Viewpoint Team Work: Mastectomy, Reconstruction, and Radiation Orit Kaidar-Person, MD*†; Ellen L. Jones, MD*†; Timothy M. Zagar, MD*†
I
n November 2016, Umberto Veronesi, an Italian surgical oncologist and one of the founders of breast conserving surgery passed away. We have come a long way since the pivotal Milan and National Surgical Adjuvant Breast and Bowel Project trials in the 1980s that resulted in a paradigm shift in the management of breast cancer, leading to the acceptance of breast conserving surgery and whole breast irradiation. A recent publication surveying the National Cancer Database1 demonstrates a new trend in the treatment of early-stage breast cancer patients, indicating an increase in the overall rates of mastectomies. Furthermore, the rate of bilateral mastectomies for unilateral disease is also increasing. The rates of bilateral mastectomies for unilateral disease increased from 5.4% of mastectomies in 1998 to 29.7% in 2011, with a concurrent increase in reconstructive procedures in this group from 36.9% to 57.2% during the same time period.1 Cosmetic outcomes are probably an important factor driving these trends. However, these surgeries should be planned with the patient’s cancer diagnosis in mind as patients who undergo mastectomy often need postoperative radiation (PMRT). Moreover, in the past decade, there has been an increase in the number of patients with indications for PMRT,2 especially after the publication from the Early Breast Cancer Trialists’ Collaborative Group in 2014, demonstrating that PMRT for patients with 1–3 lymph nodes who underwent mastectomy and axillary dissection reduced recurrence and breast cancer mortality.3 Therefore, the potential need for PMRT should be taken into consideration in the management of patients who are planned for mastectomy. An axial view of tangential fields for left breast irradiation of a 37-year-old patient is shown in Figure 1. The patient was diagnosed with a 3.2-cm left breast, invasive ductal carcinoma, that was hormone receptor positive, and HER2 (human epidermal growth factor receptor 2) negative. Sentinel lymph node biopsy revealed 1 out of 1 positive lymph nodes, which was 0.5 cm in size with a focus of extracapsular extension. A genetic evaluation was performed and she tested negative for BRCA 1/2. She was treated with preoperative chemotherapy and underwent bilateral mastectomy and left axillary dissection, which demonstrated a complete pathological response in the left From the *Department of Radiation Oncology, University of North Carolina, N.C.; and †UNC Lineberger Comprehensive Cancer Center, Chapel Hill, N.C.
Copyright © 2017 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. Plast Reconstr Surg Glob Open 2017;5:e1385; doi:10.1097/ GOX.0000000000001385; Published online 16 June 2017.
Fig. 1. Axial view of tangential fields for left breast irradiation. A shared decision with the patient was to irradiate with shallow tangents fields with deep inspiration breath-hold technique to reduce the dose to the heart and the contralateral breast. Therefore, the medial portion of the left breast and the left internal mammary nodes are not included in the radiation field. In this case, due to her “new” reconstructed anatomy, we could not match a medial electron field to cover the medial portion of the breast and the internal mammary nodes. An intensity modulated radiation therapy arc-based technique was not used due to a high mean heart dose.
breast and in the lymph nodes (0 of 8 lymph nodes). The procedure was done with immediate bilateral reconstruction with prepectoralis saline implants. The patient was referred to our care for PMRT. There are many factors to discuss in this specific case, but we would like to highlight the main concern that led to this correspondence. In the case presented, the radiation treatment could not be done appropriately without compromising on normal tissue toxicity (i.e., lung dose, heart dose, dose to the contralateral reconstructed breast) or oncological outcomes (i.e., reducing the target volumes). Even though internal mammary irradiation might have added a survival benefit in this case as data from randomized trials suggest, we decided not to irradiate the internal mammary nodes to avoid high dose radiation to the heart and the contralateral breast.4,5 Presurgical planning with a multidisciplinary perspective would have probably prevented this challenge and might have also resulted in better oncologic outcomes. Timothy Michael Zagar, MD Department of Radiation Oncology University of North Carolina Chapel Hill, N.C. E-mail: [email protected]
www.PRSGlobalOpen.com 1
PRS Global Open • 2017 DISCLOSURE
The authors have no financial interest to declare in relation to the content of this article. The Article Processing Charge was paid for by the authors. REFERENCES 1. Kummerow KL, Du L, Penson DF, et al. Nationwide trends in mastectomy for early-stage breast cancer. JAMA Surg. 2015;150:9–16. 2. Frasier LL, Holden S, Holden T, et al. Temporal trends in postmastectomy radiation therapy and breast reconstruction associated with changes in national comprehensive cancer network guidelines. JAMA Oncol. 2016;2:95–101.
2
3. Ebctcg, McGale P, Taylor C, et al. Effect of radiotherapy after mastectomy and axillary surgery on 10-year recurrence and 20year breast cancer mortality: meta-analysis of individual patient data for 8135 women in 22 randomised trials. Lancet. 2014;383: 2127–2135. 4. Whelan TJ, Olivotto IA, Parulekar WR, et al.; MA.20 Study Investigators. Regional nodal irradiation in early-stage breast cancer. N Engl J Med. 2015;373:307–316. 5. Poortmans PM, Collette S, Kirkove C, et al.; EORTC Radiation Oncology and Breast Cancer Groups. Internal mammary and medial supraclavicular irradiation in breast cancer. N Engl J Med. 2015;373:317–327.
I
n November 2016, Umberto Veronesi, an Italian surgical oncologist and one of the founders of breast conserving surgery passed away. We have come a long way since the pivotal Milan and National Surgical Adjuvant Breast and Bowel Project trials in the 1980s that resulted in a paradigm shift in the management of breast cancer, leading to the acceptance of breast conserving surgery and whole breast irradiation. A recent publication surveying the National Cancer Database1 demonstrates a new trend in the treatment of early-stage breast cancer patients, indicating an increase in the overall rates of mastectomies. Furthermore, the rate of bilateral mastectomies for unilateral disease is also increasing. The rates of bilateral mastectomies for unilateral disease increased from 5.4% of mastectomies in 1998 to 29.7% in 2011, with a concurrent increase in reconstructive procedures in this group from 36.9% to 57.2% during the same time period.1 Cosmetic outcomes are probably an important factor driving these trends. However, these surgeries should be planned with the patient’s cancer diagnosis in mind as patients who undergo mastectomy often need postoperative radiation (PMRT). Moreover, in the past decade, there has been an increase in the number of patients with indications for PMRT,2 especially after the publication from the Early Breast Cancer Trialists’ Collaborative Group in 2014, demonstrating that PMRT for patients with 1–3 lymph nodes who underwent mastectomy and axillary dissection reduced recurrence and breast cancer mortality.3 Therefore, the potential need for PMRT should be taken into consideration in the management of patients who are planned for mastectomy. An axial view of tangential fields for left breast irradiation of a 37-year-old patient is shown in Figure 1. The patient was diagnosed with a 3.2-cm left breast, invasive ductal carcinoma, that was hormone receptor positive, and HER2 (human epidermal growth factor receptor 2) negative. Sentinel lymph node biopsy revealed 1 out of 1 positive lymph nodes, which was 0.5 cm in size with a focus of extracapsular extension. A genetic evaluation was performed and she tested negative for BRCA 1/2. She was treated with preoperative chemotherapy and underwent bilateral mastectomy and left axillary dissection, which demonstrated a complete pathological response in the left From the *Department of Radiation Oncology, University of North Carolina, N.C.; and †UNC Lineberger Comprehensive Cancer Center, Chapel Hill, N.C.
Copyright © 2017 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. Plast Reconstr Surg Glob Open 2017;5:e1385; doi:10.1097/ GOX.0000000000001385; Published online 16 June 2017.
Fig. 1. Axial view of tangential fields for left breast irradiation. A shared decision with the patient was to irradiate with shallow tangents fields with deep inspiration breath-hold technique to reduce the dose to the heart and the contralateral breast. Therefore, the medial portion of the left breast and the left internal mammary nodes are not included in the radiation field. In this case, due to her “new” reconstructed anatomy, we could not match a medial electron field to cover the medial portion of the breast and the internal mammary nodes. An intensity modulated radiation therapy arc-based technique was not used due to a high mean heart dose.
breast and in the lymph nodes (0 of 8 lymph nodes). The procedure was done with immediate bilateral reconstruction with prepectoralis saline implants. The patient was referred to our care for PMRT. There are many factors to discuss in this specific case, but we would like to highlight the main concern that led to this correspondence. In the case presented, the radiation treatment could not be done appropriately without compromising on normal tissue toxicity (i.e., lung dose, heart dose, dose to the contralateral reconstructed breast) or oncological outcomes (i.e., reducing the target volumes). Even though internal mammary irradiation might have added a survival benefit in this case as data from randomized trials suggest, we decided not to irradiate the internal mammary nodes to avoid high dose radiation to the heart and the contralateral breast.4,5 Presurgical planning with a multidisciplinary perspective would have probably prevented this challenge and might have also resulted in better oncologic outcomes. Timothy Michael Zagar, MD Department of Radiation Oncology University of North Carolina Chapel Hill, N.C. E-mail: [email protected]
www.PRSGlobalOpen.com 1
PRS Global Open • 2017 DISCLOSURE
The authors have no financial interest to declare in relation to the content of this article. The Article Processing Charge was paid for by the authors. REFERENCES 1. Kummerow KL, Du L, Penson DF, et al. Nationwide trends in mastectomy for early-stage breast cancer. JAMA Surg. 2015;150:9–16. 2. Frasier LL, Holden S, Holden T, et al. Temporal trends in postmastectomy radiation therapy and breast reconstruction associated with changes in national comprehensive cancer network guidelines. JAMA Oncol. 2016;2:95–101.
2
3. Ebctcg, McGale P, Taylor C, et al. Effect of radiotherapy after mastectomy and axillary surgery on 10-year recurrence and 20year breast cancer mortality: meta-analysis of individual patient data for 8135 women in 22 randomised trials. Lancet. 2014;383: 2127–2135. 4. Whelan TJ, Olivotto IA, Parulekar WR, et al.; MA.20 Study Investigators. Regional nodal irradiation in early-stage breast cancer. N Engl J Med. 2015;373:307–316. 5. Poortmans PM, Collette S, Kirkove C, et al.; EORTC Radiation Oncology and Breast Cancer Groups. Internal mammary and medial supraclavicular irradiation in breast cancer. N Engl J Med. 2015;373:317–327.
