Elsevier

The Breast

Volume 14, Issue 2, April 2005, Pages 118-130
The Breast

REVIEW
Oncological aspects of breast reconstruction

https://doi.org/10.1016/j.breast.2004.08.006Get rights and content

Summary

Breast reconstruction has become increasingly popular over the past 20 years. There is concern that it may mask locoregional recurrence or that immediate reconstruction may compromise adjuvant treatments. We review available evidence regarding its oncological safety. The literature consists almost entirely of single institution, small retrospective reviews with variable follow-up and varying conclusions.

Most reviews suggest that breast reconstruction does not adversely affect disease-free or overall survival and that there is no significant delay in presentation with recurrent disease. Three retrospective series compared chemotherapy delivery after immediate breast reconstruction with controls having mastectomy alone. No delay in chemotherapy delivery or effect on dose intensity was demonstrated. Irradiation of a prosthetic implant has been shown to increase the rate of capsular contracture; irradiation of autogenous tissue reconstruction is usually well tolerated.

Introduction

There is an increase in the use of oncological interventions and in the availability of immediate or delayed reconstruction in the management of breast cancer. There are difficulties in considering the interactions between oncological and reconstructive interventions. The use of adjuvant therapy, both systemic and locoregional, derives its legitimacy from a large evidence base of randomised controlled trials, which define the benefits, and risks that populations of patients may derive from the application of these treatments. Despite this large evidence base, it is not possible to define the benefits of oncological adjuvant therapy for individual patients. There are a variety of rapidly evolving techniques of immediate or delayed breast reconstruction which are variably applied in differing clinical and geographical contexts. We attempt to review the evidence concerning the impact of breast reconstruction on disease-related outcomes and its interaction with oncological interventions.

Section snippets

Search strategy

The review is based primarily on a Medline search with secondary references from key articles.

Studies were included if the majority of patients were treated after 1980 and where the median or mean follow-up period was more than 1 year in the case of assessment of recurrence. A total of 84 papers were reviewed.

Recurrence risk

A number of reports have attempted to identify the impact of reconstruction on recurrence and cancer-related mortality risk. Georgiade and colleagues1 reported a series of 101 patients treated with immediate breast reconstruction (IBR) and compared them with 377 patients treated by mastectomy alone. After a median follow-up of 36 months there was no difference in relapse-free survival between the two groups. Similarly, no adverse effects on recurrence-free or overall survival were demonstrated

Immediate breast reconstruction—impact on the initiation and morbidity of chemotherapy and radiotherapy

IBR may conceivably delay the introduction of adjuvant therapies, particularly if postoperative complications occur. Patients treated with IBR are often younger and the indication for mastectomy rather than breast conservation is frequently associated with a poorer prognosis. There is therefore a substantial possibility that adjuvant therapy will be considered when IBR is performed for invasive cancer. The information necessary to finally determine whether radiotherapy or chemotherapy should be

Does radiotherapy increase the complication rate of breast reconstruction or affect cosmesis of saline or silicon implants?

Implant reconstruction is reported to have a 40% complication rate with around 10% silicon implants requiring removal within 3 years.36 The commonest problems associated with silicon or saline implants are:

  • 1.

    Capsular contraction caused by an inflammatory response to foreign material and resulting in hardening, pain and distortion of the breast. This is reported in approximately 30% patients long term.

  • 2.

    Rupture of the implant envelope or the surrounding fibrous capsule resulting in silicon

Conclusion

Multidisciplinary team working in breast units has created an environment where diagnostic, surgical and oncological interventions required for individual patient management are integrated. Breast reconstruction must be considered within the context of the totality of systemic and locoregional treatment. Availability and type of reconstruction and timing often depend on local circumstances and precedent. There is a lack of good-quality evidence on which to advise women considering breast

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