Journal of Surgical Oncology 46: 141-144 (1991)
Lactation Following Conservation Surgery and Radiotherapy for Breast Cancer GEORGE VARSOS, MD, AND JoACHlMYAHALOM, MD From the Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center New York, New York
A 38-year-old woman with early stage invasive breast cancer was treated with wide excision of the tumor, axillary lymph node dissection, and breast irradiation. Three years later, she gave birth to a normal baby. She attempted breast feeding and had full lactation from the untreated breast. The irradiated breast underwent only minor changes during pregnancy and postpartum but produced small amounts of colostrum and milk for 2 weeks postpartum. There are only a few reports of lactation after breast irradiation. These cases are reviewed, and possible factors affecting breast function after radiotherapy are discussed. Because of scant information available regarding its safety for the infant, nursing from the irradiated breast is not recommended. ~~~~
~~
KEYWORDS:breast cancer, radiotherapy, lactation, breast function, pregnancy
INTRODUCTION As an increasing number of young patients with early-stage breast cancer opt for conservation surgery and radiation therapy, future lactation becomes a relevant issue to those who consider pregnancy in the future. Unfortunately there is only anecdotal information concerning this aspect of breast function after radiation therapy [ 1-61. The experimental animal data available [7] are confined to low-energy, single-dose radiation and are of limited clinical significance. In this report we describe the breast changes and function in a patient who attempted breast feeding after breast irradiation and review the available information from the literature. CASE REPORT A 38-year-old woman developed a 2-cm mass at the 12 o’clock axis of the left breast 2 cm superior to the areola. In May 1986, she underwent a wide excision of the lesion that revealed intraductal and high-grade infiltrating duct carcinoma of the breast. All surgical margins were negative. Both estrogen and progesterone receptors were positive. An ipsilateral axillary node dissection demonstrated no metastatic involvement in the 18 lymph nodes obtained. The patient was treated postoperatively with radiation therapy. The entire left breast was treated to a total dose of 4,600 cGy (23 fractions of 200 cGy within 4% weeks) using tangential medial and lateral opposed 0 1991 Wiley-Liss, Inc.
fields. A boost dose to the tumor bed of 1,600 cGy was delivered to a 15 X 6 cm target via a temporary two plane interstitial Iridium 192 implant. The patient completed her treatment in July 1986 and was judged at follow-up visits to have an excellent cosmetic result. In January 1989, the patient, who until then was GO PO, became pregnant. During the course of her pregnancy the patient was noted to have swelling of both breasts, however, this swelling was much more pronounced on the untreated right side. In September 1989, she had a vaginal delivery of a normal child. Immediately after delivery, the production of yellowish colostrum-like fluid was observed from both breasts. However, the irradiated left breast produced a smaller volume compared to the untreated breast. The patient observed the fluid to become “milky” in color 1 day postpartum, and the baby began feeding from both breasts. Production of milk from the treated breast continued in small amounts. The baby abandoned feeding from this side (left) in favor of the unirradiated side, which became the only source for breast feeding after 2 weeks, when lactation from the left breast ceased completely. On physical examination 1 I weeks postpartum, the right breast was about three times larger and fuller than the left breast (Fig. 1). MammoAccepted for publication June 14, 1990. Address reprint requests to Dr. Joachim Yahalom, 1275 York Avenue, New York. NY 10021.
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Fig. 1. Eleven weeks postpartum. The lactating right (untreated) breast is engorged and swollen compared with the left (irradiated) side. Prior to pregnancy the breasts were symmetric.
Fig. 2. Mammogram performed during lactation period 11 weeks postpartum shows the difference between the irradiated (left) breast and untreated (right) breast.
gram (Fig. 2) demonstrated the difference in size and density but revealed no suspicious finding. Breast feed- has shown an age-related response of breast tissue to ing continues from the unirradiated side at the time of this radiation [ 121. These patients can exhibit marked underdevelopment of the breasts after puberty if doses above report 5 months postpartum. 300 cGy were delivered to their entire infantile breast DISCUSSION bud. Turner and Gomez [7] performed a series of experiDuring the past 20 years, conservation surgery followed by radiation therapy has been accepted as an ments on rabbits in order to determine the radiation effect alternative to mastectomy for early stage breast cancer on subsequent lactation at different stages of breast [8]. Recent analyses have focused on the cosmetic and development. They found that the rudimentary duct psychological aspects of the treatment [9,10]. However, epithelium, before estrogenic stimulation, was relatively the physiologic function of milk production after breast resistant to radiation. However, after estrogen stimulaconservation has been the subject of only few reports tion of the prepubertal breast, the radioresponsiveness of [ 1-61. Only limited data are available on the subject but, the duct epithelium was increased by 30-50%. When the as more women of childbearing age are successfully growth of the duct system was complete, radioresistance treated in this manner, more information will probably was again observed. During experimental pseudopregbecome available. nancy , radioresponsiveness increased, particularly of the The biopsy of a breast tumor alone should not ad- lubuloalveolar epithelial cell lining. It is of note that versely affect lactation unless the main subareolar mam- radiation data in these experiments are limited to single mary ducts are resected. Therefore, subsequent lactation doses, orthovoltage (140-kV) radiation. after modern early breast cancer treatment is most Table I lists reports of attempted breast feeding by dependent on the extent of the radiation injury to the patients who have previously been treated with breast mammary ducts and glandular tissues. In common prac- irradiation for early breast cancer. In all instances, tice, when treating the breast after limited resection of an radiation to the whole breast was given using tangential invasive cancer, a fractionated dose of radiation in a fields. All tumor bed boosts listed were given with an range of 4,500-5,500 cGy is delivered to the whole interstitial implant using Iridium- 192 with an exception breast. An additional boost radiation of 1,000-2,000 cGy of case 3, in whom external beam photons were used for is often delivered to the tumor bed area, using 1921r the boost. The TDF values" listed in the table were either temporary implant or an electron beam. Histological obtained from Rostom's published correspondence [ 131 analyses of breast tissue that have received preoperative or calculated by the authors. doses in the range of 4,000-6,000 cGy [ 111 revealed characteristic histologic changes. These changes include ductal shrinkage with formation of pyknotic nuclei and *TDF-time, dose. fractionation-factor was devised in order to compare the effect on connective tissue of different radiation schemes condensation of cytoplasm in the cells lining the ducts. [14]. It is a number generated by accounting for the fraction size, Clinical experience in the treatment of pediatric patients length of treatment, and total radiation dose.
Lactation After Breast Irradiation
143
TABLE I. Lactation Following Breast Irradiation Case No. I 2 3 4 5 6 7 8 9
Investigators
Interval between radiation and birth (yr)
Rodger et al. [3] Rodger et al. [3] Bums [ I ] David [2] Rostom and O’Cathail [4] Rostom and O’Cathail [4] Findlay et al. [5] Ulmer [6] Present case
3 3 1 4 5 3 4 8 3
Radiation dose (cGy) Whole Tumor bed breast boost 4,320-4,500 4,200-4,500 4,500 4,500 Not specified Not specified 4,860 6,000 4,800
3,000 2,000 1,000 2,025 2,000 No boost 1,600
Lactation Treated Untreated breast breast No Yes No Yes No No Yesa No Yesa
Yes Yes Yes Yes Yes Yes Yes Yes Yes
Whole breast TDF~ 71 77 93.5 70 98.6 93.5 76 108 76
asmall amount of lactation lasting 2-4 weeks. bTDF, time, dose, fractionation.
Of the nine reported cases of parturition after radiation to the breast, full lactation from the treated breast was observed in only two patients. Two additional patients lactated in small amounts. Case 7 is similar to the present case in that lactation from the treated breast occurred in small amounts for a period of < I month. In both cases, the patients could not detect a difference in the character of the colostrum or milk from the treated and untreated breast. The description of case 7 states that the baby, who initially had no breast preference, refused to nurse from the treated breast by the fourth postpartum week. This presumably occurred because of decreased lactation from that side. The baby’s response in our present case was similar. Rostom [ 131 suggested that the ability to lactate after radiation to the breast is a function of dose to the whole breast using the TDF formula. Although the number of cases is small, the TDF data, presented in Table I, support a dose factor in preserving breast lactation function. No case of full or partial lactation in the irradiated breast occurred when the TDF factor exceeded 77. The time and interval from radiation to parturition did not appear to affect milk production. In the reported cases lactation occurred as early as 10 months after radiation and up to 6 years post treatment. None of the cases reviewed showed any disruption of lactation from the untreated breast. The limited experience available in the literature does not suggest an unfavorable effect of pregnancy or lactation on the course of breast cancer [15]. The prospect is poor for full volume lactation from the treated breast. The scanty available information concerning the consequences of nursing from an irradiated breast, make it inadvisable to nurse from the treated breast. The contralateral unirradiated breast may serve as a satisfactory source for breast feeding. Milk production by an irradiated breast is not an indication of inappropriate radiotherapy, since the radiobiological characteristics of nor-
mal breast epithelium and malignant breast cells are not necessarily identical. None of the patients reviewed has had a local recurrence. Case-controlled studies indicated that pregnancy after treatment of early-stage breast cancer has not been associated with an adverse prognosis [16,17].
CONCLUSIONS Irradiation of the breast after conservation surgery may still allow full or limited postpartum lactation from the treated breast in some patients. This aspect of breast function may be dose related. Milk production from the untreated breast is not affected by irradiating the involved side.
REFERENCES 1. Bums PE: Absence of lactation in previously radiated breast.
(Letter.) Int J Radiat Oncol Biol Phys 13:1603-1604, 1987. 2. David FC: Lactation following primary radiation therapy for carcinoma of the breast. (Letter.) Int J Radiat Oncol Biol Phys 11:1425, 1985. 3. Rodger A, Corbett PJ, Chetty J: Lactation after breast conserving therapy including radiation therapy for early breast cancer, Radiother Oncol 15:243-244, 1989. 4. Rostrom AY, O’Cathail S: Failure of lactation following radiotherapy for breast cancer. (Letter.) Lancet 18:163-164, 1986. 5 . Findlay PA, Gorrell CR, D’Angelo T, Glatstein E: Lactation after breast radiation. (Letter.) Int J Radiat Oncol Biol Phys 15511512, 1988. 6. Ulmer HU: Lactation after conserving therapy of breast cancer? (Letter.) Int J Radiat Oncol Biol Phys 15512, 1988. 7. Turner CW, Gomez ET: The radiosensitivity of the cells of the mammary gland. AJR 36:79-93, 1936. 8. Henderson IC, Harris JR, Kinne DW, Hellman S: Cancer of the breast. In DeVita VT, Hellman S, Rosenberg SA (eds): “Cancer: Principles and Practice of Oncology.” 3rd ed Philadelphia: JB Lippincott Company, 1989, pp 1197-1258. 9. McCormick B, Yahalom J, Cox L, Shank B, Massie MJ: The patient’s perception of her breast following radiation and limited surgery. Int J Radiat Oncol Biol Phys 17:1299-1302, 1989. 10. Beadle GF, Silver B, Botnick L, Hellman S, Harris JR: Cosmetic results following primary radiation therapy for early breast cancer. Cancer 54:2911-2198, 1984.
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11. Schnitt SJ, Connolly JL, Hellman S, Piro A, Cohen RB: Radiation
induced changes in the breast. Hum Pathol 15545-550, 1984. 12. Kolar J, Vaclav B, Vrabec R: Breast after contact x-ray therapy for cutaneous angiomas. Arch Dermatol 96:427-430, 1967. 13. Rostom AY: Failure of lactation following radiotherapy for breast cancer. (Letter.) Int J Radiat Oncol Biol Phys 15511, 1988. 14. Orton CG, Ellis F: A simplification in the use of the NSD concept in practical radiotherapy. Br J Radio1 46529-537, 1973.
15. Petrek JA: Breast cancer and pregnancy. In Harris JR, Hellman S, Henderson LC,Kinne DW (eds): “Breast Diseases.” Philadelphia: JB Lippincott Company, 1987, pp 600-608. 16. Harvey JC, Rosen PP, Ashikari H: The effect of pregnancy on the prognosis of carcinoma of the breast following radical mastectomy. Surg Gynecol Obstet 153:723-725, 1981. 17. Cooper DR, Butterfield J: Pregnancy subsequent to mastectomy for cancer of the breast. Ann Surg 171:429-433, 1970.
Lactation Following Conservation Surgery and Radiotherapy for Breast Cancer GEORGE VARSOS, MD, AND JoACHlMYAHALOM, MD From the Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center New York, New York
A 38-year-old woman with early stage invasive breast cancer was treated with wide excision of the tumor, axillary lymph node dissection, and breast irradiation. Three years later, she gave birth to a normal baby. She attempted breast feeding and had full lactation from the untreated breast. The irradiated breast underwent only minor changes during pregnancy and postpartum but produced small amounts of colostrum and milk for 2 weeks postpartum. There are only a few reports of lactation after breast irradiation. These cases are reviewed, and possible factors affecting breast function after radiotherapy are discussed. Because of scant information available regarding its safety for the infant, nursing from the irradiated breast is not recommended. ~~~~
~~
KEYWORDS:breast cancer, radiotherapy, lactation, breast function, pregnancy
INTRODUCTION As an increasing number of young patients with early-stage breast cancer opt for conservation surgery and radiation therapy, future lactation becomes a relevant issue to those who consider pregnancy in the future. Unfortunately there is only anecdotal information concerning this aspect of breast function after radiation therapy [ 1-61. The experimental animal data available [7] are confined to low-energy, single-dose radiation and are of limited clinical significance. In this report we describe the breast changes and function in a patient who attempted breast feeding after breast irradiation and review the available information from the literature. CASE REPORT A 38-year-old woman developed a 2-cm mass at the 12 o’clock axis of the left breast 2 cm superior to the areola. In May 1986, she underwent a wide excision of the lesion that revealed intraductal and high-grade infiltrating duct carcinoma of the breast. All surgical margins were negative. Both estrogen and progesterone receptors were positive. An ipsilateral axillary node dissection demonstrated no metastatic involvement in the 18 lymph nodes obtained. The patient was treated postoperatively with radiation therapy. The entire left breast was treated to a total dose of 4,600 cGy (23 fractions of 200 cGy within 4% weeks) using tangential medial and lateral opposed 0 1991 Wiley-Liss, Inc.
fields. A boost dose to the tumor bed of 1,600 cGy was delivered to a 15 X 6 cm target via a temporary two plane interstitial Iridium 192 implant. The patient completed her treatment in July 1986 and was judged at follow-up visits to have an excellent cosmetic result. In January 1989, the patient, who until then was GO PO, became pregnant. During the course of her pregnancy the patient was noted to have swelling of both breasts, however, this swelling was much more pronounced on the untreated right side. In September 1989, she had a vaginal delivery of a normal child. Immediately after delivery, the production of yellowish colostrum-like fluid was observed from both breasts. However, the irradiated left breast produced a smaller volume compared to the untreated breast. The patient observed the fluid to become “milky” in color 1 day postpartum, and the baby began feeding from both breasts. Production of milk from the treated breast continued in small amounts. The baby abandoned feeding from this side (left) in favor of the unirradiated side, which became the only source for breast feeding after 2 weeks, when lactation from the left breast ceased completely. On physical examination 1 I weeks postpartum, the right breast was about three times larger and fuller than the left breast (Fig. 1). MammoAccepted for publication June 14, 1990. Address reprint requests to Dr. Joachim Yahalom, 1275 York Avenue, New York. NY 10021.
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Fig. 1. Eleven weeks postpartum. The lactating right (untreated) breast is engorged and swollen compared with the left (irradiated) side. Prior to pregnancy the breasts were symmetric.
Fig. 2. Mammogram performed during lactation period 11 weeks postpartum shows the difference between the irradiated (left) breast and untreated (right) breast.
gram (Fig. 2) demonstrated the difference in size and density but revealed no suspicious finding. Breast feed- has shown an age-related response of breast tissue to ing continues from the unirradiated side at the time of this radiation [ 121. These patients can exhibit marked underdevelopment of the breasts after puberty if doses above report 5 months postpartum. 300 cGy were delivered to their entire infantile breast DISCUSSION bud. Turner and Gomez [7] performed a series of experiDuring the past 20 years, conservation surgery followed by radiation therapy has been accepted as an ments on rabbits in order to determine the radiation effect alternative to mastectomy for early stage breast cancer on subsequent lactation at different stages of breast [8]. Recent analyses have focused on the cosmetic and development. They found that the rudimentary duct psychological aspects of the treatment [9,10]. However, epithelium, before estrogenic stimulation, was relatively the physiologic function of milk production after breast resistant to radiation. However, after estrogen stimulaconservation has been the subject of only few reports tion of the prepubertal breast, the radioresponsiveness of [ 1-61. Only limited data are available on the subject but, the duct epithelium was increased by 30-50%. When the as more women of childbearing age are successfully growth of the duct system was complete, radioresistance treated in this manner, more information will probably was again observed. During experimental pseudopregbecome available. nancy , radioresponsiveness increased, particularly of the The biopsy of a breast tumor alone should not ad- lubuloalveolar epithelial cell lining. It is of note that versely affect lactation unless the main subareolar mam- radiation data in these experiments are limited to single mary ducts are resected. Therefore, subsequent lactation doses, orthovoltage (140-kV) radiation. after modern early breast cancer treatment is most Table I lists reports of attempted breast feeding by dependent on the extent of the radiation injury to the patients who have previously been treated with breast mammary ducts and glandular tissues. In common prac- irradiation for early breast cancer. In all instances, tice, when treating the breast after limited resection of an radiation to the whole breast was given using tangential invasive cancer, a fractionated dose of radiation in a fields. All tumor bed boosts listed were given with an range of 4,500-5,500 cGy is delivered to the whole interstitial implant using Iridium- 192 with an exception breast. An additional boost radiation of 1,000-2,000 cGy of case 3, in whom external beam photons were used for is often delivered to the tumor bed area, using 1921r the boost. The TDF values" listed in the table were either temporary implant or an electron beam. Histological obtained from Rostom's published correspondence [ 131 analyses of breast tissue that have received preoperative or calculated by the authors. doses in the range of 4,000-6,000 cGy [ 111 revealed characteristic histologic changes. These changes include ductal shrinkage with formation of pyknotic nuclei and *TDF-time, dose. fractionation-factor was devised in order to compare the effect on connective tissue of different radiation schemes condensation of cytoplasm in the cells lining the ducts. [14]. It is a number generated by accounting for the fraction size, Clinical experience in the treatment of pediatric patients length of treatment, and total radiation dose.
Lactation After Breast Irradiation
143
TABLE I. Lactation Following Breast Irradiation Case No. I 2 3 4 5 6 7 8 9
Investigators
Interval between radiation and birth (yr)
Rodger et al. [3] Rodger et al. [3] Bums [ I ] David [2] Rostom and O’Cathail [4] Rostom and O’Cathail [4] Findlay et al. [5] Ulmer [6] Present case
3 3 1 4 5 3 4 8 3
Radiation dose (cGy) Whole Tumor bed breast boost 4,320-4,500 4,200-4,500 4,500 4,500 Not specified Not specified 4,860 6,000 4,800
3,000 2,000 1,000 2,025 2,000 No boost 1,600
Lactation Treated Untreated breast breast No Yes No Yes No No Yesa No Yesa
Yes Yes Yes Yes Yes Yes Yes Yes Yes
Whole breast TDF~ 71 77 93.5 70 98.6 93.5 76 108 76
asmall amount of lactation lasting 2-4 weeks. bTDF, time, dose, fractionation.
Of the nine reported cases of parturition after radiation to the breast, full lactation from the treated breast was observed in only two patients. Two additional patients lactated in small amounts. Case 7 is similar to the present case in that lactation from the treated breast occurred in small amounts for a period of < I month. In both cases, the patients could not detect a difference in the character of the colostrum or milk from the treated and untreated breast. The description of case 7 states that the baby, who initially had no breast preference, refused to nurse from the treated breast by the fourth postpartum week. This presumably occurred because of decreased lactation from that side. The baby’s response in our present case was similar. Rostom [ 131 suggested that the ability to lactate after radiation to the breast is a function of dose to the whole breast using the TDF formula. Although the number of cases is small, the TDF data, presented in Table I, support a dose factor in preserving breast lactation function. No case of full or partial lactation in the irradiated breast occurred when the TDF factor exceeded 77. The time and interval from radiation to parturition did not appear to affect milk production. In the reported cases lactation occurred as early as 10 months after radiation and up to 6 years post treatment. None of the cases reviewed showed any disruption of lactation from the untreated breast. The limited experience available in the literature does not suggest an unfavorable effect of pregnancy or lactation on the course of breast cancer [15]. The prospect is poor for full volume lactation from the treated breast. The scanty available information concerning the consequences of nursing from an irradiated breast, make it inadvisable to nurse from the treated breast. The contralateral unirradiated breast may serve as a satisfactory source for breast feeding. Milk production by an irradiated breast is not an indication of inappropriate radiotherapy, since the radiobiological characteristics of nor-
mal breast epithelium and malignant breast cells are not necessarily identical. None of the patients reviewed has had a local recurrence. Case-controlled studies indicated that pregnancy after treatment of early-stage breast cancer has not been associated with an adverse prognosis [16,17].
CONCLUSIONS Irradiation of the breast after conservation surgery may still allow full or limited postpartum lactation from the treated breast in some patients. This aspect of breast function may be dose related. Milk production from the untreated breast is not affected by irradiating the involved side.
REFERENCES 1. Bums PE: Absence of lactation in previously radiated breast.
(Letter.) Int J Radiat Oncol Biol Phys 13:1603-1604, 1987. 2. David FC: Lactation following primary radiation therapy for carcinoma of the breast. (Letter.) Int J Radiat Oncol Biol Phys 11:1425, 1985. 3. Rodger A, Corbett PJ, Chetty J: Lactation after breast conserving therapy including radiation therapy for early breast cancer, Radiother Oncol 15:243-244, 1989. 4. Rostrom AY, O’Cathail S: Failure of lactation following radiotherapy for breast cancer. (Letter.) Lancet 18:163-164, 1986. 5 . Findlay PA, Gorrell CR, D’Angelo T, Glatstein E: Lactation after breast radiation. (Letter.) Int J Radiat Oncol Biol Phys 15511512, 1988. 6. Ulmer HU: Lactation after conserving therapy of breast cancer? (Letter.) Int J Radiat Oncol Biol Phys 15512, 1988. 7. Turner CW, Gomez ET: The radiosensitivity of the cells of the mammary gland. AJR 36:79-93, 1936. 8. Henderson IC, Harris JR, Kinne DW, Hellman S: Cancer of the breast. In DeVita VT, Hellman S, Rosenberg SA (eds): “Cancer: Principles and Practice of Oncology.” 3rd ed Philadelphia: JB Lippincott Company, 1989, pp 1197-1258. 9. McCormick B, Yahalom J, Cox L, Shank B, Massie MJ: The patient’s perception of her breast following radiation and limited surgery. Int J Radiat Oncol Biol Phys 17:1299-1302, 1989. 10. Beadle GF, Silver B, Botnick L, Hellman S, Harris JR: Cosmetic results following primary radiation therapy for early breast cancer. Cancer 54:2911-2198, 1984.
144
Varsos and Yahalom
11. Schnitt SJ, Connolly JL, Hellman S, Piro A, Cohen RB: Radiation
induced changes in the breast. Hum Pathol 15545-550, 1984. 12. Kolar J, Vaclav B, Vrabec R: Breast after contact x-ray therapy for cutaneous angiomas. Arch Dermatol 96:427-430, 1967. 13. Rostom AY: Failure of lactation following radiotherapy for breast cancer. (Letter.) Int J Radiat Oncol Biol Phys 15511, 1988. 14. Orton CG, Ellis F: A simplification in the use of the NSD concept in practical radiotherapy. Br J Radio1 46529-537, 1973.
15. Petrek JA: Breast cancer and pregnancy. In Harris JR, Hellman S, Henderson LC,Kinne DW (eds): “Breast Diseases.” Philadelphia: JB Lippincott Company, 1987, pp 600-608. 16. Harvey JC, Rosen PP, Ashikari H: The effect of pregnancy on the prognosis of carcinoma of the breast following radical mastectomy. Surg Gynecol Obstet 153:723-725, 1981. 17. Cooper DR, Butterfield J: Pregnancy subsequent to mastectomy for cancer of the breast. Ann Surg 171:429-433, 1970.
