Consider variables before imaging reconstructed breast for cancer

Issue: April 25, 2011

There is little evidence to support surveillance imaging for cancer recurrence after breast reconstruction, but many women continue to receive it, according to Laura Esserman, MD, of the University of California, San Francisco.

"The data on surveillance imaging of the reconstructed breast are extremely limited,” Esserman said during her presentation. “The type of reconstruction, expected site and likelihood of recurrence can help to provide guidance on imaging in the setting of mastectomy and reconstruction."

According to Esserman, there are two considerations when deciding whether imaging of the breast adds value. The first consideration is the type of reconstruction. Most recurrences after a mastectomy will happen at the chest wall or the skin. Because implant reconstruction is almost always submuscular, the chest wall will be displaced to under the skin, making a physical examination the best surveillance option.

In women who have transverse rectus abdominis myocutaneous (TRAM) reconstruction or deep inferior epigastric perforator (DIEP) reconstruction, soft tissue or muscle are brought over the chest wall, which obscures recurrences that occur on the chest wall. Because these autologous tissue reconstructions comprise mostly fat, mammography can be used on these patients if necessary, Esserman said.

The second consideration in surveillance imaging of reconstructed breast is the risk for breast cancer recurrence. The risk for local recurrence after a mastectomy is low, ranging from 4% to 5%, especially if postmastectomy radiation therapy or adjuvant or neoadjuvant chemotherapy is given. About 50% of all local recurrences occur on the chest wall.

Some women are at higher risk for both distant and local recurrence. These include women with triple-negative breast cancer, women with HER-2–positive disease and a poor response to neoadjuvant therapy, and women with locally advanced disease or high-risk biology. The risk for local recurrence for these women is highest in the first 3 to 5 years. Although imaging during this time frame may be considered, there are no studies that support it. A registry might be an excellent solution for gathering more data, Esserman told HemOnc Today. – by Emily Shafer

Esserman L. Surveillance imaging of the reconstructed breast. Presented at: the 28th Annual Miami Breast Cancer Conference; March 9-12, 2011; Miami.

Disclosure: Dr. Esserman reports no relevant financial disclosures.

Imaging of the postmastectomy breast is not done routinely. Local recurrences, which are uncommon, tend to occur in the tissue close to the skin surface and are amenable to detection by physical examination. By the time it can be picked up by imaging, it can be picked up with a clinical examination. After reconstruction with an implant, the same is true. The implant is placed behind the muscle, so that the tissue where a recurrence may happen is close to the surface, and again, would be most easily picked up by physical examination.

After a person has had a TRAM flap, recurrences can occur near the edges of the flap, in which case they can also be picked up by physical examination. But, recurrences can also happen behind the flap, which cannot be picked up easily by physical examination. Those recurrences are usually picked up by symptoms the patient has, such as pain or nerve problems in the arm. Some, but not many, people will do routine mammograms in women who have had a TRAM, but I think it’s a minority of facilities that do this. The problem with doing routine mammograms on the TRAM, is that one of the common complications of a TRAM flap is fat necrosis. It’s completely benign, but on a mammogram, it can look suspicious. We found about 20 years ago that when we did routine mammograms on women with TRAM flaps, we were picking up many false alarms, and not picking up any recurrences.

– Carol H. Lee, MD
Radiologist, Memorial Sloan-Kettering Cancer Center

Disclosure: Dr. Lee reports no relevant financial disclosures.