48 - Breast reconstruction and radiotherapy: indications, techniques, and outcomes

Abstract

Breast cancer is the most common diagnosed cancer in women worldwide. Surgery remains the mainstay of treatment, but radiotherapy (RT) has been shown to optimize oncological outcomes by reducing the locoregional recurrence rate and increasing the overall survival rate. Consequently, a growing number of patients find themselves in the situation of having to integrate breast reconstruction (BR) and RT. The three most likely scenarios are: (1) BR in the context of breast-conserving surgery and RT; (2) BR in the setting of postmastectomy radiotherapy (PMRT); and (3) BR in a pre-irradiated field. Despite its therapeutic advantages, RT has traditionally been considered the single most significant predictor of increased risk of complications and poor aesthetic outcomes from BR. Oncoplastic breast-conserving surgery has gained universal acceptance for early breast cancer treatment because it allows surgeons to perform wider local excisions for optimal cancer control and repair the defect prior to RT. Both volume displacement and volume replacement procedures are viable options for partial BR when performed in appropriately-selected patients. In more advanced breast cancer, different mastectomy techniques are available for the surgical resection of the tumor. Although various algorithms have been proposed in an attempt to mitigate the adverse effects of RT on the reconstructed breast, debate remains over how best to optimize outcomes. Autologous tissue is still the gold-standard technique for BR in the setting of PMRT. Recent technological advances, such as the use of acellular dermal matrix, improved preservation of mastectomy flaps, and better knowledge of local perforator flaps have made implant-based and hybrid reconstructions reliable options for specific cases of BR in the context of RT. In general, immediate BR seems to be the most advantageous approach in the setting of PMRT. BR in a pre-irradiated field represents another great challenge for the reconstructive surgeon, as it means working with fibrotic tissue with adhesions and poor vascularization. In these circumstances, autologous tissue technique is also the most reliable options to achieve esthetically-viable, long-lasting results. Alternatively, hybrid reconstruction represents a safe and effective option for specific situations. Finally, symmetrization procedures of the contralateral breast and reconstruction of the nipple–areola complex are important to ensure good cosmetic results and patient satisfaction; however, certain issues associated with RT must be considered to avoid serious complications.