This article by Karanas and colleagues addresses
the increasingly important topic of the
treatment of breast cancer among previously
augmented women. This study reviewed the
outcomes for 58 augmented patients with
breast cancer who were treated between 1991
and 2001. Just over one-half of the patients (30
patients) were treated with mastectomy. Of
those patients, 29 underwent breast reconstruction.
The authors did not focus on the
mastectomy/reconstruction group. However,
there is little reason to think that implants
would interfere with mastectomy and/or breast
reconstruction. In fact, it is conceivable that
previous breast augmentation might even facilitate
reconstruction, because the mastectomy
flaps have been surgically “delayed” to some
extent.
The focus of this article was on augmented
patients with breast cancer who underwent
breast conservation therapy. It has been established
that breast conservation therapy can be
effectively administered to patients with implants.
1–3 However, there are conflicting data
with regard to the cosmetic outcomes and complication
rates in these cases. Some authors
have noted that patients with implants who
undergo radiotherapy enjoy good cosmetic results,
4–6 whereas others have observed high
rates of contracture and poor cosmetic
results.7–9
Among the 28 patients in this study who
chose breast conservation therapy, some underwent
implant removal at the time of
lumpectomy and some did not complete the
full course of radiotherapy. However, a total of
19 patients completed breast conservation
therapy with their implants in place. Among
this group, a large proportion (58 percent)
experienced significant complications related
to radiotherapy. These complications included
capsular contracture, poor cosmesis, pain, erosion,
an intractable seroma, and rupture.
The relatively poor outcomes observed for
these augmented patients who underwent
breast conservation therapy confirm findings
previously reported by our group 9,10 and others.
In 1996, we reported on the use of breast
conservation therapy for 33 augmented patients
with cancer.10 Complete follow-up data
were available for 26 of those patients. Most of
those patients experienced poor cosmetic outcomes,
and the majority (65 percent) developed
clinically significant capsular contracture
on the irradiated side. A large proportion
(>30 percent) of our augmented patients who
underwent breast conservation therapy required
surgical revisions. Some required multiple
attempts at capsulotomy/capsulectomy
and reimplantation, in efforts to achieve satisfactory
results.
The current study adds to the growing body
of literature suggesting that complications are
frequent and cosmetic outcomes are suboptimal
when previously augmented patients with
breast cancer undergo breast conservation
therapy. However, it is important to remember
that cosmetic results following breast conservation
therapy are very “technique dependent”
(for both augmented and nonaugmented patients).
The authors provided no details with
regard to the radio therapeutic techniques
used in these cases, stating that “data regarding
the exact dosages and fields of irradiation were
incomplete.” It is difficult to understand why
treatment details were unavailable, because the
authors claimed that they reviewed the records
of the Revlon/UCLA Breast Center and medical
records from other institutions. Because of
the importance of technique, studies evaluating
outcomes following breast conservation
therapy must consider the doses and fractions
of radiation administered, the number of treatments
given to each patient, and the total
whole-breast doses. It is also important to consider
details regarding the boost to the tumor
excision site, such as whether it was administered
with orthovoltage, photons, or iridium
implants. The lack of detailed treatment information
makes it difficult to draw firm conclusions
from this study with regard to the appropriateness
of breast conservation therapy
among augmented patients. It also makes it
difficult to compare the results presented here
with those of other published series.
Of the augmented patients in this study who
chose breast conservation therapy, five had
stage III disease and four had stage IV disease;
it is likely that these patients received adjuvant
chemotherapy, but the authors make no mention
of how many patients received adjuvant
chemotherapy or whether this had any effect
on the likelihood of developing contracture or
other complications. This information would
be interesting and is relevant because of the
increased toxicity associated with the combination
of radiotherapy and chemotherapy.
As the authors point out, there are other
concerns (beyond poor cosmesis) with regard
to the use of breast conservation therapy
among augmented patients. The local recurrence
rate following breast cancer radiotherapy
is approximately 1 percent per year.11 Local
recurrences are highly treatable (usually
with salvage mastectomy). The most important
method for the identification of recurrent cancers
is careful follow-up mammography. Many
clinical studies have suggested that breast implants
can interfere with mammographic observation
of breast tissue, possibly compromising
early detection of small tumors.12–14 This is
particularly true among patients who develop
significant capsular contracture.15 Because of
the importance of mammography in the detection
of local recurrences, it is crucial to avoid
compromising mammographic capabilities
among these patients. Because the majority of
augmented patients with breast cancer who
undergo radiotherapy seem to develop capsular
contracture, breast conservation therapy
might be relatively contraindicated for this
group, because of its adverse effects on
mammography.
It is also worth remembering that patients
who are diagnosed with breast cancer are at
increased risk of developing a second primary
tumor in the contralateral breast. Again, because
of the importance of screening mammography
in the early detection of breast cancer,
consideration must be given to the
potential adverse consequences of retaining
the implants, not only on the side with cancer
but also on the contralateral side.
There are many factors to consider when
counseling breast cancer patients with regard
to treatment options. As this study suggests,
there is growing evidence that the presence of
an implant might be a significant factor affecting
outcomes, particularly among patients who
choose breast conservation therapy. Plastic surgeons
and others who treat patients with breast
cancer must know as much as possible about
the effects of implants on breast cancer diagnosis
and treatment. Karanas and colleagues
contribute additional information on this important
subject.
REFERENCES
1. Ryu, J., Yahalom, J., Shank, B., et al. Radiation therapy
after breast augmentation or reconstruction in early
or recurrent breast cancer. Cancer 66: 844, 1990.
2. Shedbalkar, A. R., Devata, A., and Padanilam, T. A study
of effects of radiation on silicone prostheses. Plast.
Reconstr. Surg. 65: 805, 1980.
3. Kuske, R. R., Schuster, R., Klein, E., et al. Radiotherapy
and breast reconstruction: Clinical results and dosimetry.
Int. J. Radiat. Oncol. Biol. Phys. 21: 339, 1991.
4. Victor, S. J., Brown, D. M., Horwitz, E. M., et al. Treatment
outcome with radiation therapy after breast augmentation
or reconstruction in patients with primary
breast carcinoma. Cancer 82: 1303, 1998.
5. Der Hagopian, R. P., Zaworski, R. E., Sugarbaker, E. V.,
and Ketcham, A. S. Management of locally recurrent
breast cancer adjacent to prosthetic implants. Am. J.
Surg. 141: 590, 1981.
6. Jacobson, G. M., Sause, W. T., Thompson, J. W., and
Plenk, H. P. Breast irradiation following silicone gel
implants. Int. J. Radiat. Oncol. Biol. Phys. 12: 835, 1986.
7. Halpern, J., McNeese, M. D., Kroll, S. S., and Ellerbroek,
N. Irradiation of prosthetically augmented breasts:
A retrospective study on toxicity and cosmetic results.
Int. J. Radiat. Oncol. Biol. Phys. 18: 189, 1990.
8. Mark, R. J., Zimmerman, R. P., and Greif, J. M. Capsular
contracture after lumpectomy radiation therapy in
patients who have undergone uncomplicated bilateral
augmentation mammaplasty. Radiology 200: 621, 1996.
9. Handel, N., Lewinsky, B., Silverstein, M. J., et al. Conservation
therapy for breast cancer following augmentation
mammaplasty. Plast. Reconstr. Surg. 87: 873,
1991.
10. Handel, N., Lewinsky, B., Jensen, J. A., and Silverstein,
M. J. Breast conservation therapy after augmentation
mammaplasty: It is appropriate? Plast. Reconstr.
Surg. 98: 1216, 1996.
11. Grundfest-Broniatowski, G., Hermann, R. E., and Esselstyn,
C. B. Conservative surgery for carcinoma of the
breast: The Clinic experience. In H. H.
Bohmert and I. Leis Jackson (Eds.), Breast Cancer: Conservative
and Reconstructive Surgery: Thieme-
Verlag, 1989.
12. Hayes, H., Jr., Vandergrift, J., and Diner, W. C. Mammography
13. Gumucio, C. A., Pin, P., Young, V. L., et al. The effect
of breast implants on the radiographic detection of
microcalcification and soft-tissue masses. Plast. Reconstr.
Surg. 84: 772, 1989.
14. Silverstein, M. J., Handel, N., Gamagami, P., et al. Mammographic
measurements before and after augmentation
mammaplasty. Plast. Reconstr. Surg. 86: 1126, 1990.
15. Handel, N., Silverstein, M. J., Gamagami, P., et al. Factors
affecting mammographic visualization of the
breast after augmentation mammaplasty. J.A.M.A.
268: 1913, 1992.