotherapy (PMRT) is a heavily debated topic. Now, emerging evidence shows that immediate autologous breast reconstruction can tolerate radiotherapy better than previously thought in select cases.
Some surgeons consider PMRT to be a relative contraindication to immediate reconstruction and advise women to undergo mastectomy, PMRT, and then reconstruction 6 to 12 months later. Increasingly, however, other surgeons take into consideration the psychological and technical benefits of immediate reconstruction and recommend it, recognizing that outcomes in these women may be suboptimal although still equivalent or superior to delayed reconstruction.
In a recent paper published in the Lancet Oncology in December 2017,1
colleagues from Memorial Sloan Kettering Cancer Center (MSK) and 3 other academic cancer centers collaborated to summarize the challenges, controversies, and latest evidence on the optimal approaches for integrating postmastectomy radiotherapy with breast reconstruction.
The rates of immediate reconstruction have steadily increased over the period from 2001, with bigger jumps in the past 5 years. Whereas only 15% of women who underwent mastectomy had immediate reconstruction in 2011, this number has increased to about 40% in 2018.2-4
This is important because immediate reconstruction can offset the psychosocial and physical consequences of mastectomy. In addition, immediate reconstruction is technically easier to perform than delayed reconstruction due to decreased scarring and preservation of the breast contours.
These reconstructive trends have coincided with the increasing use of postmastectomy radiotherapy in women with locally advanced breast cancer.4
In our study, we found a wide spectrum of choices for the type of reconstruction and timing of procedures. One of the most significant insights was the emerging evidence that in select cases, immediate autologous reconstruction can tolerate radiotherapy better than previously thought. We also found that the timing of radiation treatment for patients who have implant reconstruction does not significantly affect the final outcome and should be individualized depending on clinical and other factors.1
Temporary Implants in Women Who May Need Radiation
In some women, it is unclear whether they will require PMRT until their mastectomy and lymph node sampling are performed. This is a reconstructive dilemma, because it is difficult to provide adequate counseling regarding the potential effects of PMRT on cosmetic outcomes. In some cases, using temporary implants (tissue expanders) is helpful because it enables the plastic surgeon to preserve the breast skin and contours after mastectomy while awaiting the decision for PMRT following review of the pathology results. This approach preserves the woman’s choice to undergo implant or autologous reconstruction and facilitates delivery of PMRT.
Autologous Reconstruction and PMRT Timing
Historically, most surgeons have not recommended autologous tissue reconstruction in patients who will require PMRT. This position stems from a 2001 study that found higher rates of fat necrosis and volume in women who underwent immediate reconstruction with autologous tissues followed by subsequent treatment with PMRT.5
However, later evidence in a 2014 systematic review found that autologous reconstruction results in acceptable outcomes in select patients who undergo PMRT following reconstruction.6
These authors suggested that immediate reconstruction with autologous tissue is a viable approach in women who have adequate tissue to compensate for the shrinkage that may occur following PMRT.