Book Chapter Review Notes.

Surgery of The Breast Principles and Art Ed. Scott Spear
Chapter 33. Prosthetic Reconstruction in the Radiated Breast.

Prosthetic breast reconstruction in the radiated breast is a complex issue.

-Radiated reconstructions tend to be of poorer quality than non-radiated reconstructions.
-Radiation increases the complication rates associated with reconstructive options
-Not all radiation is the same.
The dose, location, type, and purpose of radiation substantially affects the local tissue response and thus indirectly the hospitality of those tissues to reconstructive surgery.

Radiation may be delivered to the breast under a variety of circumstances:

-As part of breast conservation treatment, along with lumpectomy and axillary sampling.
-Postmastectomy, according to the American Society of Clinical Oncology Guidelines
-Postmastectomy for a local recurrence.
-After immediate reconstruction for unfavorable tumor
-After immediate or delayed reconstruction for recurrence

If radiation prior to reconstruction:

Indications
Dose of radiation
Quality of tissues after radiation

Lumpectomy and radiation often 5,000 cGY
Patients radiated after mastectomy more likely high-dose radiation because radiation recommended on basis of extensive or aggressive disease.

Lower dose radiation: tissues look and feel reasonably normal
Higher dose radiation: tissues look tight, inelastic, thickened.

All radiation increases risk of complications.
Obvious radiation damage advised to undergo autologous or autologous assisted types of reconstruction.

Indications for radiation by American Society of Clinical Oncology:

Tumor greater than 4 cm.
4 or more positive lymph nodes
Tumor near resection margins (skin or chest wall)

Radiation dose for these indications is usually substantial 9,500 to 10,000 cGy.

Article Review

Article Review of "Re: Trends in the Treatment of Ductal Carcinoma In Situ of the Breast." Journal of the National Cancer Institute. 96(16):1258-1259, August 18, 2004.[CORRESPONDENCE] by Gordon F. Schwartz, Michael D. Lagios, Melvin J. Silverstein.

Synopsis: At the time the article was written, the management of DCIS was in evolution to include: Breast conservation therapy, the use of adequate excision alone without radiation therapy, and the avoidance of axillary lymph node dissection for the disease. The management of DCIS needs a dedicated team for mammographic pathologic correlation, specimen radiography, inking of margins, and thorough histologic examination.

Article Review

Review of "Breast Cancer Diagnosis and Prognosis in Augmented Women" Plastic & Reconstructive Surgery 118: 587-593, 2006 by Neal Handel & Melvin J. Silverstein."

Frequently in my practice I am asked by many women who desire breast augmentation or who have already had a breast augmentation and now want a lift, removal and replacement, or surgery for capsular contracture the following question:

Do breast implants impair my ability to detect breast cancer or increase my risk of getting breast cancer?

To answer this question and as part of my own self study, I read and reviewed an article in Plastic & Reconstructive Surgery 118: 587-593, 2006 by Neal Handel & Melvin J. Silverstein. I present here notes which are helpful for my own self study as well as for patient education during consultation:

Background:
--Breast enlargement surgery is popular. More than 334,000 women underwent elective breast augmentation in 2004.
--A woman in the United States has a 1 in 7 (13.4 percent) lifetime risk of developing breast cancer.
--There is no etiologic link between implants and breast tumors. Numerous studies show that the rate of breast cancer is not increased among augmented women, and some studies demonstrate lower than expected rates.
--However, because of the large number of women undergoing augmentation, there have been persistent concerns about possible adverse effects of implants on cancer detection and treatment.

Methods:
The authors reviewed their database of women with breast cancer and determined if there was a difference in breast cancer between augmented and non-augmented women.

Results:
--There was no statistically significant difference in stage of disease between augmented and non-augmented patients. The mean tumor size, recurrence rates, and breast cancer- specific survival were virtually identical in both groups.--Augmented patients were more likely to present with palpable lesions.

Conclusion:
Augmented and nonaugmented patients are diagnosed at a similar stage of breast cancer and have a comparable diagnosis. While implants may impair mammography, they appear to facilitate detection of palpable breast cancers on physical examination.