Evaluation of the Role of Neoadjuvant Radiotherapy in the Management of Patients Treated with Mastectomy and Immediate Autologous Breast Reconstruction

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

We read with great interest the article entitled, “Neoadjuvant Radiotherapy: Changing the Treatment Sequence to Allow Immediate Free Autologous Breast Reconstruction” by Hughes et al.[1] It provides a unique and innovative perspective on how to best integrate radiotherapy into the treatment pathway for women with locally advanced breast cancer who need mastectomy and want breast reconstruction.

In the era of multidisciplinary management of breast cancer, it is important for all involved specialties to collaborate with regards to the optimal timing of treatment delivery with the aim of maximizing oncological and cosmetic outcomes. In their study, the authors provide data that could support, along with anticipated data from ongoing clinical trials (PRADA NCT 02771938),[2] a change in paradigm regarding the sequence of treatment modalities.

The reported data are very encouraging. While the focus is on the technical feasibility and short-term outcomes of immediate free autologous reconstruction, it would be educational to have more information from the oncological perspective. The authors reported a high pathological complete and near-complete response rate (57%) following neoadjuvant chemotherapy (NACT). It would be interesting to establish further details on the tumor phenotypes in evaluating these outcomes and clarifying whether the study controlled for pathological subtype. Overall, this may support the rationale for response-adapted surgery where some patients with pathologic complete response (pCR) may avoid mastectomy, with no detriment to overall survival.[3]

Deciding the radiotherapy regimen in patients receiving NACT can be the subject of controversy. It is debated whether this should be based on clinical stage at presentation or the residual tumor burden (size and number of involved axillary lymph nodes). It would be interesting to know the policy and rationale adopted by the radiation oncologists in this study.

It is well established that nodal burden, in addition to pathologic complete response, is an important prognostic factor. It would, therefore, be interesting to have more information on nodal staging to more reliably evaluate the oncological outcomes. The authors acknowledge the relatively short follow-up time of 19.7 months and we would anticipate an update with longer term outcomes.

Balancing the timing of surgery with the completion of radiotherapy can be challenging in these cases, to allow sufficient time for pathological downsizing and downstaging, while minimizing the risk of tumor regrowth and metastatic potential. The authors reported an average time of 6.4 weeks between neoadjuvant radiotherapy and surgery. Our institutional experience is to consider surgery at a median time of 2 to 4 weeks following neoadjuvant radiotherapy, prior to the peak inflammatory phase of wound healing which may increase the inherent surgical challenges.

Finally, one of the theoretical benefits in delivering radiotherapy in the neoadjuvant setting is shortening the duration of the overall treatment protocol and streamlining the patient journey. It would be helpful if the authors could comment on the total duration of treatment and its objective impact on patient-reported outcome measures and quality of life, as it may further strengthen the drive to adopt a change in practice.

• References

• 1 Hughes K, Neoh D. Neoadjuvant radiotherapy: changing the treatment sequence to allow immediate free autologous breast reconstruction. J Reconstr Microsurg 2018; 34 (08) 624-631
• 2 Primary radiotherapy and DIEP flap reconstruction trial (PRADA). Available at: https://clinicaltrials.gov/ct2/show/NCT02771938 . Accessed April 10, 2019
• 3 Cortazar P, Zhang L, Untch M. , et al. Pathological complete response and long-term clinical benefit in breast cancer: the CTNeoBC pooled analysis. Lancet 2014; 384 (9938): 164-172