Preop radiotherapy, immediate reconstruction feasible in breast cancer patients

Preoperative radiotherapy (preop RT), followed by skin-sparing mastectomy and immediate deep inferior epigastric perforator (DIEP) flap reconstruction, is technically feasible and safe in breast cancer patients who require mastectomy, the PRADA* trial suggests.

“[I]interest has grown in preop RT to avoid the adverse effects of radiation on autologous breast reconstruction. [Also,] preop RT might streamline treatment by minimizing delays associated with adjuvant post-mastectomy RT,” said the researchers. However, data on this treatment sequence is lacking, they noted.

With regard to immediate breast reconstruction, evidence shows that this may help protect women from psychosocial distress, diminished sexual wellbeing, and negative body image. [Plast Reconstr Surg 2016;138:772-780]

The researchers thus aimed to address major knowledge gaps about the safety of this treatment sequence in this patient setting. “[Our] study shows that skin-sparing mastectomy and immediate microvascular breast reconstruction can be safely performed after preop RT, with low rates of postoperative complications and good aesthetic results.”

Thirty-three women (mean age 48 years) from two National Health Service trusts in the UK were enrolled. Participants should have a laboratory diagnosis of primary breast cancer requiring mastectomy and post-mastectomy RT, and should be eligible for DIEP flap reconstruction. Preop RT was delivered prior to primary mastectomy (n=31) or before completion of mastectomy (n=2). [Lancet Oncol 2022;23:682-690]

At 4 weeks postop, only four participants had an open wound >1 cm. “[T]he wounds were minor and managed conservatively with dressings and antibiotics in three patients … [O]ne patient required re-operative intervention for debridement and skin graft,” said the researchers.

“Given the long-standing concerns regarding wound healing following RT, open wound rate is an important safety outcome. Open wounds delay adjuvant therapy, might require secondary surgical intervention, prolong treatment, and affects the breast aesthetic,” they continued. “This outcome is highly relevant to multidisciplinary teams whose preferred reconstructive strategy is expander or implant-based, because the safety of preop RT with respect to postop wound complications is even more crucial in this scenario.”

Most patients (n=22) had grade 1 adverse events (AEs). Nine had grade 2 AEs, while one patient had a grade 3 toxicity (confluent moist desquamation). There were no reports of grade 4 toxicities, serious AEs, treatment-related deaths, or discontinuations owing to AEs.

After a median follow-up of 23.6 months, no DIEP flap failures were reported, nor were there any local/regional nodal recurrences. “[Our] cohort had high-risk disease (stage T3/T4 and lymph node positive), so it is encouraging that no local recurrence or regional nodal recurrence events were observed,” said the researchers.

At 12 months postop, patients reported high satisfaction with breast reconstruction (median BREASTS Q-score**, 77/100) and favourable aesthetic outcomes (median 3D-SI*** global panel score, 4.3/5). The satisfaction rate was higher than that observed in a post-mastectomy RT study. [Plast Reconstr Surg 2018;142:594-605]

“[Our study provided] comprehensive data on the safety and aesthetic outcome of preop RT in patients with breast cancer who had skin-sparing mastectomy and DIEP flap reconstruction … [Also], preop RT can reduce treatment pathway delays that occur with post-mastectomy RT due to wound healing issues,” said the researchers.

The investigators called for further studies to compare surgical, oncologic, and quality-of-life outcomes of breast reconstruction in a randomized trial comparing preop RT against conventional post-mastectomy RT. “Future trials will evaluate the potential long-term sequelae of preop RT, including fibrosis and contracture of the skin envelope, pigmentation, erythema, and alterations in breast sensation.”

Further data on the benefits of immediate breast reconstruction following preop RT may also help encourage treatment teams who are concerned about the adverse impact of post-mastectomy RT on breast reconstruction.