Influence of Radiation Dose to Reconstructed Breast Following Mastectomy on Complication in Breast Cancer Patients Undergoing Two-Stage Prosthetic Breast Reconstruction

Jee Suk Chang, Seung Yong Song, Joo Hyun Oh, Dae Hyun Lew, Tai Suk Roh, Se Young Kim, Ki Chang Keum, Dong Won Lee, Yong Bae Kim, Jee Suk Chang, Seung Yong Song, Joo Hyun Oh, Dae Hyun Lew, Tai Suk Roh, Se Young Kim, Ki Chang Keum, Dong Won Lee, Yong Bae Kim

Abstract

Purpose: This study investigated the association between radiation dose and complication rate in patients who underwent breast reconstruction to understand the role of radiation hypofractionated regimen, boost radiation therapy (RT), and RT techniques. Methods: We retrospectively evaluated 75 patients treated with post-mastectomy adjuvant RT for breast cancer in the setting of two-stage prosthetic breast reconstruction. Near maximum radiation dose (Dmax) in the 2 or 0.03 cc of reconstructed breast or overlying breast skin was obtained from dose-volume histograms. Results: Post-RT complications occurred in 22.7% of patients. Receiver operating characteristic analysis showed that all near Dmax parameters were able to predict complication risk, which retained statistical significance after adjusting other variables (odds ratio 1.12 per Gy, 95% confidence interval 1.02-1.23) with positive dose-response relationship. In multiple linear regression model (R 2 = 0.92), conventional fractionation (β = 11.7) and 16 fractions in 2.66 Gy regimen (β = 3.9) were the major determinants of near Dmax compared with 15 fractions in 2.66 Gy regimen, followed by utilization of boost RT (β = 3.2). The effect of bolus and dose inhomogeneity seemed minor (P > 0.05). The location of hot spot was not close to the high density metal area of the expander, but close to the surrounding areas of partially deflated expander bag. Conclusions: This study is the first to demonstrate a dose-response relationship between risk of complications and near Dmax, where hypofractionated regimen or boost RT can play an important role. Rigorous RT-quality assurance program and modification of dose constraints could be considered as a critically important component for ongoing trials of hypofractionation. Based on our findings, we initiated a multi-center retrospective study (KROG 18-04) and a prospective study (NCT03523078) to validate our findings.

Keywords: breast reconstruction; dosimetric analysis; hypofractionated RT; implant; mastectomy; radiation dose.

Figures

Figure 1
Figure 1
Contoured structures for reconstructed breast radiation therapy (A). Red, 5 mm strip of the skin over the reconstructed breast; green, chest wall clinical target volume including the skin. The location of hot spot (107% of the prescribed dose) in partially deflated expander bag (B,C) and in fully inflated expander bag (D).
Figure 2
Figure 2
Receiver operating characteristic (ROC) curve and comparison of dosimetric parameters for development of (A) grade 2+ radiation dermatitis and (B) post-RT reconstruction-related complication between the areas under the ROC curve. AUC, area under curve; CW, chest wall; CI, confidence interval.
Figure 3
Figure 3
(A) Near Dmax values according to fractionation regimen and use of boost RT. HF (15), 15 fractions in 2.66 Gy; HF (16), 16 fractions in 2.66 Gy; CF, conventional fractionation. (B) Near Dmax values according to RT techniques and use of bolus material. CTV, clinical target volume; IMRT, intensity-modulated RT; 3DCRT, 3-dimensional conformal RT.
Figure 4
Figure 4
Dose-response relationship between skin D2cc and development of reconstruction-related complication. Shaded gray regions indicate the 95% confidence interval.

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