Team Work: Mastectomy, Reconstruction, and Radiation

In 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 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.

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.

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.