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J Reconstr Microsurg 2018; 34(08): 624-631
DOI: 10.1055/s-0038-1660871
Original Article: WSRM 2017 Scientific Paper
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Neoadjuvant Radiotherapy: Changing the Treatment Sequence to Allow Immediate Free Autologous Breast Reconstruction

Kimberley Hughes
1   Department of Plastic and Reconstructive Surgery, Austin Health, Melbourne, Australia
,
Derek Neoh
1   Department of Plastic and Reconstructive Surgery, Austin Health, Melbourne, Australia
› Author Affiliations
Further Information

Publication History

21 January 2018

28 April 2018

Publication Date:
16 June 2018 (online)

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Abstract

Background Locally advanced breast cancer (LABC) is traditionally treated with a multimodal approach of chemotherapy, surgery, and postmastectomy radiotherapy (PMRT). The advantages of immediate breast reconstruction (IBR) are well described and include improved aesthetic outcomes, fewer surgical procedures, shorter treatment period, and a higher quality of life. However, this sequence makes immediate free autologous reconstruction more challenging as PMRT can have deleterious and unpredictable effects on the flap. We have reversed this treatment sequence with neoadjuvant chemotherapy and radiotherapy, followed by mastectomy and immediate free autologous reconstruction. To our knowledge, this is the first series to assess the outcomes of neoadjuvant radiotherapy on immediate free microvascular breast reconstruction.

Methods A review of patients with LABC who underwent immediate free autologous breast reconstruction post neoadjuvant chemoradiotherapy between 2013 and 2017 was conducted. All reconstructions were performed by a single reconstructive team. The primary end points were flap failure and surgical complications. Secondary end points were pathological response rate and disease recurrence.

Results A total of 40 women with an average age of 48.1 (36–61) and average body mass index of 25.6 (18–37) were included. The most common choice of flap was immediate deep inferior epigastric perforator (DIEP, 31), followed by transverse or diagonal upper gracilis (5), muscle-sparing transversus abdominis (3), and stacked DIEP (1). Our major complication rate was 12.5% and minor complication 15%. There were no cases of local recurrence and only three cases (7.5%) of distant disease progression.

Conclusion From our experience, this treatment sequence allows patients to have an immediate gold standard reconstruction without an increase in surgical morbidity. It affords the benefits of IBR without concern in delaying adjuvant therapy and appears to be safe from an oncological perspective.

Keywords

autologous breast reconstruction - neoadjuvant radiotherapy - locally advanced breast cancer

Letter to this article:

Evaluation of the Role of Neoadjuvant Radiotherapy in the Management of Patients Treated with Mastectomy and Immediate Autologous Breast ReconstructionJ Reconstr Microsurg 2018; 34(08): e1-e2
DOI: 10.1055/s-0039-1688927

 

  • References

  • 1 Pazos M, Corradini S, Dian D. , et al. Neoadjuvant radiotherapy followed by mastectomy and immediate breast reconstruction: an alternative treatment option for locally advanced breast cancer. Strahlenther Onkol 2017; 193 (04) 324-331
    CrossrefPubMedGoogle Scholar
  • 2 Garg PK, Prakash G. Current definition of locally advanced breast cancer. Curr Oncol 2015; 22 (05) e409-e410
    CrossrefPubMedGoogle Scholar
  • 3 Ho AL, Tyldesley S, Macadam SA, Lennox PA. Skin-sparing mastectomy and immediate autologous breast reconstruction in locally advanced breast cancer patients: a UBC perspective. Ann Surg Oncol 2012; 19 (03) 892-900
    CrossrefPubMedGoogle Scholar
  • 4 Mirzabeigi MN, Smartt JM, Nelson JA, Fosnot J, Serletti JM, Wu LC. An assessment of the risks and benefits of immediate autologous breast reconstruction in patients undergoing postmastectomy radiation therapy. Ann Plast Surg 2013; 71 (02) 149-155
    CrossrefPubMedGoogle Scholar
  • 5 Overgaard M, Hansen PS, Overgaard J. , et al. Postoperative radiotherapy in high-risk premenopausal women with breast cancer who receive adjuvant chemotherapy. Danish Breast Cancer Cooperative Group 82b Trial. N Engl J Med 1997; 337 (14) 949-955
    CrossrefPubMedGoogle Scholar
  • 6 Overgaard M, Jensen MB, Overgaard J. , et al. Postoperative radiotherapy in high-risk postmenopausal breast-cancer patients given adjuvant tamoxifen: Danish Breast Cancer Cooperative Group DBCG 82c randomised trial. Lancet 1999; 353 (9165): 1641-1648
    CrossrefPubMedGoogle Scholar
  • 7 Ragaz J, Jackson SM, Le N. , et al. Adjuvant radiotherapy and chemotherapy in node-positive premenopausal women with breast cancer. N Engl J Med 1997; 337 (14) 956-962
    CrossrefPubMedGoogle Scholar
  • 8 Zinzindohoué 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 for invasive breast carcinoma. Ann Surg Oncol 2016; 23 (07) 2350-2356
    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 (07) 949-955
    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) 864-870
    CrossrefPubMedGoogle Scholar
  • 11 Fernández-Delgado J, López-Pedraza MJ, Blasco JA. , et al. Satisfaction with and psychological impact of immediate and deferred breast reconstruction. Ann Oncol 2008; 19 (08) 1430-1434
    CrossrefPubMedGoogle Scholar
  • 12 Tran NV, Evans GR, Kroll SS. , et al. Postoperative adjuvant irradiation: effects on transverse rectus abdominis muscle flap breast reconstruction. Plast Reconstr Surg 2000; 106 (02) 313-317 , discussion 318–320
    CrossrefPubMedGoogle Scholar
  • 13 Rogers NE, Allen RJ. Radiation effects on breast reconstruction with the deep inferior epigastric perforator flap. Plast Reconstr Surg 2002; 109 (06) 1919-1924 , discussion 1925–1926
    CrossrefPubMedGoogle Scholar
  • 14 Spear SL, Ducic I, Low M, Cuoco F. The effect of radiation on pedicled TRAM flap breast reconstruction: outcomes and implications. Plast Reconstr Surg 2005; 115 (01) 84-95
    CrossrefPubMedGoogle Scholar
  • 15 Clarke-Pearson EM, Chadha M, Dayan E. , et al. Comparison of irradiated versus nonirradiated DIEP flaps in patients undergoing immediate bilateral DIEP reconstruction with unilateral postmastectomy radiation therapy (PMRT). Ann Plast Surg 2013; 71 (03) 250-254
    CrossrefPubMedGoogle Scholar
  • 16 Carlson G. Radiation effects on breast reconstruction with the DIEP flap. Plast Reconstr Surg 2002; 109: 1925-1926
    CrossrefPubMedGoogle Scholar
  • 17 Chang EI, Liu TS, Festekjian JH, Da Lio AL, Crisera CA. Effects of radiation therapy for breast cancer based on type of free flap reconstruction. Plast Reconstr Surg 2013; 131 (01) 1e-8e
    CrossrefPubMedGoogle Scholar
  • 18 Pont LP, Marcelli S, Robustillo M. , et al. Immediate breast reconstruction with abdominal free flap and adjuvant radiotherapy: evaluation of quality of life outcomes. Plast Reconstr Surg 2017; 140 (04) 681-690
    CrossrefPubMedGoogle Scholar
  • 19 Kronowitz SJ, Hunt KK, Kuerer HM. , et al. Delayed-immediate breast reconstruction. Plast Reconstr Surg 2004; 113 (06) 1617-1628
    CrossrefPubMedGoogle Scholar
  • 20 Kronowitz SJ. Delayed-immediate breast reconstruction: technical and timing considerations. Plast Reconstr Surg 2010; 125 (02) 463-474
    CrossrefPubMedGoogle Scholar
  • 21 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 (02) 439-451
    CrossrefPubMedGoogle Scholar
  • 22 Tansley P, Ramsey K, Wong S, Guerrieri M, Pitcher M, Grinsell D. New treatment sequence protocol to reconstruct locally advanced breast cancer. ANZ J Surg 2013; 83 (09) 630-635
    CrossrefPubMedGoogle Scholar
  • 23 Tanos G, Prousskaia E, Chow W. , et al. Locally advanced breast cancer: autologous versus implant based reconstruction. Plast Reconstr Surg Glob Open 2016; 4 (02) e622
    CrossrefPubMedGoogle Scholar
  • 24 Downes KJ, Glatt BS, Kanchwala SK. , et al. Skin-sparing mastectomy and immediate reconstruction is an acceptable treatment option for patients with high-risk breast carcinoma. Cancer 2005; 103 (05) 906-913
    CrossrefPubMedGoogle Scholar
  • 25 Burdge EC, Yuen J, Hardee M. , et al. Nipple skin-sparing mastectomy is feasible for advanced disease. Ann Surg Oncol 2013; 20 (10) 3294-3302
    CrossrefPubMedGoogle Scholar
  • 26 Kelley BP, Ahmed R, Kidwell KM, Kozlow JH, Chung KC, Momoh AO. A systematic review of morbidity associated with autologous breast reconstruction before and after exposure to radiotherapy: are current practices ideal?. Ann Surg Oncol 2014; 21 (05) 1732-1738
    CrossrefPubMedGoogle Scholar
  • 27 Motwani SB, Strom EA, Schechter NR. , et al. The impact of immediate breast reconstruction on the technical delivery of postmastectomy radiotherapy. Int J Radiat Oncol Biol Phys 2006; 66 (01) 76-82
    CrossrefPubMedGoogle Scholar
  • 28 Barry M, Kell MR. Radiotherapy and breast reconstruction: a meta-analysis. Breast Cancer Res Treat 2011; 127 (01) 15-22
    CrossrefPubMedGoogle Scholar
  • 29 Fosnot J, Fischer JP, Smartt Jr JM. , et al. Does previous chest wall irradiation increase vascular complications in free autologous breast reconstruction?. Plast Reconstr Surg 2011; 127 (02) 496-504
    CrossrefPubMedGoogle Scholar
  • 30 Pierce LJ, Butler JB, Martel MK. , et al. Postmastectomy radiotherapy of the chest wall: dosimetric comparison of common techniques. Int J Radiat Oncol Biol Phys 2002; 52 (05) 1220-1230
    CrossrefPubMedGoogle Scholar
  • 31 Fracol ME, Basta MN, Nelson JA. , et al. Bilateral free flap breast reconstruction after unilateral radiation: comparing intraoperative vascular complications and postoperative outcomes in radiated versus nonradiated breasts. Ann Plast Surg 2016; 76 (03) 311-314
    CrossrefPubMedGoogle Scholar
  • 32 Odom EB, Qureshi AA, Mull AB. , et al. The impact of radiation and its timing on donor internal mammary vessels histopathology at the time of autologous microvascular breast reconstruction. J Reconstr Microsurg 2017; 33 (07) 509-517
    Article in Thieme ConnectPubMedGoogle Scholar
  • 33 Park CK, Jung WH, Koo JS. Pathologic evaluation of breast cancer after neoadjuvant therapy. J Pathol Transl Med 2016; 50 (03) 173-180
    CrossrefPubMedGoogle Scholar
  • 34 Barrou J, Bannier M, Cohen M. , 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
    CrossrefPubMedGoogle Scholar