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Treatment Outcome with Radiation Therapy afterBreast Augmentation or Reconstruction in Patientswith Primary Breast Carcinoma

BACKGROUND. Analyses were performed to determine local control and cosmeticSandra J. Victor, M.D.1

outcome of breast carcinoma patients with prosthetically augmented or recon-Douglas M. Brown, M.D.1

structed breasts who had received radiation therapy (RT).Eric M. Horwitz, M.D.1

METHODS. Twenty-one newly diagnosed breast carcinoma patients with prostheti-Alvaro A. Martinez, M.D., F.A.C.R.1

cally augmented or reconstructed breasts were treated with external beam RT. AllVijay R. Kini, M.D.1

patients received whole breast RT (median dose, 50.4 gray [Gy]) and 19 wereJane E. Pettinga, M.D.2

boosted to a median dose of 60.4 Gy. A median dose of 50.4 Gy was delivered toKenneth W. Shaheen, M.D.3

the regional lymph nodes in 12 patients. Tissue equivalent bolus material was usedPamela Benitez, M.D.2

in six patients. Seventeen patients received adjuvant systemic therapy. CosmeticPeter Y. Chen, M.D.1

results were evaluated at 3–6-month intervals.Frank A. Vicini, M.D.1

RESULTS. With a median follow-up of 32 months, good/excellent cosmetic results

were observed in 71% of patients (100% in those with augmented breasts and 54%1 Department of Radiation Oncology, Williamin those with reconstructed breasts). Four patients (19%) with fair/poor cosmeticBeaumont Hospital, Royal Oak, Michigan.outcomes required implant removal and/or revision. Multiple clinical and treat-2 Department of Surgery, William Beaumontment-related factors were analyzed for their impact on cosmetic outcome. AHospital, Royal Oak, Michigan.worsened cosmetic result was observed with increasing stage (P Å 0.076), breast

3 Department of Plastic Surgery, William Beau-reconstruction (vs. augmentation) (P Å 0.030), and bolus application (P Å 0.016).

mont Hospital, Royal Oak, Michigan.All patients with fair/poor cosmetic outcomes had time intervals from implant

insertion to RT ranging from 53–213 days. Two patients developed an isolated

local recurrence within the augmented breast.

CONCLUSIONS. Patients with prosthetically augmented breasts can undergo RT and

expect good/excellent cosmetic results. Patients with reconstructed breasts are at

a significantly greater risk for cosmetic failure. This risk may be related to the

higher percentage of patients with advanced disease, those who received bolus

application, and those who received earlier delivery of RT (after the cosmetic

procedure) in reconstructed breasts. Cancer 1998;82:1303–9.

q 1998 American Cancer Society.

KEYWORDS: breast neoplasms, mammoplasty, breast reconstruction, radiation ther-apy, breast implants.

OPresented at the Eighteenth Annual Breast Can-ver the past two decades, methods of breast carcinoma treatmenthave shifted from a traditional emphasis on mastectomy to ther-cer Symposium, San Antonio, Texas, December

apy designed to preserve or restore the normal breast anatomy. Re-11–13, 1995.sults with this treatment approach have produced survival results1–6

Address for reprints: Frank A. Vicini, M.D., De- equivalent to mastectomy with good to excellent cosmetic outcomespartment of Radiation Oncology, William Beau- in the majority of cases.7–10 At the same time, an increasing numbermont Hospital, 3601 West 13 Mile Road, Royal of women have undergone breast augmentation procedures for cos-Oak, MI 48073.

metic reasons alone, with improved cosmesis and a correspondinglyimproved self-image.11 As a result, radiation oncologists increasinglyReceived May 29, 1997; revision received Octo-

ber 9, 1997; accepted October 9, 1997. are presented with the task of treating breast carcinoma patients with

q 1998 American Cancer Society

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1304 CANCER April 1, 1998 / Volume 82 / Number 7

TABLE 1 TABLE 2Indications for Postmastectomy Radiation TherapyAJCC Stage Distribution of Patients with Augmented and

Reconstructed Breasts¢4 positive axillary lymph nodesPrimary tumor õ5 cm with positive axillaStage Augmented ReconstructedInvolvement of skin or chest wallInflammatory breast carcinoma0 1/8 (13%) 0/13 (0%)

I 4/8 (50%) 0/13 (0%) Positive surgical marginIIA 3/8 (37%) 2/13 (15%)IIB 0/8 (0%) 6/13 (46%)IIIA 0/8 (0%) 4/13 (31%)IIIB 0/8 (0%) 1/13 (8%)

lary lymph node dissection. Prostheses were placed 5–252 months prior to the diagnosis and treatment ofAJCC: American Joint Committee on Cancer.

breast carcinoma in these patients. Five of these pa-tients had submuscular implants (two saline and threesilicone) and three had subglandular implants (all sili-cone). In the remaining 13 patients, immediate breastaugmented and/or reconstructed breasts. Unfortu-

nately, the literature provides only limited information reconstruction (IBR) was performed after a modifiedradical mastectomy. Prostheses were placed from 1–regarding the outcome of these patients after radiation

therapy (RT). Some studies suggest that irradiating a 12 months (median, 7 months) prior to adjuvant RT.Eleven of these patients had submuscular implants (5reconstructed/augmented breast may result in an un-

acceptable rate of cosmetic failure12–15 whereas others saline tissue expanders, 4 saline, and 2 silicone) andthe remaining 2 patients had subcutaneously locatedhave found no detrimental effect if certain suboptimal

RT techniques are avoided.16–19 It has been reported saline-filled implants. No patient underwent a free flapreconstruction. Overall, 16 patients (76%) had sub-that implant location, patient age, tumor stage, axillary

lymph node status, degree of wound healing, RT dose, muscular implants (11 saline and 5 silicone) and 5patients (24%) had subcutaneous implants (2 salinepostoperative chemotherapy, postoperative RT, and

the time interval between implant insertion and RT and 3 silicone).can affect the cosmetic outcome.19–21 The purpose ofthis study was to review our experience with RT in Treatmentbreast carcinoma patients with prosthetically aug- All patients were treated with external beam RT (4- ormented and/or reconstructed breasts and to deter- 6-megavolt [MV] photons) using tangential fields to amine whether any clinical or treatment-related factors median dose of 50 gray (Gy) to the whole augmented/are associated with the ultimate cosmetic outcome in reconstructed breast (range, 45–54 Gy). In postmas-these patients. tectomy patients, the indications for RT are listed in

Table 2. Nineteen patients received a supplementalboost to the tumor bed/scar to a median dose of 60MATERIALS AND METHODS

Patients Gy (range, 57–66 Gy). Electrons were utilized to deliverthe boost dose in all 19 patients (median energy, 9Between January 1, 1977 and June 1, 1995, 21 patients

with prosthetically augmented (8 patients) or recon- megaelectron volts). Regional lymph nodes were irra-diated in 12 patients: 2 of 8 patients (25%) treatedstructed (13 patients) breasts were referred for RT to

William Beaumont Hospital, Royal Oak, Michigan, for who had prosthetically augmented breasts and 10 of13 patients (77%) who had reconstructed breasts. Anewly diagnosed breast carcinoma. Pretreatment

workup included history and physical examination as median dose of 50.4 Gy (range, 45–50 Gy) was deliv-ered using 4- or 6-MV photons through a direct orwell as chest radiographs, routine blood studies, and

additional diagnostic studies as needed to exclude anterior field matched to the tangential breast fields.Tissue equivalent bolus material was placed on themetastatic disease. Patients ranged in age from 29–64

years (mean, 43 years) and were staged according to skin to increase the surface dose in 6 of 21 patients(29%). Seventeen of 21 patients (81%) received adju-the criteria of the 1992 American Joint Committee on

Cancer (AJCC) staging system (Table 1).22 TNM staging vant systemic therapy: 12 patients (57%) receivedmultiagent systemic chemotherapy and 5 patientsshowed the following distribution: 1 Stage 0 patient,

4 Stage I patients, 11 Stage II patients, and 5 Stage III (24%) received hormonal therapy (tamoxifen). Thechemotherapy regimes varied slightly during this pe-patients.

Eight patients had prosthetically augmented riod but most patients receiving chemotherapy weretreated with cyclophosphamide, doxorubicin, and 5-breasts and were referred after lumpectomy and axil-

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RT after Breast Augmentation/Reconstruction/Victor et al. 1305

TABLE 3florouracil or with methotrexate. All chemotherapyCosmetic Outcome by Clinical and Treatment-Related Factorswas completed prior to RT. Hormonal therapy began

at the completion of RT.Excellent/good Fair/poor

Cosmetic results were evaluated by the radiationoncologist and the surgeon according to the following Augmented breasts 8/8 (100%) 0/8 (0%)

Reconstructed breasts 7/13 (54%) 6/13 (46%)guidelines at 3–6-month intervals23: Excellent (BakerSaline 9/13 (69%) 4/13 (31%)Class I): restoration of irradiated breast tissues/recon-Silicone 6/8 (75%) 2/8 (25%)structed breast to the preirradiation condition: main-Submuscular 10/16 (63%) 6/16 (38%)

tenance of soft pliable tissue, minimal long term skin Subcutaneous 5/5 (100%) 0/5 (0%)changes, little distortion of the prosthesis, Good (Baker Adjuvant chemotherapy 9/12 (75%) 3/12 (25%)

Adjuvant hormones 3/5 (60%) 2/5 (40%)Class II): mild fibrosis with some retraction of the im-None 3/4 (75%) 1/4 (25%)plant, but without major asymmetry compared withBolus 2/6 (33%) 4/6 (67%)the contralateral, nonirradiated breast, Fair (BakerNo bolus 13/15 (87%) 2/15 (13%)

Class III): moderate fibrosis and retraction causing Age °50 yrs 14/17 (82%) 3/17 (18%)asymmetry, but without major disfigurement of the Age ú50 yrs 2/4 (50%) 2/4 (50%)

Three-field RT 9/12 (75%) 3/12 (25%)irradiated augmented or reconstructed breast, andTangents 6/9 (67%) 3/9 (33%)Poor (Baker Class IV): marked fibrosis, contraction,

and/or distortion.RT: radiation therapy.

StatisticsFor statistical purposes, two categories were identified:good to excellent and fair to poor (cosmetic failure). of 21 patients (19%) developed severe contractures or

prosthetic encapsulation requiring either prostheticCosmesis was assessed prior to simple mastectomy inpatients who developed a local recurrence. Saline tis- removal or repositioning and/or reconstruction. Two

of these 4 patients developed severe contractures withsue expanders were analyzed as saline implants. Allintervals were calculated from the date of completion prosthetic encapsulation 7 and 12 months, respec-

tively, after RT. The third patient developed fibrosis atof RT. Follow-up was complete through December 1,1995. Local tumor control and cosmetic outcome were the matchline between the supraclavicular field and

the tangential fields with severe implant contractureassessed. Statistical differences were assessed by theFisher’s exact test and Fisher’s exact test for trend with toward the matchline 1 year after completing RT. All

three patients required prosthetic removal or reposi-midpoint P correction, Student’s t test, and box plots.P values ° 0.05 were considered statistically signifi- tioning and/or reconstruction. The fourth patient de-

veloped severe blistering and cellulitis of the recon-cant.structed breast during RT. This patient subsequentlydeveloped significant scarring and the implant wasRESULTS

The median follow-up in surviving patients was 32 removed 8 months after RT. The remaining 2 patientsof the 6 with a fair/poor cosmetic result developedmonths (range, 5–83 months). Two patients devel-

oped an isolated local recurrence (10 and 52 months, marked fibrosis/scaring in the reconstructed breast 8and 21 months, respectively, after treatment. Neitherrespectively, after treatment) within the augmented

breast and both were treated successfully with simple patient had their implant removed. At last follow-up,1 of these patients was alive with no evidence of dis-mastectomy. Both patients had excellent cosmetic re-

sults prior to breast removal and both patients were ease at 22 months and the other had died of metastaticdisease 52 months after treatment. Hence, in only fourwithout evidence of disease at 2 and 15 months, re-

spectively, after mastectomy. Four patients, all in the of six patients with a fair to poor cosmetic outcomewas implant removal subsequently necessary. Fair toreconstructed group, had died of metastatic disease at

last follow-up. Two of these 4 patients had excellent poor cosmetic results were observed with time inter-vals from implant insertion to RT that ranged fromcosmetic outcomes (18 and 19 months, respectively,

of follow-up) and 2 patients had poor cosmetic out- 53–213 days. No patient developed prosthetic ruptureor systemic symptoms related to the prosthesis.comes (24 and 52 months, respectively, of follow-up).

No patients failed regionally or were lost to follow-up. The cosmetic outcome by stage and clinical/treat-ment-related factors are presented in Tables 3 and 4.Excellent/good cosmetic results were obtained in

15 of 21 patients (71%): 8 of 8 (100%) in the group of Multiple clinical and treatment-related factors wereanalyzed for their impact on the risk of precipitatingpatients with augmented breasts and 7 of 13 (54%) in

the group of patients with reconstructed breasts. Four a fair/poor cosmetic outcome (i.e., stage, use of bolus

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TABLE 4Cosmetic Outcome by AJCC Stage

Breast augmentation Breast reconstruction

Stage Excellent/good Fair/poor Excellent/good Fair/poor

0 1/1 (100%) 0/1 (0%) 0/0 (0%) 0/0 (0%)I 4/4 (100%) 0/4 (0%) 0/0 (0%) 0/0 (0%)IIA 3/3 (100%) 0/3 (0%) 1/2 (50%) 1/2 (50%)IIB 0/0 (0%) 0/0 (0%) 4/6 (67%) 2/6 (33%)IIIA 0/0 (0%) 0/0 (0%) 1/4 (25%) 3/4 (75%)IIIB 0/0 (0%) 0/0 (0%) 1/1 (100%) 0/1 (0%)

AJCC: American Joint Committee on Cancer.

TABLE 5 augmented breasts (100%) experienced a good/excel-Clinical and Treatment-Related Factors Affecting Cosmetic Outcome lent cosmetic result, compared with 54% of patients

with reconstructed breasts (P Å 0.030). No patient de-Prognostic factors P value (univariate)

veloped soft tissue necrosis, hematomas, severe pain,arm edema, brachial plexopathy, rib fractures, pros-Stage 0.076a

Bolus application 0.016b thetic leakage, frozen shoulders, or systemic symp-Type of plastic procedure/repair (augmented vs. toms.

reconstructed breasts) 0.030b

Implant type (silicone vs. saline) NSb

Implant location NSb DISCUSSIONThree-field RT NSb

Oncologists increasingly are faced with decisions re-Adjuvant therapy NSb

garding therapy recommendations in patients whoAge NSc

have either undergone breast augmentation or desireTotal RT dose NSd

postmastectomy breast reconstruction. Numerous au-RT: radiation therapy; NS: not stated. thors have analyzed the dosimetric characteristics ofa Fisher’s exact test for trend with midpoint correction. breast prostheses and have concluded that althoughb Fisher’s exact test with midpoint correction.

implant dosimetry may differ from normal tissue, noc Student’s t test.negative impact on dose to the surrounding tissue isd Box plot.

observed with the standard RT techniques currentlyin use.18,24–26 In the current analysis, patients withprosthetically augmented breasts undergoing breast-conserving therapy had excellent cosmetic resultsapplication, type of plastic procedure/repair [augmen-

tation vs. reconstruction], implant type [silicone vs. whereas women with reconstructed breasts after mas-tectomy did not have as good cosmetic outcomes. Fac-saline], implant location [retroglandular vs. subpect-

oral], use of adjuvant systemic therapy [chemotherapy tors associated with cosmetic failure in these patientsincluded disease stage, the use of bolus application,and/or hormonal], use of three-field RT, age, and total

RT dose and energy) (Table 5). Although all numbers and the earlier delivery of RT (after the cosmetic proce-dure). These findings suggest that most women withwere extremely small, there was a trend toward wors-

ening cosmesis with increasing stage (P Å 0.076, Fish- augmented breasts and many with reconstructedbreasts can be treated with RT, but RT technique mayer’s exact for trend with midpoint correction) (Table

5). The use of bolus application had a significant im- impact cosmesis in these patients.A number of contradictory articles reporting thepact on cosmetic outcome. Approximately 87% of pa-

tients who were treated without bolus application had clinical experiences of RT in patients with augmentedor reconstructed breasts have appeared in the litera-a good to excellent result, compared with 37% who

were treated with bolus application (P Å 0.016). Note ture. Some studies attempted to analyze various clini-cal and/or treatment-related factors for their impactthat in Table 4 patients with higher stage disease were

more likely to have bolus application utilized with the on cosmetic outcome. Other studies merely were de-scriptive, with relatively small numbers of patients,RT. The type of plastic procedure/repair was a signifi-

cant predictor of cosmetic outcome. All 8 patients with and did not focus on potential risk factors for cosmetic

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RT after Breast Augmentation/Reconstruction/Victor et al. 1307

TABLE 6Review of Literature Reporting Cosmetic Results in Patients with Prosthetically Augmented Breasts Treatedwith RT for Breast Carcinoma

Cosmesis Factors negatively affectingInstitution (% excellent/good) cosmetic outcome

Washington University18 100% 5/5 NSCornell Medical Center16 86% 6/7 NSMSKCC21 33% 1/3 Subglandular prosthesisSaint John’s Hospital17 85% 17/20 Subglandular prosthesisVan Nuys, California15 35% 9/26 Subglandular prosthesisWilliam Beaumont Hospital 100% 8/8 NS

RT: radiation therapy; NS: not stated; MSKCC: Memorial Sloan-Kettering Cancer Center.

TABLE 7Review of Literature Reporting Cosmetic Results in Patients with Reconstructed Breasts Treated with RT forBreast Carcinoma

Cosmesis Factors negatively affecting cosmeticInstitution (% excellent/good) outcome

Washington University19 42% 23/55 Use of bolus application, reconstructionprocedure, age ú50 yrs, and IBR

M. D. Anderson Cancer Center 20 41% 16/39 Postreconstruction RTCornell Medical Center16 60% 3/5 NSSaint Barnabas27 78% 7/9 NSWilliam Beaumont Hospital 54% 7/13 Use of bolus application and higher stage

RT: radiation therapy; IBR: immediate breast reconstruction; NS: not stated.

failure, making data interpretation difficult (Tables 6 tients obtained excellent to good ratings, which corre-lated to a Baker Class I and II. Patients age õ 50 yearsand 7). In addition, the definition of cosmetic outcome

differs between series, making comparisons imprecise. had a greater percentage of good to excellent cosmeticresults (58% vs. 35%; P Å 0.07). Similar to our findings,The largest postmastectomy reconstruction series

did report on factors associated with cosmetic failure the only significant RT factor found to impact cosm-esis negatively was the use of bolus application. Withafter IBR in 142 patients.12 An early IBR failure was

defined as the removal of the prosthesis within 7 weeks bolus application, good to excellent cosmesis was ob-tained in only 37% of cases versus 81% without bolusafter reconstruction whereas a late failure was removal

after 7 weeks. The overall failure rate was 16% for the application (P Å 0.003). The timing of the reconstruc-tion in relation to mastectomy or RT influenced cos-total series. The risk of early and late IBR failure was

8% each (11 of 142 patients and 10 of 131 patients, metic results in patients with reconstructed breasts.Good to excellent results were obtained in 32% of pa-respectively). Only the histologic pattern of the pri-

mary tumor (i.e., invasive vs. in situ carcinoma) pre- tients when RT was administered within 6 weeks ofmastectomy versus 55% when it was delayed (P Ådicted for early failure. The risk of late IBR failure was

found to be related to age at IBR and the use of postop- 0.08). Cosmesis was found to be independent of theRT dose.18erative RT to the chest wall. When the chest wall was

irradiated, the risk of late failure was 27.5-fold higher The detriment in cosmesis found by Kuske et al.18

and our study when bolus application was utilized isthan when women did not receive RT to the chest wall.At Washington University, Kuske et al.18 reported not surprising. Bolus is a tissue equivalent material

placed on the skin surface to increase the dose to thatthe results of treatment of 72 augmented or recon-structed breasts in 66 patients. Cosmesis was rated by organ, when indicated (Table 2). Previous data have

shown that as the whole breast dose is increased (ina photographic review of 44 patients and documentedas excellent, good, fair, or poor, according to a modi- patients with reconstructed breasts or postlumpec-

tomy patients), the cosmetic result deteriorates sec-fied Baker classification. Approximately 49% of pa-

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ondary to late tissue effects on the skin. Unfortunately, retromuscular implants). All patients underwentbreast-conserving therapy and six patients receivedin postmastectomy patients these doses (ú50–60 Gy)

are required to sterilize subclinical, microscopic dis- systemic chemotherapy. No patient developed a localrecurrence, but two patients developed distant metas-ease.

In 1992, Chu et al. reported their experience with tases. Cosmetic results were judged using a numericscoring system matched with excellent, good, fair, orRT (without bolus application) of 39 prosthetically

augmented or reconstructed breasts in 37 patients poor. Seventeen of the 20 patients (85%) had excellentor good cosmetic results. Cosmesis tended to dependwith primary or recurrent breast carcinoma. Local tu-

mor control was achieved in all patients with primary on the location of the implant; all 6 of the patientswith retromuscular implants (100%) had excellent orbreast carcinoma and in 78% of patients with recurrent

breast carcinoma. Cosmetic results were scored as ex- good results, compared with 11 of the 14 patients(79%) with subcutaneously placed implants.17cellent, good, fair, or poor. As in our series, acceptable

results were obtained in the majority of patients. Over- In contrast to the studies mentioned earlier andour data, some series report a more significant rate ofall, an excellent or good cosmetic result was achieved

in 87% of the patients. Among the patients with pri- fair to poor cosmetic outcomes. Halpern et al.13 re-ported 11 patients who had undergone subcutaneousmary breast carcinoma, the cosmetic outcome was ex-

cellent/good in 6 of 7 augmented breasts (86%) and 3 mastectomy with silicone implantation. Fair to poorcosmesis resulted in 8 patients (73%). Of these pa-of 5 breasts (60%) reconstructed after mastectomy.16

Ryu et al.21 from Memorial Sloan-Kettering Cancer tients, three had fibrosis and encapsulation prior toreceiving RT and two received RT within 1 month afterCenter reported the long term results of 14 patients

with augmented or reconstructed breasts treated after reconstruction.Handel et al.14 initially reported that 10 of 15RT. Cosmesis subjectively was rated as excellent, good,

fair, or poor. An excellent to good cosmetic result was women (67%) with Stage I or II breast carcinoma un-dergoing breast-conserving therapy who had pre-obtained in 9 of 13 patients (69%). Four patients re-

ceived RT for primary breast carcinoma after augmen- viously augmented breasts experienced significantcapsular contractures, and 4 women (27%) requiredtation mammoplasty (three patients) or reconstruc-

tion (one patient) whereas the remaining 10 patients surgical alteration. In an updated report, Handel etal.15 evaluated 26 women who underwent RT after aug-were treated for recurrence after reconstruction. Two

patients with augmented breasts and primary breast mentation mammoplasty. In 65% of these patients,significant contracture occurred on the irradiated side.carcinoma had fair cosmetic results whereas the third

patient had a good cosmetic result. The patient with At last follow-up, eight patients had undergone correc-tive surgery. However, some difficulty in drawing con-reconstructed breasts and primary breast carcinoma

had excellent results, but follow-up was õ6 months. clusions from these data does exist as is evident onreview of the RT techniques and doses. ApproximatelyOverall, three patients, all of whom had subcutane-

ously placed prostheses, developed documented im- 33% of patients received doses ¢ 70 Gy, orthovoltageRT was delivered in 2 patients (which, due to beamplant encapsulation whereas none of the five patients

with subpectoral implants developed late complica- quality, is known to produce a more severe superficialtissue reaction), and iridium implants were utilized fortions. Two patients underwent a scar-release proce-

dure 1–3 years after completion of RT because of en- the boost in 2 patients (which could have caused agreater than prescribed dose to be delivered to acapsulation. Both of these patients were scored as hav-

ing an excellent ultimate cosmetic result. The authors greater volume).Although the definition of cosmetic outcome dif-concluded that RT-induced encapsulation of a pros-

thesis does occur, perhaps more frequently in breasts fers between institutions, it appears that the majorityof patients with prosthetically augmented breasts canwith subcutaneously placed implants, but this encap-

sulation may well be corrected by a scar-release proce- be offered RT with the expectation of excellent localcontrol and good to excellent cosmetic results (Tabledure. In our series, patients with subcutaneously

placed prostheses actually had a better cosmetic out- 6). Although data are conflicting, patients with recon-structed breasts appear to be at a significantly greatercome than patients with subpectoral placement of

their implant. This anomalous result was probably re- risk for cosmetic failure (Table 7). Based on our data,this risk may be related in part to the higher percent-lated to the earlier stage disease found in these pa-

tients. age of patients with advanced stage of disease, theuse of bolus application, and irradiation after breastIn 1994 Guenther et al.17 reported on 20 women

in whom breast carcinoma developed after augmen- reconstruction (vs. augmentation). Although the riskof cosmetic failure is increased in these patients, irra-tation mamoplasty (14 subcutaneous implants and 6

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RT after Breast Augmentation/Reconstruction/Victor et al. 1309

12. Barreau-Pouhaer L, Monique G, Rietjens M, Arriagada R,diation still is necessary because tumor control shouldContesso G, Martins R, et al. Risk factors for failure of imme-not be compromised for the sake of cosmesis. In pa-diate breast reconstruction with prosthesis after total mas-

tients with advanced disease and for whom it is known tectomy for breast cancer. Cancer 1992;70:1145–51.preoperatively that adjuvant RT after mastectomy will 13. Halpern J, McNeese MD, Kroll SS, Ellerbroek N. Irradiation

of prosthetically augmented breast: a retrospective study onbe required, consideration should be given as totoxicity and cosmetic results. Int J Radiat Oncol Biol Physwhether they should undergo immediate breast recon-1990;18:189–91.struction with a possibly worsened cosmetic outcome

14. Handel N, Lewinsky B, Silverstein MJ, Gordon P, Sierk K.or whether reconstruction should be delayed until Conservation therapy for breast cancer following augmen-after RT is completed. tation mammoplasty. Plast Reconstr Surg 1991;87:873–8.

15. Handel N, Lewinsky B, Jensen JA, Silverstein MJ. Breast con-servation therapy after augmentation mammaplasty: is itREFERENCESappropriate? Plast Reconstr Surg 1996;98(7):1216–24.1. Fischer B, Redmond D, Poisson R. Eight-year results of a

16. Chu FCH, Kaufmann TP, Dawson GA, Kim YS, Rajaratnamrandomized clinical trial comparing total mastectomy andS, Hoffman LA. Radiation therapy of cancer in prostheticallylumpectomy with or without irradiation in the treatment ofaugmented or reconstructed breasts. Radiology 1992;185:breast cancer. N Engl J Med 1989;320:822–8.429–33.2. Blichert-Toft M. Danish randomized trial comparing breast

17. Guenther J, Tokita K, Giuliano A. Breast-conserving surgeryconservation therapy with mastectomy: six years of life-tableand radiation after augmentation mammoplasty. Canceranalysis. Monogr Natl Cancer Inst 1992;11:19–25.1994;73:2613–8.3. van Dongen JA, Bartelink H, Fentiman IS, Lerut T, Mignolet

18. Kuske RR, Schuster RH, Klein E, Young L, Perez C, FinebergF, Olthuis G, et al. Randomized clinical trial to assess theB. Radiotherapy and breast reconstruction: clinical resultsvalue of breast-conserving therapy in stage I and stage IIand dosimetry. Int J Radiat Oncol Biol Phys 1991;21:339–46.breast cancer, EORTC 10801 trial. Monogr Natl Cancer Inst

19. Schuster RH, Kuske RR, Young VL, Fineberg B. Breast recon-1992;11:15–8.struction in women treated with radiation therapy for breast4. Fowble B, Solin LJ, Schultz DJ, Goodman R. Ten year resultscancer: cosmesis, complications, and tumor control. Plastof conservative surgery and irradiation for stage I and IIReconstr Surg 1992;90:445–52.breast cancer. Int J Radiat Oncol Biol Phys 1991;21:269–77.

20. Evans G, Schusterman M, Kroll S, Miller M, Rece G, Robb5. Veronesi U, Banfi A, Salvadori B, Luini A, Saccozzi R, ZucaliG, et al. Reconstruction and the irradiated breast: is there aEM, et al. Breast conservation is the treatment of choice inrole for implants? Plast Reconstr Surg 1995;96:1111–8.small breast cancer: long-term results of a randomized trial.

21. Ryu J, Yahalom J, Shank B, Chaglassian TA, McCormick B.Eur J Cancer 1990;26:668–70.Radiation therapy after breast augmentation or reconstruc-6. Sarrazin D, Le MG, Arriagada R, Contesso G, Fontaine F,tion in early or recurrent breast cancer. Cancer 1990;66:Spielmann M, et al. Ten-year results of a randomized trial844–7.comparing a conservative treatment to mastectomy in early

22. American Joint Committee on Cancer: Breast. In: Beahrsbreast cancer. Radiother Oncol 1989;14:177–84.OH, Henson DR, Hutter RVP, Kennedy BJ, editors. Manual7. Abner AL, Recht A, Vicini FA. Cosmetic results after surgery,for staging of cancer. 4th edition. Philadelphia: J.B. Lippin-chemotherapy and radiation therapy for early breast cancer.cott, 1992:149–54.Int J Radiat Oncol Biol Phys 1991;21:331–8.

23. Spear SL, Baker JR. Classification of capsular contracture8. Bader JL, Lippman ME, Swain SM. Cosmetic evaluation fol-after prosthetic breast reconstruction. Plast Reconstr Surglowing lumpectomy and radiation for early breast cancer is1995;96:1119–23.similar with and without adjuvant adriamycin/cytoxan. Proc

24. Shedbalkar AR, Devata A, Padanilam T. A study of effects ofAm Soc Clin Oncol 1987;6:62.radiation on silicone prostheses. Plast Reconstr Surg9. Delouche G, Bachelot F, Premont M, Kurtz JM. Conservation1980;65:805.treatment of early breast cancer: long term results and com-

25. McGinley PH, Powell WR, Bostwick J. Dosimetry of a siliconeplication. Int J Radiat Oncol Biol Phys 1987;13:29.breast prosthesis. Radiology 1980;135:223.10. Rose MA, Olivotto I, Cady B, Koufman C, Osteen R, Silver

26. Krishnan L, Krishnan EC. Electron beam irradiation afterB, et al. Conservative surgery and radiation therapy for earlyreconstruction with silicone gel implants in breast cancer.breast cancer: long-term cosmetic results. Arch SurgAm J Clin Oncol 1986;9:223–6.1989;124:153–7.

27. Stabile RJ, Santoro E, Dispaltro F, Sanfilippo M. Recon-11. Edgerton MT, McClary AR. Augmentation mammoplasty:structive breast surgery following mastectomy and ad-psychiatric implications and surgical indications. Plast Re-junctive radiation therapy. Cancer 1980;45:2738–43.constr Surg 1958;21:279.

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