Neoadjuvant Radiotherapy to Facilitate Immediate Breast Reconstruction: A Systematic Review and Current Clinical Trials
Postmastectomy radiotherapy currently is used for locally advanced breast cancers that carry a high risk of locoregional failure. However, radiotherapy can have deleterious effects on immediate breast reconstruction (IBR). Neoadjuvant radiotherapy (NART) to facilitate postmastectomy IBR is an emerging new therapeutic sequence. A systematic review was undertaken to evaluate the current evidence on the feasibility and safety of this sequence.
A comprehensive search of MEDLINE, EMBASE, Cochrane Library, Web of Science, and ClinicalTrials.gov from inception to 2018 was conducted, resulting in 592 records. The review included 18 retrospective and prospective studies of NART and IBR.
The majority of the studies used whole-breast radiotherapy with 50 Gy, conventionally fractionated, and waited 6–8 weeks before surgery. The IBR methods were varied, with both implant and autologous reconstructions. No intraoperative complications occurred, and the postoperative complication rates ranged from 3 to 36%. The partial and total flap loss rates were very low. Studies reporting cosmetic outcomes rated the majority of cases as good or excellent. The pathologic complete response rates ranged from 17 to 55%, and the locoregional recurrence rates were low (≤ 10%), with a short follow-up period. The current MD Anderson Cancer Center prospective clinical trial is described.
The initial results of NART and IBR demonstrate the safety of this treatment both technically and oncologically. Longer follow-up evaluation of these studies and larger prospective controlled clinical trials are needed to establish this new therapeutic sequence as a standard of care.
This work was supported by the PH and Fay Etta Robinson Distinguished Professorship in Cancer Research (H.M.K.) and a Cancer Center Support grant from the National Institutes of Health (NIH) (CA16672).
Dr. Benjamin D. Smith has received previous grant funding from Varian Medical Systems and has current licensing/royalties from Oncora Medical. The remainder of the authors have no conflicts of interest to disclose.
- 10.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;42:949–55.CrossRefPubMedGoogle Scholar
- 11.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-year single-institution study. Eur J Surg Oncol. 2011;37:864–70.CrossRefPubMedGoogle Scholar
- 15.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
- 19.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;122:439–51.CrossRefPubMedGoogle Scholar
- 21.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. In: Cancer research conference: San Antonio breast cancer symposium, SABCS. 2017;78(4 Supplement 1).Google Scholar
- 22.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. In: Cancer research conference: 39th Annual CTRC AACR San Antonio breast cancer symposium United States. 2017;77(4 Supplement 1).Google Scholar
- 24.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 postoperative surgical complications. Eur J Cancer. 2018;92(Suppl 3):S65.CrossRefGoogle Scholar