Commentary (Deutsch): Treatment of Complications After Breast-Conservation Therapy

Sequelae that affect quality of life in women following breastconservation therapy can be grouped into three categories: (1) those that affect cosmesis such as skin changes, distortion, and asymmetry of the breasts; (2) those that cause physical symptoms such as local pain, decreased mobility of the ipsilateral shoulder, and in extreme cases, respiratory and cardiovascular impairments; and (3) those that require further treatment such as breast infection and abscess, arm edema, soft-tissue and bone necrosis, rib fractures, in-breast tumor recurrence, and second malignancies within the treated area.

Changes in skin pigmentation, distortions of the breast from surgery, and asymmetry of the breasts mainly affect the cosmetic outcome but usually do not cause physical symptoms. Symptomatic sequelae such as decreased shoulder mobility, breast pain, and musculoskeletal pain rarely affect the cosmetic outcome. However, other adverse events such as arm edema, breast infection, soft-tissue and bone necrosis, fat necrosis, and in-breast tumor recurrence will have an obvious effect on quality of life, because a diagnostic and therapeutic intervention is often required and cosmesis may be adversely affected.

Local Recurrence

An in-breast tumor recurrence is the most serious local event following breast-conservation therapy. The authors present an interesting discussion of the management of a local recurrence; however, I am not sure there is any benefit to determining whether the recurrence is a true recurrence or a second primary breast cancer. Local treatment will usually be the same, and differentiating recurrence from a new primary will not likely affect decisions concerning systemic therapy.

Although mastectomy is the most commonly accepted treatment for an in-breast tumor recurrence, especially following lumpectomy and breast irradiation, the authors note that several series have reported treating patients with salvage wide excision or repeat lumpectomy and local radiotherapy using either brachytherapy or limited-field external-beam irradiation. However, the cosmetic result after two lumpectomies in the same breast is likely to be inferior to the result after a single lumpectomy because of differences in symmetry and size.

The series reported by Deutsch[1] is probably one of the largest in which repeat high-dose external-beam radiotherapy with electrons was administered to the operative area in women with an in-breast tumor recurrence after a previous lumpectomy and whole-breast irradiation. Thus, in this series, all women had received at least 10,000 cGy of radiation to a portion of the breast and, even with additional follow-up since publication, no long-term complications such as soft-tissue necrosis, rib fracture, or persistent breast pain have been reported. The ultimate cosmetic result after repeat treatment depended mainly on the appearance of the breast following the second lumpectomy.

Fat Necrosis, Infection, and Musculoskeletal Pain

The authors provide an interesting and important discussion about some of the sequelae of breast-conservation therapy that, although important in terms of effect on cosmesis and quality of life, have not been given the same attention as arm edema and skin pigmentation changes. These include fat necrosis, infection, and musculoskeletal pain.

They note that cellulitis or abscess of the breast may occur at any time before, during, or after radiation therapy. Their discussion suggests that cellulitis or abscess occurring within the first few months of surgery is likely to be a true "surgical complication," possibly related to the presence and aspiration of a persistent seroma at the lumpectomy site. They present an important discussion of the treatment of breast infections and emphasize the need for early institution of antibiotic therapy. Although the authors suggest skin biopsy to rule out local recurrence in patients who fail to respond to conservative therapy, I suggest that a needle or punch biopsy be performed postradiotherapy. An incisional biopsy of an infected area after irradiation will often heal with scarring, retraction, and changes in skin pigmentation.

The authors' interesting discussion of fat necrosis emphasizes that this is a diagnostic or therapeutic problem, associated mainly with brachytherapy. Mammography is often accurate in differentiating fat necrosis from recurrent tumor. If tissue confirmation is necessary, needle biopsy as opposed to excisional biopsy should be considered.

The musculoskeletal effects of breast-conservation therapy are usually mild and rarely have a significant impact on quality of life. In the early postoperative period following breast surgery with axillary dissection, range of motion of the ipsilateral shoulder is often decreased, although this impairment frequently resolves. Limited ipsilateral shoulder motion occurring as a late sequela is rare. In one series, Deutsch and Flickinger[2] reported a 1.5% incidence of decreased shoulder motion in 331 patients treated with postoper- ative radiotherapy for primary breast cancer. Moreover, in some women, radiotherapy was not clearly the causative agent.

Cosmesis

The authors make the important point that "a minimum of 3 years" is necessary to determine whether a good or excellent cosmetic result is likely to be durable. In many patients, an excellent cosmetic result at 3 years posttherapy becomes only a fair or good cosmetic result at 10 to 15 years, primarily due to progressive asymmetry between the two breasts. A recent study by Deutsch and Flickinger showed that an excellent or good cosmetic result, as opposed to a fair or poor result, was associated with white race (P = .0056), a smaller separation between the tangential fields used to irradiate the breast (P = .001), and most interestingly, no use of tamoxifen (P = .025).[3] An increased interval from surgery was associated with fewer changes in pigmentation (P = .0058) and smaller size of the treated breast (P < .0001).

It appears that the irradiated breast will not increase in size by fat deposition to the same extent as the opposite breast. Thus, over many years of follow- up, the size of the irradiated breast tends to change very little, whereas the nonirradiated breast may increase in size and become more ptotic. This is seen mainly in women who have had a marked weight gain over many years.

Conclusions

It must be emphasized that the majority of patients treated with breast-conservation surgery and radiotherapy will have a good or excellent cosmetic result, and very few will develop symptomatic late sequelae. However, it is important that patients be followed regularly (for life) following breast-conservation therapy, not only to detect the occasional case of very late in-breast tumor recurrence, but also to detect and manage sequelae such as arm edema, shoulder mobility problems, and even second malignancies-all of which may occur decades following treatment.

Financial Disclosure:The author has no significant financial interest or other relationship with the manufacturers of any products or providers of any service mentioned in this article.

References:

1.

Deutsch M: Repeat high-dose externalbeam irradiation for in-breast tumor recurrenceafter previous lumpectomy and whole breastirradiation. Int J Radiat Oncol Biol Phys53:687-691, 2002.

2.

Deutsch M, Flickinger JC: Shoulder andarm problems following radiotherapy for primarybreast cancer. Am J Clin Oncol 24:172-176, 2001.

3.

Deutsch M, Flickinger JC: Patient characteristicsand treatment factors affecting cosmesisfollowing lumpectomy and breastirradiation. Am J Clin Oncol. In press.