One of my breast cancer patients called me today. She recently underwent bilateral mastectomies and immediate breast reconstruction with DIEP flaps. She recovered very well from the surgery but unfortunately her pathology results showed that she had cancer extending almost to the edge of the mastectomy specimen. The exact medical jargon used by the pathologist was.... "invasive carcinoma extending to 1mm from the margin". She also had DCIS (ductal carcinoma in situ) "extending to 0.2mm from the margin."
From a purist's perspective, these results still represent "clear margins". In other words, no tumor was found at the edge of the mastectomy specimen so there is no reason to believe there is any cancer left in my patient's breast. BUT, it's very close and that is certainly worrisome.
She called me today because she visited with her oncologist (cancer doc) and a radiation oncologist (cancer doc specializing in radiotherapy) and radiation therapy was recommended (in addition to the planned chemotherapy).
She explained to the radiation oncologist that she was worried the radiation therapy would ruin her DIEP flap reconstruction. She is right to be fearful of this - patients undergoing radiation therapy after an autologous reconstruction (ie a reconstruction using their own tissue) have a 28% risk of needing further surgery to correct asymmetry caused by the radiation changes (usually firming and shrinking) of the irradiated breast.
The response she received from the radiation oncologist baffled me (and is actually the reason behind this blogpost)...... "DIEP flap? What's a DIEP flap?.... if you'd had a TRAM flap then you wouldn't be needing radiation".
What?
This is a ridiculous statement. Let me clarify why...
This lady is being recommended radiation therapy as an insurance policy to decrease the risk of local recurrence (cancer coming back in the same breast). This is a consequence of her "near margins" which in turn are a result of the mastectomy specimen. Obviously the mastectomy was completed before the reconstruction was even started. If this lady had only had the mastectomy (without reconstruction) the margins would be the same. The breast reconstruction, and moreover, the type of breast reconstruction has absolutely nothing to do with it. The margins, the pathologist reading and the recommendation for radiation therapy would have been exactly the same whether reconstruction was performed or not.
So what's the take home message if you're considering breast reconstruction surgery? Choose whichever method of reconstruction is best for you. Your decision will not influence the likelihood of your cancer coming back in any way. The risk of cancer recurrence is related to the characteristics of the cancer itself and the mastectomy margins, not the method of reconstruction.
Dr C
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Dr Chrysopoulo is a board certified breast reconstruction surgeon specializing in DIEP flap breast reconstruction surgery. He and his partners perform over 350 DIEP flap procedures each year with a success rate of over 99%. PRMA Plastic Surgery, San Antonio, Texas. Toll Free: (800) 692-5565. Keep up to date with the latest breast reconstruction news by following Dr Chrysopoulo's Breast Cancer Reconstruction Blog.
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