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Long-term cosmetic outcome after preoperative radio-/chemotherapy in locally advanced breast cancer patients

Langfristiges kosmetisches Ergebnis nach neoadjuvanter Radio‑/Chemotherapie bei lokal fortgeschrittenen Brustkrebspatientinnen

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Abstract

Background

Preoperative radiotherapy and chemoradiotherapy (PRT/PCRT) represent an increasingly used clinical strategy in different tumor sites. We have previously reported on a PRT/PRCT protocol in patients with locally advanced non-inflammatory breast cancer (LABC) with promising clinical results. However, concerns regarding a possible unfavorable influence on cosmesis still exist. Thus, the aim of the current study was to examine long-term cosmetic outcome in our series of LABC patients treated with PRT/PCRT followed by breast-conserving surgery (BCS) or mastectomy (ME).

Patients and methods

Of the 315 patients treated with PRT/PCRT in the years 1991 to 1999, 203 were still alive at long-term follow-up of mean 17.7 years (range 14–21). Thirty-seven patients were lost to follow-up and 58 patients refused to be contacted, which resulted in 107 patients (64 patients after BCS and 43 after mastectomy) being available and willing to undergo further cosmetic assessment. One patient had a complete response after PRT/PCRT and refused surgery. PRT/PCRT consisted of external beam radiation therapy (EBRT) with 50 Gy (5 × 2 Gy/week) to the breast and the supra-/infraclavicular lymph nodes combined with a consecutive electron boost or (in case of BCS) a 10-Gy interstitial brachytherapy boost with Ir-192 prior to EBRT. Overall, chemotherapy was administered either prior to RT or concomitantly in the majority of patients. BCS and mastectomy were performed with and without reconstruction. The cosmetic outcome was assessed by patient questionnaire, panel evaluation, and breast retraction assessment (BRA) score.

Results

Eighty percent of all BCS patients rated their overall cosmetic result as “excellent” or “good” as compared to 55.8% after mastectomy. Patient and panel ratings on cosmetic outcomes were similar between the two groups. No grade III or IV fibrosis were detected in any of the groups. The median BRA score after breast conserving surgery was 2.9.

Conclusion

PRT/PCRT is associated with low grades of fibrosis and a good to excellent long-term cosmetic outcome.

Zusammenfassung

Hintergrund

Die präoperative Radiotherapie und Chemoradiotherapie (PRT/PCRT) stellen eine zunehmend angewandte klinische Strategie bei verschiedenen Tumorentitäten dar. Wir haben bereits über ein PRT/PRCT-Protokoll bei Patientinnen mit lokal fortgeschrittenem nichtinflammatorischem Mammakarzinom (LABC) mit vielversprechenden klinischen Ergebnissen berichtet. Es bestehen jedoch immer noch Bedenken hinsichtlich eines möglichen ungünstigen Einflusses auf die Kosmetik. Ziel der aktuellen Studie war es daher, das langfristige kosmetische Ergebnis unserer Behandlungsserie von mit PRT/PCRT behandelten LABC-Patienten, die eine brusterhaltenden Operation (BCS) oder einer Mastektomie (ME) erhielten, zu untersuchen.

Patienten und Methoden

Von den 315 Patientinnen, die in den Jahren 1991 bis 1999 mit PRT/PCRT behandelt wurden, lebten noch 203 Patientinnen bei einer Langzeitbeobachtung von durchschnittlich 17,7 Jahren (Spanne 14–21 Jahre). Von den Patientinnen konnten 37 nicht mehr kontaktiert werden und 58 lehnten eine Kontaktaufnahme ab, was dazu führte, dass 107 Patientinnen (64 Patientinnen nach BCS und 43 nach ME) zur Verfügung standen und bereit waren, sich einer weiteren kosmetischen Beurteilung zu unterziehen. Eine Patientin hatte eine komplette pathologische Remission und verweigerte eine anschließende Operation. Die PRT/PCRT bestand aus einer externen Strahlentherapie (EBRT) mit 50 Gy (5 × 2 Gy/Woche) an der Brust und den supra-/infraklavikulären Lymphknoten, kombiniert mit einem konsekutiven Elektronenboost oder (bei BCS) einer interstitiellen Brachytherapie von 10 Gy mit Ir-192 vor EBRT. Insgesamt wurde die Chemotherapie entweder vor der RT oder bei der Mehrzahl der Patientinnen gleichzeitig verabreicht. Die BCS und ME wurden mit und ohne Rekonstruktion durchgeführt. Das kosmetische Ergebnis wurde anhand des Patientenfragebogens, der Einschätzung von Fachpersonal und der Bewertung der Asymmetrie der Brustwarzen (BRA) beurteilt.

Ergebnisse

Von allen BCS-Patientinnen bewerteten 80 % ihr gesamtes kosmetisches Ergebnis als „ausgezeichnet“ oder „gut“ im Vergleich zu 55,8 % nach ME. Die Bewertungen der Patientinnen und des Fachpersonals zu den kosmetischen Ergebnissen waren in beiden Gruppen ähnlich. In keiner der Gruppen wurde eine Fibrose Grad III oder IV festgestellt. Der mediane BRA-Score nach BCS betrug 2,9.

Schlussfolgerung

Eine PRT/PCRT ist mit niedrigen Fibrosegraden und einem guten bis hervorragenden kosmetischen Langzeitergebnis verbunden.

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Abbreviations

60 Co:

Cobalt 60

BCS:

Breast-conserving surgery

BCT:

Breast-conserving treatment

BRA:

Breast retraction assessment

DFS:

Disease-free survival

EBRT:

External beam radiation therapy

EORTC:

European Organisation for Research and Treatment of Cancer

G:

Grading

Gy:

Gray

HR:

Hazard ratio

HR+:

Hormone receptor positive

HR–:

Hormone receptor negative

IMRT:

Intensity modulated radiotherapy

Inv:

Investigator

LDF:

Latissimus dorsi flap

LENT-SOMA:

Late Effects of Normal Tissues—subjective, objective, management

LHRH:

Luteinizing hormone-releasing hormone

ME:

Mastectomy

MRM:

Modified radical ME

n. a.:

Not available

No:

Number

OS:

Overall survival

pCR:

Pathological complete response

PCRT:

Preoperative radiochemotherapy

PRT:

Preoperative radiotherapy

RR:

Risk ratio

RT:

Radiotherapy

SAS:

Statistical analysis system

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Author information

Authors and Affiliations

  1. Medical Faculty, Department of Radiation Oncology, Heinrich Heine University, Dusseldorf, Germany

    Christiane Matuschek, Jan Haussmann, Edwin Bölke, Vanessa Speer, Freddy Joel Djiepmo Njanang, Bálint Tamaskovics, Stephan Roth & Wilfried Budach

  2. Department of Senology, Gynecology and Obstetrics, EVK, Teaching Hospital Heinrich Heine University, Dusseldorf, Germany

    Carolin Nestle-Kraemling

  3. Department of Senology, Sana Kliniken Dusseldorf, Dusseldorf, Germany

    Sylvia Wollandt

  4. Department of Dermatology, Medical Faculty, Heinrich Heine University, Dusseldorf, Germany

    Peter Arne Gerber

  5. Department of General, Visceral and Thoracic Surgery, Harzkliniken, Goslar, Germany

    Klaus Orth

  6. Department of Senology and Breast Surgery, Marienhospital, Dusseldorf, Germany

    Werner Audretsch

  7. Division of Biostatistics and Bioinformatics, Department of Oncology, The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, The Johns Hopkins University School of Medicine, Baltimore, MD, USA

    Kai Kammers

  8. Department of Gynecology, Heinrich Heine University, Dusseldorf, Germany

    Eugen Ruckhaeberle, Tanja Fehm & Svjetlana Mohrmann

  9. Department of Radiation Oncology, LMU University, Munich, Germany

    Stefanie Corradini

  10. Radiotherapy Insitute, Bergisch Gladbach, Germany

    Guido Lammering

Authors
  1. Christiane Matuschek
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  2. Carolin Nestle-Kraemling
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  3. Jan Haussmann
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  4. Edwin Bölke
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  5. Sylvia Wollandt
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  6. Vanessa Speer
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  7. Freddy Joel Djiepmo Njanang
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  8. Bálint Tamaskovics
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  9. Peter Arne Gerber
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  10. Klaus Orth
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  11. Eugen Ruckhaeberle
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  12. Tanja Fehm
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  13. Stefanie Corradini
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  14. Guido Lammering
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  15. Svjetlana Mohrmann
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  16. Werner Audretsch
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  17. Stephan Roth
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  18. Kai Kammers
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  19. Wilfried Budach
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Contributions

C. Matuschek, C. Nestle-Kraemling, E. Bölke, and W. Budach had the idea, coordinated the work, and wrote parts of the manuscript. J. Haussmann did the literature research, prepared the data for analysis, and wrote parts of the manuscript. K. Kammers and J. Haussmann did the statistical analysis. S. Wollandt, V. Speer, F.J. Djiepmo Njanang, P.A. Gerber, K. Orth, E. Ruckhaeberle, T. Fehm, S. Corradini, G. Lammering, S. Mohrmann, S. Roth wrote parts of the manuscript. W. Audretsch operated all patients. J. Haussmann contributed significantly to the discussion on the interpretation of the results. C. Matuschek, J. Haussmann, and P.A. Gerber prepared the figures and tables. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Edwin Bölke.

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Conflict of interest

C. Matuschek, C. Nestle-Kraemling, J. Haussmann, E. Bölke, S. Wollandt, V. Speer, F.J. Djiepmo Njanang, B. Tamaskovics, P.A. Gerber, K. Orth, E. Ruckhaeberle, T. Fehm, S. Corradini, G. Lammering, S. Mohrmann, W. Audretsch, S. Roth, K. Kammers, and W. Budach declare that they have no competing interests.

Ethical standards

The study was approved by the local ethics committee (No.: 4070).

Additional information

The authors C. Matuschek and C. Nestle-Kraemling contributed equally to the manuscript.

The work is a part of the thesis of S. Wollandt and V. Speer.

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Matuschek, C., Nestle-Kraemling, C., Haussmann, J. et al. Long-term cosmetic outcome after preoperative radio-/chemotherapy in locally advanced breast cancer patients. Strahlenther Onkol 195, 615–628 (2019). https://doi.org/10.1007/s00066-019-01473-2

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