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01-04-2017 | Original Article

Neoadjuvant radiotherapy followed by mastectomy and immediate breast reconstruction

An alternative treatment option for locally advanced breast cancer

Authors: Montserrat Pazos, M.D., Dr. med. Stefanie Corradini, M.D., Darius Dian, M.D. D.Sc., Vera von Bodungen, M.D., Nina Ditsch, M.D., Rachel Wuerstlein, M.D., Stephan Schönecker, M.D., Nadia Harbeck, M.D., Heike Scheithauer, M.D., Claus Belka, M.D.

Published in: Strahlentherapie und Onkologie | Issue 4/2017

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.

Garg PK, Prakash G (2015) Current definition of locally advanced breast cancer. Curr Oncol 22:e409–e410. doi:10.3747/co.22.2697 CrossRefPubMedPubMedCentral

Bauerfeind I (2015) Empfehlung zur Diagnostik, Therapie und Nachsorge Mammakarzinome. Manual. Tumorzentrum, München

Corradini S, Niyazi M, Niemoeller OM et al (2015) Adjuvant radiotherapy after breast conserving surgery – a comparative effectiveness research study. Radiother Oncol 114:28–34. doi:10.1016/j.radonc.2014.08.027 CrossRefPubMed

Wright FC, Eskicioglu C, Glazier J et al (2008) Women with locally advanced breast cancer are not at higher risk for contralateral synchronous breast cancer. Breast J 14:556–561. doi:10.1111/j.1524-4741.2008.00647.x CrossRefPubMed

Bear HD, Anderson S, Smith RE et al (2006) Sequential preoperative or postoperative docetaxel added to preoperative doxorubicin plus cyclophosphamide for operable breast cancer:National Surgical Adjuvant Breast and Bowel Project Protocol B‑27. J Clin Oncol 24:2019–2027. doi:10.1200/JCO.2005.04.1665 CrossRefPubMed

Yang TJ, Morrow M, Modi S et al (2015) The effect of molecular subtype and residual disease on locoregional recurrence in breast cancer patients treated with neoadjuvant chemotherapy and postmastectomy radiation. Ann Surg Oncol 22(Suppl 3):S495–S501. doi:10.1245/s10434-015-4697-7 CrossRefPubMedPubMedCentral

Budach W, Matuschek C, Bölke E et al (2015) DEGRO practical guidelines for radiotherapy of breast cancer V: Therapy for locally advanced and inflammatory breast cancer, as well as local therapy in cases with synchronous distant metastases. Strahlenther Onkol 191:623–633. doi:10.1007/s00066-015-0843-1 CrossRefPubMedPubMedCentral

Wenz F, Sperk E, Budach W et al (2014) DEGRO practical guidelines for radiotherapy of breast cancer IV: radiotherapy following mastectomy for invasive breast cancer. Strahlenther Onkol 190:705–714. doi:10.1007/s00066-014-0687-0 CrossRefPubMed

McGuire SE, Gonzalez-Angulo AM, Huang EH et al (2007) Postmastectomy radiation improves the outcome of patients with locally advanced breast cancer who achieve a pathologic complete response to neoadjuvant chemotherapy. Int J Radiat Oncol Biol Phys 68:1004–1009. doi:10.1016/j.ijrobp.2007.01.023 CrossRefPubMedPubMedCentral

10.

Overgaard M, Hansen PS, Overgaard J et al (1997) 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 337:949–955. doi:10.1056/NEJM199710023371401 CrossRefPubMed

11.

Gerber B, Marx M, Untch M, Faridi A (2015) Breast reconstruction following cancer treatment. Dtsch Arztebl Int 112:593–600. doi:10.3238/arztebl.2015.0593 PubMedPubMedCentral

12.

Sbitany H, Wang F, Peled AW et al (2014) Immediate implant-based breast reconstruction following total skin-sparing mastectomy: defining the risk of preoperative and postoperative radiation therapy for surgical outcomes. Plast Reconstr Surg 134:396–404. doi:10.1097/PRS.0000000000000466 CrossRefPubMed

13.

Mioton LM, Gaido J, Small W et al (2013) Differences in breast aesthetic outcomes due to radiation: a validated, quantitative analysis of expander-implant reconstruction. Can J Plast Surg 21:73–77CrossRefPubMedPubMedCentral

14.

Classen J, Nitzsche S, Wallwiener D et al (2010) Fibrotic changes after postmastectomy radiotherapy and reconstructive surgery in breast cancer. A retrospective analysis in 109 patients. Strahlenther Onkol 186:630–636. doi:10.1007/s00066-010-2158-6 CrossRefPubMed

15.

Hughes K, Brown C, Perez V et al (2012) The effect of radiotherapy on implant-based breast reconstruction in the setting of skin-sparing mastectomy: clinical series and review of complications. Anticancer Res 32:553–557PubMed

16.

Berbers J, van Baardwijk A, Houben R et al (2014) “Reconstruction: before or after postmastectomy radiotherapy?” A systematic review of the literature. Eur J Cancer 50:2752–2762. doi:10.1016/j.ejca.2014.07.023 CrossRefPubMed

17.

Kronowitz SJ (2010) Delayed-immediate breast reconstruction: technical and timing considerations. Plast Reconstr Surg 125:463–474. doi:10.1097/PRS.0b013e3181c82d58

18.

Ribuffo D, Atzeni M, Guerra M et al (2013) Treatment of irradiated expanders: protective lipofilling allows immediate prosthetic breast reconstruction in the setting of postoperative radiotherapy. Aesthetic Plast Surg 37:1146–1152. doi:10.1007/s00266-013-0221-2

19.

Krueger EA, Wilkins EG, Strawderman M et al (2001) Complications and patient satisfaction following expander/implant breast reconstruction with and without radiotherapy. Int J Radiat Oncol Biol Phys 49:713–721CrossRefPubMed

20.

Giacalone PL, Rathat G, Daures JP et al (2010) 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 122:439–451. doi:10.1007/s10549-010-0951-7 CrossRefPubMed

21.

Zinzindohoué C, Bertrand P, Michel A et al (2016) 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. doi:10.1245/s10434-016-5146-y

22.

Paillocher N, Florczak AS, Richard M et al (2016) 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. doi:10.1016/j.ejso.2016.03.024

23.

Kaidar-Person O, Kuten A, Belkacemi Y (2014) Primary systemic therapy and whole breast irradiation for locally advanced breast cancer: a systematic review. Crit Rev Oncol Hematol 92:143–152. doi:10.1016/j.critrevonc.2014.04.005 CrossRefPubMed

24.

Chevallier B, Roche H, Olivier JP et al (1993) Inflammatory breast cancer. Pilot study of intensive induction chemotherapy (FEC-HD) results in a high histologic response rate. Am J Clin Oncol 16:223–228CrossRefPubMed

25.

Sautter-Bihl ML, Sedlmayer F, Budach W et al (2014) DEGRO practical guidelines: radiotherapy of breast cancer III-radiotherapy of the lymphatic pathways. Strahlenther Onkol 190:342–351. doi:10.1007/s00066-013-0543-7 CrossRefPubMed

26.

Budach W, Bölke E, Kammers K et al (2015) Adjuvant radiation therapy of regional lymph nodes in breast cancer – a meta-analysis of randomized trials – an update. Radiat Oncol 10:1–7. doi:10.1186/s13014-015-0568-4 CrossRef

27.

Wu S‑G, Sun J‑Y, Zhou J et al (2014) Number of negative lymph nodes can predict survival of breast cancer patients with four or more positive lymph nodes after postmastectomy radiotherapy. Radiat Oncol 9:1–9. doi:10.1186/s13014-014-0284-5 CrossRef

28.

Gerber B, Krause A, Dieterich M et al (2009) The oncological safety of skin sparing mastectomy with conservation of the nipple-areola complex and autologous reconstruction: an extended follow-up study. Ann Surg 249:461–468. doi:10.1097/SLA.0b013e31819a044f CrossRefPubMed

29.

Buzdar AU, Ibrahim NK, Francis D et al (2005) Significantly higher pathologic complete remission rate after neoadjuvant therapy with trastuzumab, paclitaxel, and epirubicin chemotherapy: results of a randomized trial in human epidermal growth factor receptor 2‑positive operable breast cancer. J Clin Oncol 23:3676–3685. doi:10.1200/JCO.2005.07.032 CrossRefPubMed

30.

Matuschek C, Bölke E, Roth SL et al (2012) Long-term outcome after neoadjuvant radiochemotherapy in locally advanced noninflammatory breast cancer and predictive factors for a pathologic complete remission : results of a multivariate analysis. Strahlenther Onkol 188:777–781. doi:10.1007/s00066-012-0162-8 CrossRefPubMed

31.

Roth SL, Audretsch W, Bojar H et al (2010) Retrospective study of neoadjuvant versus adjuvant radiochemotherapy in locally advanced noninflammatory breast cancer : survival advantage in cT2 category by neoadjuvant radiochemotherapy. Strahlenther Onkol 186:299–306. doi:10.1007/s00066-010-2143-0 CrossRefPubMed

32.

Budach W, Matuschek C, Bölke E et al (2015) Erratum to: DEGRO practical guidelines for radiotherapy of breast cancer V: Therapy for locally advanced and inflammatory breast cancer, as well as local therapy in cases with synchronous distant metastases. Strahlenther Onkol 191:634. doi:10.1007/s00066-015-0863-x CrossRefPubMedPubMedCentral

33.

Corradini S, Niemoeller OM, Niyazi M et al (2014) Timing of radiotherapy following breast-conserving surgery: outcome of 1393 patients at a single institution. Strahlenther Onkol 190:352–357. doi:10.1007/s00066-013-0540-x CrossRefPubMed

34.

Desai S, Hurley J, Takita C et al (2013) Impact of surgery-radiation interval on locoregional outcome in patients receiving neo-adjuvant therapy and mastectomy. Breast J 19(4):427–430. doi:10.1111/tbj.12140 CrossRefPubMed

35.

Gerlach B, Audretsch W, Gogolin F et al (2003) Remission rates in breast cancer treated with preoperative chemotherapy and radiotherapy. Strahlenther Onkol 179:306–311. doi:10.1007/s00066-003-1019-y CrossRefPubMed

36.

Clarke-Pearson EM, Chadha M, Dayan E et al (2013) Comparison of irradiated versus nonirradiated DIEP flaps in patients undergoing immediate bilateral DIEP reconstruction with unilateral postmastectomy radiation therapy (PMRT). Ann Plast Surg 71:250–254. doi:10.1097/SAP.0b013e31828986ec CrossRefPubMed

37.

Garvey PB, Clemens MW, Hoy AE et al (2014) Muscle-sparing TRAM flap does not protect breast reconstruction from postmastectomy radiation damage compared with the DIEP flap. Plast Reconstr Surg 133:223–233. doi:10.1097/01.prs.0000436845.92623.9a CrossRefPubMedPubMedCentral

38.

Himsl I, Drinovac V, Lenhard M et al (2012) The use of porcine acellular dermal matrix in silicone implant-based breast reconstruction. Arch Gynecol Obstet 286:187–192. doi:10.1007/s00404-012-2266-x CrossRefPubMed

39.

Miller CL, Colwell AS, Horick N et al (2016) Immediate implant reconstruction is associated with a reduced risk of lymphedema compared to mastectomy alone: a prospective cohort study. Ann Surg 263:399–405. doi:10.1097/SLA.0000000000001128 CrossRefPubMedPubMedCentral

40.

Lerouge D, Touboul E, Lefranc J‑P et al (2004) Combined chemotherapy and preoperative irradiation for locally advanced noninflammatory breast cancer: updated results in a series of 120 patients. Int J Radiat Oncol Biol Phys 59:1062–1073. doi:10.1016/j.ijrobp.2003.12.034 CrossRefPubMed

Title: Neoadjuvant radiotherapy followed by mastectomy and immediate breast reconstruction
An alternative treatment option for locally advanced breast cancer
Authors: Montserrat Pazos, M.D.
Dr. med. Stefanie Corradini, M.D.
Darius Dian, M.D. D.Sc.
Vera von Bodungen, M.D.
Nina Ditsch, M.D.
Rachel Wuerstlein, M.D.
Stephan Schönecker, M.D.
Nadia Harbeck, M.D.
Heike Scheithauer, M.D.
Claus Belka, M.D.
Publication date: 01-04-2017
Publisher: Springer Berlin Heidelberg
Published in: Strahlentherapie und Onkologie / Issue 4/2017
Print ISSN: 0179-7158
Electronic ISSN: 1439-099X
DOI: https://doi.org/10.1007/s00066-017-1100-6

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Neoadjuvant radiotherapy followed by mastectomy and immediate breast reconstruction

An alternative treatment option for locally advanced breast cancer

Abstract

Background

Patients

Results

Conclusion

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Springer Medicine

Abstract

Background

Patients

Results

Conclusion

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