Preoperative Radiotherapy Trials to Facilitate Immediate Breast Reconstruction after Mastectomy
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Purpose of Review
Postmastectomy radiotherapy (PMRT) is often a component of treatment algorithms for locally advanced or node-positive breast cancer. Breast reconstruction may be delayed or not performed due to negative effects of PMRT on the reconstruction. Administering radiotherapy in the preoperative setting allows for immediate breast reconstruction (IBR) to be performed in patients who have indications for PMRT and desire IBR. This review summarizes the current literature on this new concept.
Most prospective treatment protocols included neoadjuvant systemic therapy followed by radiotherapy (RT) dose of 50–50.4 Gy conventionally fractionated and mastectomy with immediate autologous reconstruction after 6–8 weeks. There were no cases of IBR being aborted due to technical complications and overall postoperative complications ranged from 3 to 36%. These were typically non-operatively managed, and cosmetic results when evaluated were favorable. Initial oncologic outcomes indicate low locoregional recurrence rates (≤ 10%) and high 5-year overall survival rates of 87–98%.
Although published studies are heterogeneous in nature, they suggest that preoperative RT followed by mastectomy with IBR is technically feasible and safe. Larger prospective studies with longer follow-up times may establish this as a new standard in the multidisciplinary treatment of high-risk breast cancer.
KeywordsPost-mastectomy radiotherapy Mastectomy Immediate breast reconstruction Preoperative radiotherapy Breast cancer
This work was supported by the PH and Fay Etta Robinson Distinguished Professorship in Cancer Research (HMK) and a Cancer Center Support Grant from the National Institutes of Health (NIH) (CA16672).
Compliance with Ethical Standards
Conflict of Interest
Henry Kuerer reports personal fees and other from Genomic Health, Inc.; other from Physicians’ Education Resource, LLC; personal fees from TME, Inc.; personal fees from McGraw-Hill Professional, UpToDate, Inc.; grants from National Cancer Institute; other from Annals of Surgical Oncology; other from NRG Oncology (Institutional PI and Breast Committee); other from American Society of Breast Surgeons (Chair, Publications Committee); and personal fees from NEJM Group, Inc. outside the submitted work. Puneet Singh declares no conflicts of interest relevant to this manuscript.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
- 2.Recht A, Comen EA, Fine RE, Fleming GF, Hardenbergh PH, Ho AY, et al. Postmastectomy radiotherapy: an American Society of Clinical Oncology, American Society for Radiation Oncology, and Society of Surgical Oncology focused guideline update. J Clin Oncol. 2016;34(36):4431–42. https://doi.org/10.1200/JCO.2016.69.1188.CrossRefPubMedGoogle Scholar
- 4.• Schaverien MV, Macmillan RD, McCulley SJ. Is immediate autologous breast reconstruction with postoperative radiotherapy good practice?: a systematic review of the literature. J Plast Reconstr Aesthet Surg. 2013;66(12):1637–51. https://doi.org/10.1016/j.bjps.2013.06.059This systematic review included published studies on immediate breast reconstruction and adjuvant radiation therapy and demonstrated a similar incidence of complications between immediate reconstruction with radiotherapy and delayed reconstruction after radiotherapy. CrossRefPubMedGoogle Scholar
- 5.Ayoub Z, Strom EA, Ovalle V, Perkins GH, Woodward WA, Tereffe W, et al. A 10-year experience with mastectomy and tissue expander placement to facilitate subsequent radiation and reconstruction. Ann Surg Oncol. 2017;24(10):2965–71. https://doi.org/10.1245/s10434-017-5956-6.CrossRefPubMedGoogle Scholar
- 8.Renehan AG, Malcomson L, Emsley R, Gollins S, Maw A, Myint AS, et al. Watch-and-wait approach versus surgical resection after chemoradiotherapy for patients with rectal cancer (the OnCoRe project): a propensity-score matched cohort analysis. Lancet Oncol. 2016;17(2):174–83. https://doi.org/10.1016/S1470-2045(15)00467-2.CrossRefPubMedGoogle Scholar
- 9.•• Paillocher N, Florczak AS, Richard M, et al. Evaluation of mastectomy with immediate autologous latissimus dorsi breast reconstruction following neoadjuvant chemotherapy and radiation therapy: A single institution study of 111 cases of invasive breast carcinoma. Eur J Surg Oncol. 2016;42(7):949–55. https://doi.org/10.1016/j.ejso.2016.03.024This retrospective study of patients who received preoperative radiotherapy followed by mastectomy and immediate breast reconstruction demonstrated that this sequence of therapies did not increase complication rates, oncologic outcomes were favorable and patient satisfaction was high. CrossRefPubMedGoogle Scholar
- 10.•• Monrigal E, Dauplat J, Gimbergues P, et al. Mastectomy with immediate breast reconstruction after neoadjuvant chemotherapy and radiation therapy. A new option for patients with operable invasive breast cancer. Results of a 20 years single institution study. Eur J Surg Oncol. 2011;37(10):864–70. https://doi.org/10.1016/j.ejso.2011.07.009This retrospective study of preoperative radiotherapy and immediate breast reconstruction is the largest published series and showed no additional early or late complications with this technique. CrossRefPubMedGoogle Scholar
- 11.Pazos M, Corradini S, Dian D, von Bodungen V, Ditsch N, Wuerstlein R, et al. Neoadjuvant radiotherapy followed by mastectomy and immediate breast reconstruction : an alternative treatment option for locally advanced breast cancer. Strahlenther Onkol. 2017;193(4):324–31. https://doi.org/10.1007/s00066-017-1100-6.CrossRefPubMedGoogle Scholar
- 13.Barrou J, Bannier M, Cohen M, Lambaudie E, Gonçalves A, Bertrand P, et al. Pathological complete response in invasive breast cancer treated by skin sparing mastectomy and immediate reconstruction following neoadjuvant chemotherapy and radiation therapy: comparison between immunohistochemical subtypes. Breast. 2017;32:37–43. https://doi.org/10.1016/j.breast.2016.12.014.CrossRefPubMedGoogle Scholar
- 16.•• Giacalone PL, Rathat G, Daures JP, Benos P, Azria D, Rouleau C. New concept for immediate breast reconstruction for invasive cancers: feasibility, oncological safety and esthetic outcome of post-neoadjuvant therapy immediate breast reconstruction versus delayed breast reconstruction: a prospective pilot study. Breast Cancer Res Treat. 2010;122(2):439–51. https://doi.org/10.1007/s10549-010-0951-7This is the first prospective trial of patients receiving preoperative chemotherapy and immediate breast reconstruction. In this small cohort, there were no differences in early or late complications compared to a group who received postmastectomy radiotherapy and delayed reconstruction and cosmetic outcomes were rated favorably by physicians and patients. CrossRefPubMedGoogle Scholar
- 17.• Zinzindohoue C, Bertrand P, Michel A, et al. A prospective study on skin-sparing mastectomy for immediate breast reconstruction with latissimus dorsi flap after neoadjuvant chemotherapy and radiotherapy in invasive breast carcinoma. Ann Surg Oncol. 2016;23(7):2350–6. https://doi.org/10.1245/s10434-016-5146-yThis prospective multicenter trial demonstrated a low rate of skin necrosis after preoperative radiotherapy and autologous reconstruction with or without implant and none required a second surgery. CrossRefPubMedGoogle Scholar
- 18.Baker C, Chao MW, Jassal S, et al. The safety and pathological impact of neoadjuvant radiotherapy for local advanced breast cancer undergoing mastectomy and autologous reconstruction. Cancer Research Conference: San Antonio Breast Cancer Symposium, SABCS. 2017;78(4 Supplement 1).Google Scholar
- 21.Thiruchelvam P, Hadjiminas D, Cleator S, et al. Neoadjuvant radiotherapy in mastectomy and immediate autologous free flap reconstruction. Findings from the primary radiotherapy and DIEP flap (PRADA) pilot study. Cancer Res Conf: 39th Annual CTRC AACR San Antonio Breast Cancer Symposium United States. 2017;77(4 Supplement 1):P3-14-07.Google Scholar
- 22.Chao M, Foroudi F, Jassal S, et al. The use of neoadjuvant radiotherapy in high risk or locally advanced breast cancer patients prior to definitive surgery with mastectomy and autologous breast reconstruction does not impact on post operative surgical complications. Eur J Cancer. 2018;92(Supplement 3):S65.CrossRefGoogle Scholar
- 26.Baltodano PA, Reinhardt ME, Flores JM, Abreu FM, Chattha A, Kone L, et al. Preoperative radiotherapy is not associated with increased post-mastectomy short-term morbidity: analysis of 77,902 patients. Plast Reconstr Surg Glob Open. 2017;5(3):e1108. https://doi.org/10.1097/GOX.0000000000001108.CrossRefPubMedPubMedCentralGoogle Scholar