Treatment/Prognosis

Question 1

What are the most important factors that predict for LRR?

Answer 1

Increasing number of LNs with Dz and breast tumor size are the most important factors that predict for LRR.

Question 2

What are the basic principles of treating LABC?

Answer 2

Inoperable LABC: neoadj chemo is used to shrink the tumor and potentially convert it to be operable.

Operable LABC: Neoadj or adj chemo are used. Modified radical mastectomy (MRM) (including levels I–II axillary LNs) is the definitive locoregional Tx. PMRT is indicated in all initial stage III Dz. Hormonal therapy and trastuzumab are incorporated as appropriate per receptor status of Dz.

Question 3

What is a Halsted radical mastectomy?

Answer 3

Halsted radical mastectomy includes resection of all breast parenchyma with overlying skin and major and minor pectoral muscles en bloc with axillary LNs.

Question 4

What is spared with a MRM?

Answer 4

MRM spares the pectoralis muscles.

Question 5

What is spared with a total or simple mastectomy?

Answer 5

In a total or simple mastectomy, only the breast tissue is removed with overlying skin. Axillary LNs are not dissected.

Question 6

What is considered an “adequate” axillary LND for purposes of staging and clearance?

Answer 6

Oncologic resection of levels I–II is considered standard and adequate. The LNs and axillary fat pad need to be removed en bloc. An axillary LND is considered full if ≥10 LNs are removed without neoadj chemo; often after neoadj chemo the LN yield is reduced. If suspicious nodes are palpable on intraop evaluation of level III, then level III dissection should be performed.

Question 7

Which major trial demonstrated that not all pts with sentinel lymph node (SLN) Bx+ Dz need completion axillary LND?

Answer 7

The American College of Surgeons Oncology Group (ACOSOG) Z11 (Guiliano AE et al., Ann Surg 2010) enrolled 856 pts with cN0 T1–2 BC who underwent upfront breast-conserving Sg and SLN Bx. Pts with 1–2+ SLN were randomized to axillary lymph node dissection (ALND) + tangent RT vs. RT alone. There was no difference in breast/axillary recurrence.

Question 8

Do clinically node+ pts always need axillary LND?

Answer 8

Yes—always! Whether the pt rcv’s upfront Sg or neoadj chemo, a full axillary LND is always needed for clinically node positive (cN+) Dz. Omission of ALND should only be considered on protocol.

Question 9

What is standard systemic chemo?

Answer 9

Standard chemo at present includes an anthracycline- and taxane-based regimen (e.g., doxorubicin (adriamycin)/cyclophosphamide [AC] and paclitaxel).

Question 10

Does adding paclitaxel to standard AC chemo improve the outcomes of pts with BC?

Answer 10

Yes. Adding paclitaxel improves response rates, DFS, and OS.

NSABP 27 randomized operable pts to preop AC, preop AC + taxol, or preop AC + postop taxol. Here, the addition of taxol did not improve survival outcomes but did improve pCR in the preop group (26% vs. 13%). (Rastogi P et al., JCO 2008)

The CALGB 9344 study randomized 3,121 operable pts with LN+ Dz and found that adding taxol q3wks × 4 to AC × 4 improved DFS and OS (Henderson IC et al., JCO 2003). In a retrospective study of 1,500 pts on CALGB 9344, the benefit of taxol appeared to be in HER2+ tumors and not HER2–/ER+ tumors. (Hayes DF et al., NEJM 2007)

ECOG E1199 randomized 4,950 stages II–IIIA BC pts to AC q3wks × 4 → taxol q3wks × 4, AC q3wks × 4 → taxol × 12 weekly, AC q3wks × 4 → Taxotere q3wks × 4, and AC q3wks × 4 → Taxotere × 12 weekly. The weekly taxol arm had improved DFS (HR 1.27) and OS (HR 1.32). The effect was significant in all pts, including those with ER+/HER2– tumors. (Sparano JA et al., NEJM 2008)

Question 11

Which meta-analysis showed the benefit of anthracyclines?

Answer 11

The EBCTG/Oxford Overview meta-analysis of 18,000 women showed a benefit of anthracyclines over cyclophosphamide/methotrexate/5-fluorouracil (CMF) (improved DFS and OS), although CMF > no chemo.

Question 12

What is meant by “dose-dense” chemo?

Answer 12

Dose-dense chemo is administered q2wks as opposed to q3wks.

Question 13

Has dose-dense chemo been demonstrated to be sup in a prospective randomized trial?

Answer 13

Yes. Intergroup trial C9741 randomized 2,005 node+ pts to AC × 4 → taxol × 4 given q3wks vs. q2wks. Filgrastim was given for BM support in the q2wks arm. 4-yr DFS improved from 75% to 82% with the q2wk schedule. The risk ratio for OS was 0.69 in favor of the q2wk schedule. Median f/u was 36 mos. Severe neutropenia was also less frequent with the dose-dense schedule.

Question 14

What is the rationale for the use of neoadj chemo for LABC?

Answer 14

Neoadj chemo may convert pts with unresectable LABC to resectability. It may also be used to shrink large breast tumors requiring mastectomy in resectable pts to be managed with breast conserving surgery (BCS). Neoadj trials have the advantage of providing pathologic assessment of chemo response at the time of Sg. If the tumor is not responsive to 1 chemo regimen and progresses clinically, a different chemo regimen can be used.

Question 15

Which pts have inoperable Dz and definitely need neoadj chemo?

Answer 15

Women with fixed axillary LN (stage N2a), major skin involvement (stage T4b–4d), +/- CW involvement.

Question 16

What major study determined whether neoadj chemo improves survival compared to adj chemo in LABC?

Answer 16

NSABP B18 was designed to assess whether preop AC resulted in improved DFS and OS c/w postop AC. Secondary aims were to assess response to preop AC and correlate with survival and LR outcomes. Rates of BCS were also assessed. All women were deemed operable at enrollment, and the majority had T2 or smaller primary and cN0 Dz. At the most recent f/u (16 yrs) (Rastogi P et al., JCO 2008), there has been no significant difference in OS or DFS b/t the women treated with neoadj vs. adj chemo. There is a trend, however, for women <50 yo for improved DFS and OS when treated preoperatively (p = 0.09 and 0.06, respectively). There was a 27% conversion rate from mastectomy to BCS.

Question 17

What procedures should be done prior to starting neoadj chemo for LABC?

Answer 17

Core Bx and clip localization of the breast tumor (in case the pt has a CR to chemo). If clinically node+, clip should be placed in the involved LN prior to chemo.

Question 18

In NSABP 18 and 27, did pCR at the time of Sg correlate with good OS and DFS outcomes?

Answer 18

Yes. In both NSABP 18 and NSABP 27, pCR at the time of Sg correlated with improved OS and DFS c/w non-pCR pts.

Question 19

What other seminal neoadj chemo trials addressed neoadj vs. adj chemo and its role regarding BCS?

Answer 19

EORTC 10902 randomized 698 pts with early BC to preop vs. postop chemo (5-FU/epirubicin/cyclophosphamide × 4). Endpoints were BCS, DFS, OS, and tumor response. At 10-yr f/u, there was no difference in OS or LRR. Neoadj chemo was associated with an improved rate of BCS. (Van der Hage JA et al., JCO 2001)

Question 20

In EORTC 10902, was there a difference in the # of BCS b/t arms? Was there a difference in outcomes b/t planned breast-conserved pts and breast-converted pts?

Answer 20

BCS increased from 22% to 35% in the preop chemo arm. Although the initial f/u of EORTC 10902 indicated that converted breast-conserved pts did worse in terms of OS c/wplanned pts—an indication that prechemo staging remains relevant. However, the most recent 10-yr f/u data indicate that there is no difference in survival outcomes b/t these 2 groups. (Van der Hage JA et al., JCO 2001)

Question 21

PMRT was the standard of care for many decades. Why did it fall out of favor in the 1980s?

Answer 21

Historically, PMRT was typically offered b/c pts presented at later stages and no chemo was given. Historical series, while uniformly demonstrating improved LC, did not demonstrate survival benefit.

Meta-analysis by Cuzick et al. (9 trials) demonstrated no OS survival benefit with PMRT at 10 yrs. (Cancer Treat Rep 1987)

An update by Cuzick demonstrated that PMRT increased cardiac mortality and slightly decreased BC mortality. (JCO 1994)

Question 22

What are some criticisms of older PMRT data and meta-analysis?

Answer 22

Criticisms of older PMRT data include the significant heterogeneity of surgical and RT techniques, old RT techniques with associated cardiac and pulmonary toxicity, and lack of systemic therapy, implying that clinically undetectable systemic Dz was not well controlled.

Question 23

What 3 randomized prospective trials are considered to represent the “modern” PMRT experience?

Answer 23

The Premenopausal Danish Trial (DBCG 82b) (Overgaard M et al., NEJM 1997), the Postmenopausal Danish Trial (DBCG 82c) (Overgaard M et al., Lancet 1999), and the British Columbia PMRT Trial (Ragaz J et al., JNCI 2005) represent the “modern” PMRT experience.

Question 24

What were the design and study outcomes of Premenopausal Danish Trial DBCG 82b?

Answer 24

In Premenopausal Danish Trial DBCG 82b, 1,708 women were randomized to mastectomy and adj CMF + chemo (8 cycles) or – RT (9 cycles). Inclusion criteria were +axillary LN, tumor >5 cm, or involvement of skin or pectoral fascia. 10-yr OS was 54% (+PMRT) and 45% (–PMRT, p <0.001). Crude cumulative LRR was 32% –PMRT and 9% +PMRT. The survival benefit was seen for all pts (N0–3).

Question 25

What are some criticisms of DBCG 82b trial?

Answer 25

Criticisms of the DBCG 82b trial include the inadequate surgical Tx of axilla resulting in a median of 7 nodes removed, an excess of LF occurring in the axilla (44% in the CMF arm), and the use of now-outdated CMF chemo.

Question 26

What were the design and trial outcomes of Postmenopausal Danish Trial 82c?

Answer 26

In Postmenopausal Danish Trial 82c, 1,375 postmenopausal women <70 yo were randomized to postmastectomy tamoxifen × 1 yr vs. tamoxifen + PMRT. Inclusion criteria, surgical characteristics, and RT were as for the Premenopausal Danish Trial 82b. PMRT significantly improved LR (–PMRT 35% vs. +PMRT 8%), DFS (–PMRT 24% vs. +PMRT 36%), and OS (–PMRT 34% vs. +PMRT 45%) at 10-yr f/u (all significant).

Question 27

What are some criticisms of Postmenopausal Danish Trial 82c?

Answer 27

In Postmenopausal Danish Trial 82c, as in the Premenopausal Danish Trial 82b, inadequate surgical Tx of the axilla resulted in a median of only 7 axillary LNs removed at Sg. A suboptimal duration of tamoxifen was also employed (1 yr vs. the typical 5 yrs).

Question 28

What was the Sg performed in the Danish 82b and 82c trials?

Answer 28

Pts were surgically managed with total mastectomy + axillary LN sampling (aimed at removing at least 5 LNs, full dissection was not required). A median of 7 nodes were removed. 15% had only 0–3 LNs removed, and 75% had <9 LNs removed. This is significantly less than most centers in the United States, where ≥10 LNs represent adequate dissection.

Question 29

How was the RT given in the Danish 82b and 82c trials?

Answer 29

For 82b, PMRT was given after cycle 1 of CMF and 3–5 wks postop. For 82c, PMRT was given 2–4 wks postop. The RT dose was 48–50 Gy given in 22–25 fx to the CW with ant photon fields to cover SCV, ICV, and undissected axillary nodes and an ant electron field to cover the IM nodes and CW. Posterior axillary boost (PAB) was used for pts with a large AP diameter.

Question 30

What was the design of the British Columbia Trial?

Answer 30

In the British Columbia Trial, 318 premenopausal, high-risk pts with positive axillary LNs were randomized to CMF chemo × 6–12 mos vs. CMF + RT. Sg involved total mastectomy + axillary LND (median removal of 11 LNs). RT used Co-60 to 37.5 Gy in 16 fx. A 5-field technique was employed, including an en face photon field to cover bilat IM nodes.

Question 31

What are the relevant outcomes of the British Columbia Trial?

Answer 31

In the British Columbia Trial, at 20-yr f/u, adj RT improved LRR before DM (13% vs. 39%), DFS (48% vs. 31%), and OS (47% vs. 37%) (all significant). The benefit was extended to those with 1–3 LN+ Dz as well as those with >4 LN+ Dz.

Question 32

What are some criticisms of the British Columbia Trial?

Answer 32

In the British Columbia Trial, LRF was high c/wmany current series, CMF chemo was employed, and the RT fields included en face photons for IM nodal coverage (though no excessive cardiac deaths were observed).

Question 33

What was demonstrated by the Early Breast Cancer Trialists’ Collaborative Group (EBCTCG) RT meta-analysis?

Answer 33

The EBCTCG meta-analysis (Lancet 2005) included 78 randomized trials of 42,000 women. In node-negative women treated with BCS, the addition of adj RT reduced 5-yr LR from 22.9% to 6.7%, and reduced 15-yr BC mortality from 31.2% to 26.1%. In node+ women treated with BCS, the addition of adj RT reduced 5-yr LR from 41.1% to 11.0%, and reduced 15-yr BC mortality from 55.0% to 47.9%. In node-negative women treated with mastectomy and axillary clearance, the addition of adj RT reduced 5-yr LR from 6.3% to 2.3%, but increased 15-yr BC mortality from 27.7% to 31.3% (absolute loss of 3.6%). In node+ women treated with mastectomy and axillary clearance, the addition of adj RT reduced 5-yr LR from 22.8% to 5.8%, and reduced 15-yr BC mortality from 60.1% to 54.7%. Use of tamoxifen for 5 yrs reduced the risk of LR by appx 50% in ER+ pts. Chemo alone reduced the risk of LR by appx one-third when considering all pts. RT was associated with excess contralat BC, lung cancer, and cardiac mortality, though many other trials were included in this analysis. An updated EBCTCG meta-analysis (Lancet 2014) in mastectomy pts with adequate axillary Sg showed no benefit to PMRT in terms of LR, overall recurrence, or BC mortality in node-negative women, but confirmed a significant reduction in LR and BC mortality in women with 1–3 and ≥4 positive axillary LNs.

Similar conclusions were also supported by 2 other meta-analyses. (Whelan TJ et al., JCO 2000; Gebski V et al., JNCI 2006)

Question 34

Have there been any prospective randomized trials evaluating PMRT in pts treated with neoadj chemo?

Answer 34

No. There have been no published prospective randomized trials evaluating PMRT in pts treated with neoadj chemo. Trials are currently ongoing.

Question 35

What was demonstrated in the retrospective series from MDACC regarding PMRT in pts treated with neoadj chemo?

Answer 35

Huang E et al. analyzed the outcomes of 542 pts who had been enrolled in prospective clinical trials and treated with neoadj chemo, mastectomy, and RT. These pts were c/w134 pts enrolled in the same trials who rcvd no adj RT. Clinical stage, margin status, and hormone receptor status did not favor the adj RT group. CSS was improved with adj RT in pts with clinical stage IIIB or SCV LN+ Dz, clinical T4 tumors, and pathologically ≥4 +nodes. LRR was improved even for those pts with clinical stage III or SCV LN+ Dz who achieved a pCR on neoadj chemo. (JCO 2004)

Question 36

What is the LR rate without LN RT for pts with clinical LN+ Dz who achieve a pCR to neoadj chemo?

Answer 36

9%–13%. Data from the NSABP B-18 and B-27 trials were pooled to report rates of LRR to the breast/LNs without RT to the regional LN (RT was directed to the breast s/p BCS). (Mamounas et al., JCO 2012)

Question 37

What is the LR rate without LN RT for pts with clinical LN+ Dz who do not achieve a pCR to neoadj chemo?

Answer 37

15%–21%. Data from the NSABP B-18 and B-27 trials were pooled to report rates of LRR to the breast/LNs without RT to the regional LN (RT was directed to the breast s/p BCS). (Mamounas et al., JCO 2012)

Question 38

What are the present NCCN guidelines for PMRT?

Answer 38

Per NCCN 2018 guidelines, PMRT is a category 1 recommendation for pts with ≥4 +LNs. PMRT should be strongly considered for 1–3 +LNs, and “considered” for LN– pts with large tumors (T3, N0).

Question 39

What are some arguments for providing PMRT to pts with 1–3 positive axillary LNs?

Answer 39

An argument for treating pts with 1–3 LN Dz with PMRT is that all 3 modern randomized trials (Danish 82b, Danish 82c, and British Columbia) showed significant OS benefit with PMRT. This was true in subgroup analysis of this population and even when analysis was restricted to pts who had at least 8 axillary LNs removed in Danish trials. (Overgaard M et al., Radiother Oncol 2007)

In EBCTCG meta-analysis, pts with 1–3 LN Dz experienced similar reduction in LR and BC mortality with PMRT as pts with ≥4 +LNs (Lancet 2014).

More recent data from the EORTC 22922 trials (Poortmans, NEJM 2015) found a DFS benefit in select pts treated with regional nodal RT. ∼1/4 of the pts on this trial were treated with mastectomy (the rest rcvd BCS).

Question 40

Do the LF rates in pts with N1 Dz (1–3 LN+) in the Danish and British Columbia PMRT trials represent the typical experience in this subset of pts in United States?

Answer 40

No. The cumulative 10-yr LRR +/– DM for pts with 1–3 LN Dz on retrospective review of pts in prospective trials conducted by the NSABP, the ECOG, and MDACC was 4%–13%. (Recht A et al., JCO 1999; Katz A et al., JCO 2000; Taghian AG et al., JCO 2004)

Question 41

For pts who undergo mastectomy with 1–3 +LNs, what other clinicopathologic factors should be considered when recommending PMRT?

Answer 41

Retrospective studies from the IBCSG, NSABP, and MDACC have suggested that factors such as +LVI, high grade, younger age, ≤10 LN examined, ≥20% LN+, larger tumor size (T2 or ≥4 cm), and close margins produce 10-yr LRR >15%.

Question 42

Under what circumstances should regional LN be treated along with the CW (comprehensive PMRT)?

Answer 42

Comprehensive PMRT (CW + LN) is recommended for most pts who have an LRR risk that warrants PMRT b/c the benefit of RT of regional LN outweighs in most cases the added toxicity. All stage III pts should rcv comprehensive PMRT. Per the 2018 NCCN Guidelines, strongly consider PMRT to CW + LN in the setting of 1–3 + LN and consider PMRT to CW + LN if T3N0 tumor or +margin CW RT alone (without LN RT) can be considered for those with T1–3N0 who are being treated for +margin only.

Question 43

Should the IM nodes be included in all comprehensive PMRT fields?

Answer 43

This is controversial and would be an extrapolation from 2 randomized trials which included IM node irradiation as part of comprehensive RT in early-stage BC after BCS, but neither compared comprehensive PMRT with or without IM node irradiation.

EORTC 22922/10925 (Poortmans PM et al., NEJM 2015) trial randomized pts with a central or medial tumor, or a lat tumor with positive axillary LN treated with BCS or mastectomy with ALND (sentinel LN Bx → ALND for sentinel LN+ allowed in the latter yrs) to RT ± RNI (regional nodal irradiation) including the 1st 3–5 intercostal spaces and SCV. RNI reduced 10-yr BC mortality from 14.4% to 12.5% (p = 0.02) and trended toward improving 10-yr OS from 80.7% to 82.3% (p = 0.06).

NCIC MA.20 trial (Whelan TJ et al., NEJM 2015) randomized pts who underwent BCS and sentinel LN Bx or ALND who were either LN+ or LN– but with high-risk features (tumor ≥5 cm or tumor ≥2 cm with <10 axillary nodes removed, and at least 1 of the following: grade 3, ER–, +LVI) to WBI alone or WBI + RNI (including the ipsi IM nodes and SCV). RNI significantly improved 10-yr DFS from 77.0% to 82.0% (p = 0.01), but had no significant effect on BC mortality or OS.

DBCG-IMN is a prospective population-based cohort study which reported survival outcomes for early-stage LN+ BC pts, all of whom rcvd RNI (with IM node RT for right-sided and without IM node RT for left-sided BC) (Thorsen LBJ et al., JCO 2016). 8-yr OS was improved by 3.7% for right-sided pts, with no difference in deaths from ischemic heart Dz in the 2 groups. Some RT oncologists believe that b/c the IM nodes were included in randomized trials, Tx of the IM nodes should be the gold standard. Others argue that b/c 3 randomized trials examining the role of IM nodal dissection failed to improve OS, that Tx of clinically uninvolved IM nodes is not warranted. (Lacour J et al., Cancer 1976; Meir P et al., Cancer 1989; Veronesi U et al., Eur J Cancer 1999)

NCCN 2018 states that “the NCCN panel recommends irradiation of ICV and supraclavicular areas, IM nodes, and any part of the axillary bed that may be suspicious (category 1 for ≥4 positive nodes; 2A for 1-3 positive nodes).”

Question 44

Should pts with T3N0 BC who have had a mastectomy without neoadj chemo be treated with PMRT?

Answer 44

This is controversial. Traditionally, pts with T3N0 without other risk factors have been treated with CW-only PMRT or comprehensive PMRT. However, 2 recent retrospective studies have demonstrated that the LF rates are low for T3N0 pts after mastectomy alone with adj chemo, questioning the role of PMRT. This is an evolving area of research, so pts with pT3N0 without other risk factors should be considered for PMRT with appropriate discussion of risk and benefits of RT.

Taghian AG et al. (JCO 2006): subset meta-analysis of 5 NSABP postmastectomy chemo trials, with 313 pts with ≥5-cm tumors (N0). The 10-yr isolated LRF was 7.1%, and LRF ± DM was 10%. Almost all LRRs were in the CW. However, the median size of the tumor was 5.5 cm, so the data may not be applicable for very large tumors.

Floyd SR et al. (IJROBP 2006): review of a multi-institutional database for ≥5-cm tumors (N0). Of 70 pts, the 5-yr LRF was 7.6%. LVI was a significant prognostic factor for LF.

Note that the EORTC 22922 trial included regional nodal RT in pts with T3N0 tumors s/p mastectomy and a DFS benefit was seen. (Poortmans et al., NEJM 2015)

Question 45

How should stage II pts with LN+ BC s/p neoadj chemo and MRM be managed?

Answer 45

For pts who undergo MRM and achieve a pCR in both LN and breast, the LF rate is 0%–10% without RT (NSABP B-18, MDACC data) and omission of PMRT can be considered. For pts who undergo MRM and achieve pCR in LN but have persistent Dz in the breast, the LF rate is 10%–13% without RT (NSABP B-18, MDACC data). These pts can be considered for no RT, CW RT only, or CW + RNI. For pts with persistently +LN s/p neoadj chemo, the LF rate is 15%–20% without RT (NSABP B-18, MDACC data). These pts need comprehensive PMRT.

Question 46

How should stage II pts with LN+ BC s/p neoadj chemo and BCS be managed?

Answer 46

Pts with pCR in LN and breast will still need WBI. For pts with pCR in LN but persistent Dz in the breast, consider RNI if the pt is young (<50 yo). For pts with persistently +LNs after preop chemo, give WBI + RNI.

Question 47

What question is the NSABP B-51 trial asking?

Answer 47

NSABP B-51 is randomizing women with cT1–3N1 BC with Bx-proven axillary LN mets who convert to pN0 after neoadj chemo to rcv or omit RNI. BCS pts all rcv WBI and are randomized to ± RNI, and mastectomy pts are randomized to no RT vs. comprehensive RT (CW + RNI).

Question 48

What question is the Alliance A011202 trial asking?

Answer 48

A011202 is randomizing women with cT1–3N1 BC with Bx-proven axillary LN mets who remain pN1 after neoadj chemo to ALND vs. axillary RT.

Question 49

How is IBC managed?

Answer 49

IBC is managed using combined-modality therapy with neoadj chemo, MRM, and comprehensive PMRT.

Question 50

What are 2 acceptable PMRT schedules for IBC?

Answer 50

Conventional: 50 Gy comprehensive RT → 10–16 Gy CW boost.

MDACC: hyperfx RT: 1.5 Gy BID to 51 Gy comprehensive RT → 15 Gy boost in 10 fx BID to 66 Gy. Hyperfx is recommended for pts with high-risk features.

Question 51

In the MDACC retrospective analysis (Bristol IJ et al., IJROBP 2008), which IBC pts benefited from escalation of postmastectomy RT dose from 60 Gy to 66 Gy?

Answer 51

Pts with (a) unknown/close/+margins, (b) less than PgR to neoadj chemo, and (c) age <45 yrs.

Question 52

What are the options for a pt with poor response and unresectable Dz after induction chemo for IBC?

Answer 52

Alternative chemo; if there is still NR, can consider preop RT (conventional or hyperfractionated) → consideration for Sg.

Question 53

For pts who want breast reconstruction after mastectomy, when should the breast reconstruction be done relative to the rest of the adj Tx?

Answer 53

Per NCCN guidelines, if implant reconstruction is planned, a tissue expander can be placed at the time of Sg and it can be exchanged for a permanent implant either before or after RT. However, if autologous reconstruction is planned, this should be performed after RT, b/c cosmesis of the autologous tissue is harmed by RT. In pts with initial T4b–d Dz (i.e., skin involvement), all reconstruction should be delayed to 6–12 mos after RT, b/c skin-sparing mastectomy is contraindicated.