Correspondence

Breast Reconstruction after Breast-Cancer Surgery

N Engl J Med 2009; 360:418-421January 22, 2009

Article

To the Editor:

Cordeiro (Oct. 9 issue)1 describes a patient who may undergo postoperative radiation therapy after mastectomy. He states that the best therapeutic option would be prosthesis-based breast reconstruction. Because of the patient's limited abdominal tissue, the possible use of the superior gluteal artery perforator (SGAP) flap is mentioned but rejected in favor of an expander–implant approach. However, this operative approach is at odds with the results of several studies confirming the significantly increased risk of capsular contracture and other secondary complications in patients who received radiation as compared with patients with implants who did not receive radiation2,3 and as compared with patients undergoing autogenous breast reconstruction who received radiation.4 Hence, we would strongly recommend autogenous-tissue transfer in this patient, so as to avoid the radiotherapy-related risk of formation of a capsular contracture. Free microvascular transplantation of the SGAP flap would provide an excellent long-lasting cosmetic result in this patient. This procedure may be performed with insufficient abdominal tissue, as in the patient described by Cordeiro, or even after previous transfer of a deep inferior epigastric perforator flap for autogenous reconstruction of the contralateral breast (Figure 1Figure 1A 57-Year-Old Patient after Reconstruction of Her Breasts.).

Justus P. Beier, M.D.
Raymund E. Horch, M.D.
Alexander D. Bach, M.D.
University Hospital of Erlangen, 91054 Erlangen, Germany
justus.beier@uk-erlangen.de

4 References

1
Cordeiro PG. Breast reconstruction after surgery for breast cancer. N Engl J Med 2008;359:1590-1601
Full Text | Web of Science | Medline

2
Cordeiro PG, McCarthy CM. A single surgeon's 12-year experience with tissue expander/implant breast reconstruction. II. An analysis of long-term complications, aesthetic outcomes, and patient satisfaction. Plast Reconstr Surg 2006;118:832-839
CrossRef | Web of Science | Medline

3
Behranwala KA, Dua RS, Ross GM, Ward A, A'Hern R, Gui GP. The influence of radiotherapy on capsule formation and aesthetic outcome after immediate breast reconstruction using biodimensional anatomical expander implants. J Plast Reconstr Aesthet Surg 2006;59:1043-1051
CrossRef | Web of Science | Medline

4
Pomahac B, Recht A, May JW, Hergrueter CA, Slavin SA. New trends in breast cancer management: is the era of immediate breast reconstruction changing? Ann Surg 2006;244:282-288[Erratum, Ann Surg 2007;245(3):table of contents.]
CrossRef | Web of Science | Medline

To the Editor:

In his review of reconstruction after surgery for breast cancer, Cordeiro draws attention to the lack of guidelines on breast reconstruction. The Association of Breast Surgery at BASO (the British Association of Surgical Oncology), the British Association of Plastic, Reconstructive and Aesthetic Surgeons, and the Training Interface Group in Breast Surgery recently have produced a guide to good practice1 in which we have defined the processes and standards for surgical teams to ensure that the appropriate equipment, facilities, training, and time are available for the safe performance of oncologic reconstructive breast surgery.

Although we agree that controlled trials are difficult to conduct in this group of women, the proposed multicenter, randomized Quality of Life after Mastectomy and Breast Reconstruction trial2 in the United Kingdom will assess the impact of the type and timing of breast reconstruction on quality of life after mastectomy.

We hope our guidance will help patients, providers, and payers to understand that there are standards for the safest possible performance of breast reconstruction after breast cancer.

Martin J.R. Lee, M.Sc., F.R.C.S.
Hugh M. Bishop, D.M., F.R.C.S.
Association of Breast Surgery, London WC2A 3PE, United Kingdom
martin.lee@uhcw.nhs.uk

Fazel T. Fatah, F.R.C.S.
British Association of Plastic Reconstructive, and Aesthetic Surgeons, London WC2A 3PE, United Kingdom

2 References

1
Oncoplastic breast surgery: a guide to good practice. Eur J Surg Oncol 2007;33:Suppl 1:S1-S23. [Erratum, Eur J Surg Oncol 2008;34(6):II.] (Also available at http://www.baso.org.uk/Downloads/Oncoplastic_Guidelines.pdf.)

2
Potter S, Winters ZE. The QUEST study: a multicentre randomised trial to assess the impact of the type and timing of breast reconstruction on quality of life following mastectomy. Breast Cancer Res 2008;10:Suppl 2:P87. abstract. (Also available at http://breast-cancer-research.com/content/10/S2/P87.)

To the Editor:

In his review of breast reconstruction with silicone implants, Cordeiro states “it is now clear that silicone and breast implants are not linked to cancer, immunologic or neurologic disorders, or any other systemic disease.” However, four references cited by the author as showing silicone was safe all showed that silicone was not entirely safe.

Sanchez-Guerrero et al.1 found significant morning stiffness as a sign of immune activation, Karlson et al.2 described significant antibodies to single-stranded DNA, and Gaubitz et al.3 found significant antinuclear-antibody positivity and neuropathy. Arthralgias, tingling, myalgias, and fatigue occurred in 50 to 75% of these patients. The magnetic resonance imaging study reported on by Brown et al.4 showed fibromyalgia in 25% of patients with extracapsular rupture and in 13% of the other patients (expected rate, 3%). These findings point to a new undefined syndrome.

Our experience confirms the findings of Rohrich et al.5 that implant removal stabilizes and ultimately improves these symptoms. Plastic surgeons and rheumatologists need to get together to define the syndrome, study the influence of implant removal, and establish a health assessment-like questionnaire that plastic surgeons could use to counsel patients.

Frank B. Vasey, M.D.
Louis Ricca, M.D.
University of South Florida College of Medicine, Tampa, FL 33612
fvasey@health.usf.edu

5 References

1
Sanchez-Guerrero J, Colditz GA, Karlson EW, Hunter DJ, Speizer FE, Liang MH. Silicone breast implants and the risk of connective-tissue diseases and symptoms. N Engl J Med 1995;332:1666-1670
Full Text | Web of Science | Medline

2
Karlson EW, Hankinson SE, Liang MH, et al. Association of silicone breast implants with immunologic abnormalities: a prospective study. Am J Med 1999;106:11-19
CrossRef | Web of Science | Medline

3
Gaubitz M, Jackisch C, Domschke W, Heindel W, Pfleiderer B. Silicone breast implants: correlation between implant ruptures, magnetic resonance spectroscopically estimated silicone presence in the liver, antibody status and clinical symptoms. Rheumatology (Oxford) 2002;41:129-135
CrossRef | Web of Science | Medline

4
Brown SL, Pennello G, Berg WA, Soo MS, Middleton MS. Silicone gel breast implant rupture, extracapsular silicone, and health status in a population of women. J Rheumatol 2001;28:996-1003
Web of Science | Medline

5
Rohrich RJ, Kenkel JM, Adams WP, Beran S, Conner WC. A prospective analysis of patients undergoing silicone breast implant explantation. Plast Reconstr Surg 2000;105:2529-2537
CrossRef | Web of Science | Medline

To the Editor:

Cordeiro judiciously addresses the issue of reconstructive breast surgery in patients undergoing mastectomy, with a special focus on the aesthetic outcome. As radiation oncologists, we agree that breast reconstruction is problematic in previously irradiated tissues, significantly increasing the risk of subsequent complications. Immediate reconstructive surgery also interacts unfavorably with postmastectomy radiation therapy. The initiation of radiotherapy is delayed, and anatomical changes induced by implant-based procedures create technical difficulties.1 Radiation treatment planning is technically altered, with major compromises in terms of optimal chest-wall coverage, avoidance of the heart, minimization of the radiation dose to the lung, and treatment of the ipsilateral internal mammary lymph nodes, leading to potential uncertainties in the efficacy of postmastectomy radiation therapy.2 The recent availability of intensity-modulated radiation treatment techniques may improve the quality of dose distribution after reconstructive surgery.3 Multidisciplinary preoperative discussion remains necessary in order to optimize the timing of breast reconstruction in patients with high-risk breast cancer.

Cyrus Chargari, M.D.
Youlia M. Kirova, M.D.
Alain Fourquet, M.D.
Institut Curie, 75005 Paris, France
chargari-vdg@hotmail.fr

3 References

1
Chawla AK, Kachnic LA, Taghian AG, Niemierko A, Zapton DT, Powell SN. Radiotherapy and breast reconstruction: complications and cosmesis with TRAM versus tissue expander/implant. Int J Radiat Oncol Biol Phys 2002;54:520-526
CrossRef | Web of Science | Medline

2
Motwani SB, Strom EA, Schechter NR, et al. The impact of immediate breast reconstruction on the technical delivery of postmastectomy radiotherapy. Int J Radiat Oncol Biol Phys 2006;66:76-82
CrossRef | Web of Science | Medline

3
Koutcher L, Ballangrud A, Cordeiro P, McCormick B, Hunt M, Beal K. Postmastectomy intensity modulated radiation therapy (IMRT) in women who undergo immediate breast reconstruction. Int J Radiat Oncol Biol Phys 2007;69:Suppl:S222-S222
CrossRef | Web of Science

Author/Editor Response

Patients with stage III breast cancer who undergo postmastectomy radiation therapy often have limited options for reconstruction. Radiation therapy to the chest wall can injure normal tissues and adversely affect the aesthetic outcomes in both implant-based and autologous tissue–based reconstruction. However, a significant percentage of patients with immediate implant reconstructions can attain acceptable results despite postoperative radiation therapy and — most importantly — patient satisfaction remains high.1 Patients who are not satisfied can undergo implant removal and subsequent reconstruction with autologous tissue such as a gluteus flap, as described by Beier et al. Irradiated flaps have been shown to have a greater than 85% rate of late complications and require a high rate (28%) of secondary flaps for salvage.2 If the patient were to proceed with an immediate gluteus reconstruction, the postoperative radiation would potentially ruin the result; therefore, the recommendation for immediate implant reconstruction makes sense.

The silicone controversy has largely been resolved, since most large studies provide support for the concept that the use of silicone is safe. A court-appointed National Science Panel performed a systematic review of all studies providing scientific evidence of any association between silicone breast implants and all types of systemic and connective diseases and concluded that there was no association.3 The current position of the Food and Drug Administration (FDA) is that “in the past decade, a number of independent studies have examined whether silicone gel–filled breast implants are associated with connective tissue disease or cancer. The studies, including a report by the Institute of Medicine, have concluded there is no convincing evidence that breast implants are associated with either of these diseases.”4 The FDA approved the use of silicone implants “based on a thorough review of each company's clinical (core) and preclinical studies, a review of studies by independent scientific bodies and deliberations of advisory panels of outside experts that heard public comment from hundreds of stakeholders.”4

Finally, Chargari et al. summarize some of the problems associated with reconstruction in patients who have undergone or potentially will undergo radiation therapy. However, it is possible to deliver adequate postoperative radiation with reconstruction when the patient is cared for by a multidisciplinary team that addresses all the different issues surrounding both oncologic treatment and reconstructive options.1,5

Peter G. Cordeiro, M.D.
Memorial Sloan-Kettering Cancer Center, New York, NY 10065

5 References

1
Cordeiro PG, Pusic AL, Disa JJ, McCormick B, VanZee K. Irradiation after immediate tissue expander/implant breast reconstruction: outcomes, complications, aesthetic results, and satisfaction among 156 patients. Plast Reconstr Surg 2004;113:877-881
CrossRef | Web of Science | Medline

2
Tran NV, Chang DW, Gupta A, Kroll SS, Robb GL. Comparison of immediate and delayed free TRAM flap breast reconstruction in patients receiving postmastectomy radiation therapy. Plast Reconstr Surg 2001;108:78-82
CrossRef | Web of Science | Medline

3
Tugwell P, Wells G, Peterson J, et al. Do silicone breast implants cause rheumatologic disorders? A systematic review for a court-appointed National Science Panel. Arthritis Rheum 2001;44:2477-2484
CrossRef | Web of Science | Medline

4
FDA approves silicone gel-filled breast implants after in-depth evaluation. Rockville, MD: Food and Drug Administration, 2006. (Accessed January 5, 2009, at http://www.fda.gov/bbs/topics/NEWS/2006/NEW01512.html.)

5
McCormick B, Wright J, Cordeiro PG. Breast reconstruction combined with radiation therapy: long-term risks and factors related to decision making. Cancer J 2008;14:264-268
CrossRef | Web of Science | Medline

Citing Articles (3)

Citing Articles

1
C.D. Taeger, R.E. Horch, A. Dragu, J.P. Beier, U. Kneser. (2011) Perforatorlappen. Der Chirurg
CrossRef
2
Harun Seyhan, Jürgen Kopp, Justus P. Beier, Melanie Vogel, Oke Akkermann, Ulrich Kneser, Stephan Schwartz, Arndt Hartmann, Raymund E. Horch. (2011) Smooth and textured silicone surfaces of modified gel mammary prostheses cause a different impact on fibroproliferative properties of dermal fibroblasts. Journal of Plastic, Reconstructive & Aesthetic Surgery 64:3, e60-e66
CrossRef
3
Adrian Dragu, Rainer Linke, Torsten Kuwert, Frank Unglaub, Ulrich Kneser, Michael Stürzl, Raymund E. Horch, Alexander D. Bach. (2010) Tc-99m Sestamibi SPECT/CT as a New Tool for Monitoring Perfusion and Viability of Buried Perforator Based Free Flaps in Breast Reconstruction After Breast Cancer. Clinical Nuclear Medicine 35:1, 36-37
CrossRef