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- Title
Premastectomy Radiotherapy and Immediate Breast Reconstruction: A Randomized Clinical Trial.
- Authors
Schaverien, Mark V.; Singh, Puneet; Smith, Benjamin D.; Qiao, Wei; Akay, Catherine L.; Bloom, Elizabeth S.; Chavez-MacGregor, Mariana; Chu, Carrie K.; Clemens, Mark W.; Colen, Jessica S.; Ehlers, Richard A.; Hwang, Rosa F.; Joyner, Melissa M.; Largo, Rene D.; Mericli, Alexander F.; Mitchell, Melissa P.; Shuck, John W.; Tamirisa, Nina; Tripathy, Debasish; Villa, Mark T.
- Abstract
Key Points: Question: Is premastectomy radiotherapy (PreMRT), followed by mastectomy and immediate breast reconstruction (IMBR), feasible and safe? Findings: In this randomized clinical trial with 49 patients, patients received either hypofractionated (40.05 Gy/15 fractions; n = 24) or conventionally fractionated (50 Gy/25 fractions; n = 25) regional nodal irradiation including the internal mammary chain. Mastectomy with IMBR was performed at a median of 23 days after radiotherapy; there were no complete flap losses and no recurrences at a median of 29.7 months of follow-up. Meaning: This study found that PreMRT followed by IMBR with autologous microvascular flap breast reconstruction is feasible and safe, shortening the time to complete breast reconstruction. Importance: Premastectomy radiotherapy (PreMRT) is a new treatment sequence to avoid the adverse effects of radiotherapy on the final breast reconstruction while achieving the benefits of immediate breast reconstruction (IMBR). Objective: To evaluate outcomes among patients who received PreMRT and regional nodal irradiation (RNI) followed by mastectomy and IMBR. Design, Setting, and Participants: This was a phase 2 single-center randomized clinical trial conducted between August 3, 2018, and August 2, 2022, evaluating the feasibility and safety of PreMRT and RNI (including internal mammary lymph nodes). Patients with cT0-T3, N0-N3b breast cancer and a recommendation for radiotherapy were eligible. Intervention: This trial evaluated outcomes after PreMRT followed by mastectomy and IMBR. Patients were randomized to receive either hypofractionated (40.05 Gy/15 fractions) or conventionally fractionated (50 Gy/25 fractions) RNI. Main Outcome and Measures: The primary outcome was reconstructive failure, defined as complete autologous flap loss. Demographic, treatment, and outcomes data were collected, and associations between multiple variables and outcomes were evaluated. Analysis was performed on an intent-to-treat basis. Results: Fifty patients were enrolled. Among 49 evaluable patients, the median age was 48 years (range, 31-72 years), and 46 patients (94%) received neoadjuvant systemic therapy. Twenty-five patients received 50 Gy in 25 fractions to the breast and 45 Gy in 25 fractions to regional nodes, and 24 patients received 40.05 Gy in 15 fractions to the breast and 37.5 Gy in 15 fractions to regional nodes, including internal mammary lymph nodes. Forty-eight patients underwent mastectomy with IMBR, at a median of 23 days (IQR, 20-28.5 days) after radiotherapy. Forty-one patients had microvascular autologous flap reconstruction, 5 underwent latissimus dorsi pedicled flap reconstruction, and 2 had tissue expander placement. There were no complete autologous flap losses, and 1 patient underwent tissue expander explantation. Eight of 48 patients (17%) had mastectomy skin flap necrosis of the treated breast, of whom 1 underwent reoperation. During follow-up (median, 29.7 months [range, 10.1-65.2 months]), there were no locoregional recurrences or distant metastasis. Conclusions and Relevance: This randomized clinical trial found PreMRT and RNI followed by mastectomy and microvascular autologous flap IMBR to be feasible and safe. Based on these results, a larger randomized clinical trial of hypofractionated vs conventionally fractionated PreMRT has been started (NCT05774678). Trial Registration: ClinicalTrials.gov Identifier: NCT02912312 This randomized clinical trial evaluates outcomes among patients who received premastectomy radiotherapy and regional nodal irradiation followed by mastectomy and immediate breast reconstruction.
- Subjects
BREAST surgery; RADIOTHERAPY; MAMMAPLASTY; PATIENT safety; RESEARCH funding; DATA analysis; STATISTICAL sampling; QUESTIONNAIRES; FISHER exact test; MULTIPLE regression analysis; PREOPERATIVE care; TREATMENT effectiveness; RANDOMIZED controlled trials; DESCRIPTIVE statistics; MANN Whitney U Test; ODDS ratio; QUALITY of life; STATISTICS; MASTECTOMY; COMPARATIVE studies; RADIATION doses; PROGRESSION-free survival; CONFIDENCE intervals; DATA analysis software; OVERALL survival
- Publication
JAMA Network Open, 2024, Vol 7, Issue 4, pe245217
- ISSN
2574-3805
- Publication type
Article
- DOI
10.1001/jamanetworkopen.2024.5217