breast cancer

INTRODUCTION

In women, is the most common malignancy and the second most common cause of death in the United States.

About 1 in 7 women are likely to develop breast cancer. Modified radical mastectomy is one of the standard treatment options for breast cancer. Quality-of-life issues are attracting more attention following such curative procedures. Following modified radical mastectomy, many women opt for immediate breast reconstruction. Following this surgery, some women may have an inadequate area of skin, which can be a problem in many breast reconstructions.

In the 1980s, Rodovan introduced the technique of tissue expansion using inflatable expanders that has rapidly become one of the methods of breast reconstruction. This allows development of adequate area of skin so that an appropriate and acceptable permanent implant can be placed at a later date. The temporary tissue expander is inserted subcuta-neously (fig 1) at the time of mastectomy. Three to 6 months later, the temporary tissue expander is replaced with a permanent breast prosthesis (fig 2). This method has the advantage due to its simplicity and the perfect texture and color match obtained after tissue expansion. canada pharmacy mall

Figure 1. A temporary tissue expander that is inserted

Figure 1. A temporary tissue expander that is inserted sub-cutaneously at the time of mastectomy

Radiation therapy is an integral part of the management of breast cancer. The issue of irradiating the prosthetically augmented breast is being encountered with increasing frequency. In such patients, radiotherapy is need for preventing loco-regional relapse. Following mastectomy and reconstruction, indications for adjuvant radiotherapy include positive deep surgical margins, four or more involved axillary lymph nodes, extra capsular nodal extension, skin involvement, stages ТЗ, T4 and N3 and recurrent breast carcinoma. Radiation therapy is also necessary in carcinoma arising in cosmetically augmented breasts, carcinoma occurring after a mastectomy and reconstruction for severe fibrocystic disease, and inner quadrant or central tumors with metastatic axillary nodes.

Figure 2. The temporary tissue expander

Figure 2. The temporary tissue expander is replaced with a permanent breast prosthesis following adequate expansion of skin, 4-6 months later.

Earlier, Jackson et al, studied the outcome in 10 Howard University Hospital patients who received post-mastectomy radiation following insertion of a temporary tissue expander. A two-year follow-up indicated good cosmesis in the majority (7 out of ten) of the patients. Of the remaining, one patient developed a leak from her prosthesis necessitating removal of her prosthesis. In the other two patients, the damaged prosthetic device had to be removed resulting in poor wound healing, seroma formation and tissue necrosis. These defects were not noticed during the course of radiation treatment and during routine examination. Detection of damage occurring in the temporary tissue expander during the course of radiotherapy might have averted the failures.

Subtle geometrical changes occurring in the prosthesis such as leaks, shape-volume alterations, and changes occurring in tissues adjacent to the tissue expander can be imperceptible to the radiation oncologist during the course of treatment. Furthermore, the mechanical stress and strain of the prosthesis during radiation can cause it to expand abnormally and extend beyond the planned radiation treatment field (fig 4 and 5), leading to dosimetric discrepancy. Heightened concern about this problem prompted us to monitor the temporary tissue expander and its surroundings at different stages of radiation treatment.
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The medical literature is replete with papers on the cosmetic outcome of breast reconstruction following irradiation. Surprisingly few of these articles discuss ways to monitor  the  prosthesis  during  the  course  of radiation treatment, apart from clinical examination. Changes occurring to the prosthesis in relation to the surrounding structures can lead to significant changes in the planned dosimetry, which in turn can cause inaccuracies in radiation delivery in such patients. Radiation oncologists should ensure the accuracy and precision of the delivery of radiation during treatment. To achieve this, it is important that the implanted prosthesis does not undergo any alterations during radiation therapy. We feel that addition of an imaging tool during the course of radiation treatment may help us to mitigate this problem. In this paper, we address this concern.