Annals of Surgical Oncology

, Volume 26, Issue 10, pp 3312–3320 | Cite as

Neoadjuvant Radiotherapy to Facilitate Immediate Breast Reconstruction: A Systematic Review and Current Clinical Trials

  • Puneet Singh
  • Karen Hoffman
  • Mark V. Schaverien
  • Kate J. Krause
  • Charles Butler
  • Benjamin D. Smith
  • Henry M. KuererEmail author
Breast Oncology



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 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.

Supplementary material

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Supplementary material 1 (DOCX 11 kb)
10434_2019_7538_MOESM2_ESM.doc (64 kb)
Supplementary material 2 (DOC 64 kb)


  1. 1.
    Jagsi R. Postmastectomy radiation therapy: an overview for the practicing surgeon. ISRN Surg. 2013;2013:212979.CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    Recht A, Comen EA, Fine RE, 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;34:4431–42.CrossRefPubMedGoogle Scholar
  3. 3.
    Kuerer HM, Cordeiro PG, Mutter RW. Optimizing breast cancer adjuvant radiation and integration of breast and reconstructive surgery. Am Soc Clin Oncol Educ Book. 2017;37:93–105.CrossRefPubMedGoogle Scholar
  4. 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;66:1637–51.CrossRefPubMedGoogle Scholar
  5. 5.
    Ayoub Z, Strom EA, Ovalle V, et al. A 10-year experience with mastectomy and tissue expander placement to facilitate subsequent radiation and reconstruction. Ann Surg Oncol. 2017;24:2965–71.CrossRefPubMedGoogle Scholar
  6. 6.
    Craig ES, Clemens MW, Koshy JC, et al. Outcomes of acellular dermal matrix for immediate tissue expander reconstruction with radiotherapy: a retrospective cohort study. Aesthet Surg J. 2018;39(3):279–88.CrossRefGoogle Scholar
  7. 7.
    Appelt AL, Pløen J, Harling H, et al. High-dose chemoradiotherapy and watchful waiting for distal rectal cancer: a prospective observational study. Lancet Oncol. 2015;16:919–27.CrossRefPubMedGoogle Scholar
  8. 8.
    Renehan AG, Malcomson L, Emsley R, 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;17:174–83.CrossRefPubMedGoogle Scholar
  9. 9.
    Pinsolle V, Grinfeder C, Mathoulin-Pelissier S, Faucher A. Complications analysis of 266 immediate breast reconstructions. J Plast Reconstr Aesthet Surg. 2006;59:1017–24.CrossRefPubMedGoogle Scholar
  10. 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. 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
  12. 12.
    Lee KT, Bang SI, Pyon JK, Hwang JH, Mun GH. Method of breast reconstruction and the development of lymphoedema. Br J Surg. 2017;104:230–7.CrossRefPubMedGoogle Scholar
  13. 13.
    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;193:324–31.CrossRefPubMedGoogle Scholar
  14. 14.
    Hughes K, Neoh D. Neoadjuvant radiotherapy: changing the treatment sequence to allow immediate free autologous breast reconstruction. J Reconstr Microsurg. 2018;34:624–31.CrossRefPubMedGoogle Scholar
  15. 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
  16. 16.
    Baltodano PA, Reinhardt ME, Flores JM, 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:e1108.CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    Gerlach B, Audretsch W, Gogolin F, et al. Remission rates in breast cancer treated with preoperative chemotherapy and radiotherapy. Strahlenther Onkol 2003;179:306–11.CrossRefPubMedGoogle Scholar
  18. 18.
    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;19:892–900.CrossRefPubMedGoogle Scholar
  19. 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
  20. 20.
    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;23:2350–6.CrossRefPubMedGoogle Scholar
  21. 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. 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
  23. 23.
    Chao M, Foroudi F, Jassal S, et al. Tumor downstaging in high-risk or locally advanced breast cancer patients undergoing neoadjuvant radiotherapy prior to definitive surgery and autologous breast reconstruction. Eur J Cancer. 2018;92(Suppl 3):S57–8.CrossRefGoogle Scholar
  24. 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
  25. 25.
    Grinsell D, Pitcher M, Wong S, Guerrieri M, Nielsen HHM. Immediate autologous breast reconstruction after neoadjuvant chemoradiotherapy for breast cancer: initial results of the first 29 patients. ANZ J Surg. 2018;88:E137–41.CrossRefPubMedGoogle Scholar
  26. 26.
    O’Halloran N, McVeigh T, Martin J, Keane M, Lowery A, Kerin M. Neoadjuvant chemoradiation and breast reconstruction: the potential for improved outcomes in the treatment of breast cancer. Irish J Med Sci. 2019;188:75–83.CrossRefGoogle Scholar
  27. 27.
    Ricci JA, Epstein S, Momoh AO, Lin SJ, Singhal D, Lee BT. A meta-analysis of implant-based breast reconstruction and timing of adjuvant radiation therapy. J Surg Res. 2017;218:108–16.CrossRefPubMedGoogle Scholar

Copyright information

© Society of Surgical Oncology 2019

Authors and Affiliations

  • Puneet Singh
    • 1
  • Karen Hoffman
    • 2
  • Mark V. Schaverien
    • 3
  • Kate J. Krause
    • 4
  • Charles Butler
    • 3
  • Benjamin D. Smith
    • 2
  • Henry M. Kuerer
    • 1
    Email author
  1. 1.Department of Breast Surgical OncologyThe University of Texas MD Anderson Cancer CenterHoustonUSA
  2. 2.Department of Radiation OncologyThe University of Texas MD Anderson Cancer CenterHoustonUSA
  3. 3.Department of Plastic SurgeryThe University of Texas MD Anderson Cancer CenterHoustonUSA
  4. 4.Research Medical LibraryThe University of Texas MD Anderson Cancer CenterHoustonUSA

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