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Neoadjuvant radiotherapy followed by mastectomy and immediate breast reconstruction

An alternative treatment option for locally advanced breast cancer

Neoadjuvante Radiotherapie vor Mastektomie und sofortiger Brustrekonstruktion

Eine Therapiealternative beim lokal fortgeschrittenen Mammakarzinom

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Abstract

Background

The optimal sequence of mastectomy with immediate breast reconstruction (IBR) and radiotherapy (RT) for the treatment of locally advanced breast cancer (LABC) is still under debate. Increased rates of postoperative complications are described following postmastectomy RT. Neoadjuvant RT aims to improve the aesthetic results and simplify the reconstructive pathway.

Patients

A total of 22 patients diagnosed with LABC and treated with neoadjuvant RT followed by mastectomy and IBR between 04/2012 and 03/2015 were retrospectively analyzed. RT consisted of external beam RT to the breast and the regional lymphatics, if indicated. Both implant-based and autologous tissue-transfer reconstruction techniques were used.

Results

At the time of RT, 10 patients had no prior surgery and 12 patients had previously undergone breast-conserving surgery (BCS) with positive resection margins without the possibility to perform a second BCS. Additional neoadjuvant chemotherapy was administered in 18 patients prior to RT. A complete pathological response was achieved in 55.0% of patients. The 2‑year overall survival rate was 89.3%, the 2‑year disease-free-survival 79.8% and the local-recurrence-free survival was 95.2%. The cosmetic result was excellent or good in 66% of the patients treated with upfront mastectomy and 37% of the patients who had previously undergone BCS. Among patients who received implant-based IBR, 4 patients developed serious wound-healing problems with implant loss. The most satisfactory results were achieved with autologous tissue reconstruction.

Conclusion

A sequential neoadjuvant chemo-/radiotherapy to allow IBR following mastectomy in selected cases of LABC seems feasible and can be safely attempted. Careful patient selection, close monitoring, and continuous patient support is mandatory to ensure compliance in this treatment strategy.

Zusammenfassung

Fragestellung

Die optimale Therapiesequenz von Mastektomie mit sofortiger Brustrekonstruktion (IBR) und Radiotherapie (RT) beim lokal fortgeschrittenen Mammakarzinom (LABC) ist bisher nicht abschließend geklärt. Da die postoperative RT ein erhöhtes Risiko für postoperative Wundheilungsstörungen aufweist, bietet die neoadjuvante RT vor Mastektomie mit sofortigem Wiederaufbau eine Therapiealternative.

Patienten

Retrospektiv ausgewertet wurden 22 LABC-Patientinnen mit neoadjuvanter RT vor Mastektomie und IBR zwischen April 2012 und März 2015. Bestrahlt wurden die Brust, sowie bei entsprechender Indikation der angrenzende Lymphabfluss. Die IBR erfolgte mittels Implantaten, Eigengewebe oder einem kombinierten Verfahren.

Ergebnisse

Eine primäre Mastektomie erhielten 10 Patientinnen; 12 Patientinnen wurden bereits brusterhaltend mit positiven Resektionsrändern operiert und aufgrund fehlender Möglichkeit zur Nachresektion sekundär mastektomiert. Eine neoadjuvante Chemotherapie vor RT bekamen 18 Patientinnen. Eine pathologische Komplettremission wurde in 55 % der Patientinnen erzielt. Die 2‑Jahres-Gesamtüberlebensrate betrug 89,3 %, das krankheitsfreie Überleben 79,8 % und das lokalrezidivfreie Überleben 95,2 %. Das kosmetische Ergebnis war bei 66 % der primär Mastektomierten ausgezeichnet bis sehr gut und bei 37 % der sekundär mastektomierten Patientinnen hervorragend. Wundheilungsstörungen mit Implantatverlust entwickelten 4 Patientinnen mit implantatbasierter IBR. Der Wiederaufbau mit Eigengewebe erzielte die besten Ergebnisse.

Schlussfolgerung

Eine sequentielle neoadjuvante Chemo-/Radiotherapie vor Mastektomie und IBR erzielt bei selektionierten LABC-Patientinnen gute onkologische und kosmetische Ergebnisse. Eine sorgfältige Patientenselektion und umfassende Patientenbetreuung sind ausschlaggebend, um die Compliance für diese Therapiestrategie zu gewährleisten.

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Authors and Affiliations

  1. Department of Radiation Oncology, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany

    Montserrat Pazos M.D.,  Stefanie Corradini M.D., Stephan Schönecker M.D., Heike Scheithauer M.D. & Claus Belka M.D.

  2. Mednord Munich Clinic, Heidemannstraße 5b, 80939, Munich, Germany

    Darius Dian M.D. D.Sc.

  3. Breast Center, Department of Obstetrics and Gynecology, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany

    Vera von Bodungen M.D., Nina Ditsch M.D., Rachel Wuerstlein M.D. & Nadia Harbeck M.D.

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  1. Montserrat Pazos M.D.
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Correspondence to Stefanie Corradini M.D..

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Conflict of interest

M. Pazos, S. Corradini, D. Dian, V. von Bodungen, N. Ditsch, R. Wuerstlein, S. Schönecker, N. Harbeck, H. Scheithauer, and C. Belka declare that they have no competing interests.

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All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed consent was obtained from all individual participants included in the study.

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M. Pazos and S. Corradini: the authors contributed equally to the manuscript.

H. Scheithauer and C. Belka: the authors contributed equally to the manuscript.

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Pazos, M., Corradini, S., Dian, D. et al. Neoadjuvant radiotherapy followed by mastectomy and immediate breast reconstruction. Strahlenther Onkol 193, 324–331 (2017). https://doi.org/10.1007/s00066-017-1100-6

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