Follow-up to Handel, N., Lewinsky, B., Silverstein, M. J., Gordon, P., and Zierk, K. Conservation therapy for
breast cancer following augmentation mammaplasty. Plast. Reconstr. Surg. 87: 873, 1991.
Breast conservation therapy consisting of lumpectomy, axillary lymph node dissection, and whole breast
irradiation is an increasingly popular alternative to mastectomy in patients with breast cancer. At many
centers, the majority of new breast cancer cases are now treated with conservation therapy.
The major reasons for the popularity of conservation therapy are that cure rates are equivalent to those of
mastectomy1-3 and cosmetic results are excellent in the majority of cases.4-6 Most patients are left with an
intact, sensate breast that does not differ significantly in appearance or consistency from its pretreatment
state.
Several years ago we became interested in studying the efficacy of conservation therapy in patients who
had undergone breast augmentation. Our interest in this subject was stimulated when we realized that as
the population of women with implants ages, increasing numbers of breast cancers will be diagnosed in
this group. It is well established that breast implants (saline or silicone gel) do not interfere with the
administration of radiation therapy.7-9 Several previous studies addressed the question of cosmetic
outcome following irradiation in the presence of implants; most concluded that cosmetic results were good
in the majority of patients.10-12
In our practice, however, we observed a number of patients who developed significant capsular contracture
following radiation treatment. This led to a review of our experience with breast conservation therapy in
augmented patients and culminated in publication of two articles on this topic.
In a study published in 1991, we reviewed our experience with 17 augmented breast cancer patients
treated with conservation therapy.13 We reported that the majority (67 percent) developed significant
capsular contracture on the irradiated side (an average of 12 weeks after completion of treatment). We
tentatively concluded that breast conservation therapy in augmented patients yields a high incidence of
contracture and unsatisfactory cosmetic results.
By 1996, we had used conservation therapy in 33 augmented cancer patients. We published our findings in
26 patients for whom complete follow-up data were available.14 This study yielded similar results; the
majority of patients (65 percent) developed significant capsular contracture on the irradiated side. A large
proportion of patients (> 30 percent) required revision surgery, and some required repeated attempts at
capsulotomy or capsulectomy and reimplantation in an effort to achieve a satisfactory outcome.
Our experience since our most recent publication has remained the same. The majority of augmented
patients treated with breast conservation therapy have unsatisfactory cosmetic results, and many require
corrective surgery to alleviate symptomatic contracture. Other researchers have made similar
observations, and there are now a number of publications that document an increased risk of contracture
following irradiation of the augmented15 and reconstructed breast.16,17 It must be acknowledged, however,
that this area remains controversial. Some investigators believe that augmented patients can undergo
radiation therapy and routinely expect good to excellent cosmetic results.18
In addition to a possible poor cosmetic outcome, there are other concerns that must be addressed when
considering the use of breast conservation therapy in augmented patients. Individuals treated with this
therapy require careful follow-up mammography to detect any early sign of local recurrence. Breast
implants may interfere with mammographic visualization of breast tissue.19,20 Our own research21,22 and
that of others23 suggest that mammography is especially compromised in women with capsular
contracture. Because of the crucial role of mammography in detecting local recurrence, it is critical to avoid
compromising mammography in women treated with breast conservation therapy.
Based on our own observations and other published data, we conclude that breast conservation therapy is
not optimal treatment in the majority of augmented cancer patients. Augmented women who are irradiated
are predisposed to contracture. The success of subsequent operations to ameliorate symptoms of
contracture is limited because of radiation damage to the tissues. Additionally, radiation significantly
increases the risk of wound healing problems and other postoperative complications in these individuals.
One option that may be recommended to augmented women diagnosed with cancer is explantation before
conservation therapy, with the expectation that the implant will not be replaced later. It would be logical in
most cases to recommend bilateral explantation, both for the sake of symmetry and to avoid any potential
interference with mammography on the opposite side (at increased risk for developing a second cancer).
Another option, of course, is mastectomy with reconstruction.
If augmented patients wish to proceed with breast conservation therapy and retain their implants, they
must be fully informed of the potential risks and side effects. These include a poor cosmetic result, the
probable need for later corrective surgery, the increased risks associated with secondary surgery on the
irradiated side, and potential interference with early mammographic detection of local recurrence.
REFERENCES
1. Montague, E. D., Ames, F. C., Schell, S. R., et al. Conservative surgery and irradiation as an alternative
to mastectomy in the treatment of clinically favorable breast cancer. Cancer 54: 2668, 1984.
2. Fisher, B., Redmond, C., and Poisson, R. Eight-year results of a randomized clinical trial comparing total
mastectomy and lumpectomy with or without irradiation in the treatment of breast cancer. N. Engl. J. Med.
320: 822, 1989.
3. Veronesi, U., Banfi, A., Salvadori, B., et al. Breast conservation is the treatment of choice in small breast
cancer: Long-term results of a randomized trial. Eur. J. Cancer 26: 668, 1990.
4. Harris, J. R., Levene, M. B., Svensson, G., and Hellman, S. Analysis of cosmetic results following
primary radiation therapy for stages I and II carcinoma of the breast. Int. J. Radiat. Oncol. Biol. Phys. 5:
257, 1979.
5. Clarke, D., Martinez, A., and Cox, R. S. Analysis of cosmetic results and complications in patients with
stage I and II breast cancer treated by biopsy and irradiation. Int. J. Radiat. Oncol. Biol. Phys. 9: 1807,
1983.
6. Rose, M. A., Olivotto, I., Cady, B., et al. Conservative surgery and radiation therapy for early breast
cancer: Long-term cosmetic results. Arch. Surg. 124: 153, 1989.
7. McGinley, P. H., Powell, W. R., and Bostwick, J. Dosimetry of a silicone breast prosthesis. Radiology
135: 223, 1980.
8. Krishnan, L., and Krishnan, E. C. Electron beam irradiation after reconstruction with silicone gel implant
in breast cancer. Am. J. Clin. Oncol. 9: 223, 1986.
9. Ryu, J., Yahalom, J., Shank, B., Chaglassian, T. A., and McCormick, B. Radiation therapy after breast
augmentation or reconstruction in early or recurrent breast cancer. Cancer 66: 844, 1990.
10. Stabile, R. J., Santoro, E., Dispaltro, F., and Sanfilippo, L. J. Reconstructive breast surgery following
mastectomy and adjunctive radiation therapy. Cancer 45: 2738, 1980.
11. Jacobson, G. M., Sause, W. T., Thomson, J. W., and Plenk, H. P. Breast irradiation following silicone
gel implants. Int. J. Radiat. Oncol. Biol. Phys. 12: 835, 1986.
12. Kuske, R. R., Schuster, R., Klein, E., Young, L., Perez, C. A., and Fineberg, B. Radiotherapy and
breast reconstruction: Clinical results and dosimetry. Int. J. Radiat. Oncol. Biol. Phys. 21: 339, 1991.
13. Handel, N., Lewinsky, B., Silverstein, M. J., Gordon, P., and Zierk, K. Conservation therapy for breast
cancer following augmentation mammaplasty. Plast. Reconstr. Surg. 87: 873, 1991.
14. Handel, N., Lewinsky, B., Jensen, J. A., and Silverstein, M. J. Breast conservation therapy after
augmentation mammaplasty: Is it appropriate? Plast. Reconstr. Surg. 98: 1216, 1996.
15. 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.
16. Rosato, R. M., and Dowden, R. V. Radiation therapy as a cause of capsular contracture. Ann. Plast.
Surg. 32: 342, 1994.
17. Evans, G. R., Schusterman, M. A., Kroll, S. S., et al. Reconstruction and the radiated breast: Is there a
role for implants? Plast. Reconstr. Surg. 96: 1111, 1995.
18. 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.
19. Gumucio, C. A., Pin, P., Young, V. L., Destouet, J., Monsees, B., and Eichling, J. The effect of breast
implants on the radiographic detection of microcalcification and soft-tissue masses. Plast. Reconstr. Surg.
84: 772, 1989.
20. Eklund, G. W., Busby, R. C., Miller, S. H., and Job, J. S. Improved imaging of the augmented breast.
A.J.R. Am. J. Roentgenol. 151: 469, 1988.
21. Handel, N., Silverstein, M. J., Gamagami, P., Jensen, J. A., and Collins, A. Factors affecting
mammographic visualization of the breast after augmentation mammaplasty. J.A.M.A. 268: 1913, 1992.
22. Handel, N., Silverstein, M. J., and Gamagami, P. The effect of breast implants on mammography and
cancer detection. Perspect. Plast. Surg. 7: 1, 1993.
23. Monsees, B. S., and Destouet, J. M. Mammography in aesthetic and reconstructive breast surgery.
Perspect. Plast. Surg. 5: 103, 1991.