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Table 1.  Complication Types
Complication Types
Table 2.  Types of Interventions for Surgical Site Complications
Types of Interventions for Surgical Site Complications
1.
Veronesi  U, Cascinelli  N, Mariani  L,  et al.  Twenty-year follow-up of a randomized study comparing breast-conserving surgery with radical mastectomy for early breast cancer.  N Engl J Med. 2002;347(16):1227-1232.PubMedGoogle ScholarCrossref
2.
Fisher  B, Anderson  S, Bryant  J,  et al.  Twenty-year follow-up of a randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of invasive breast cancer.  N Engl J Med. 2002;347(16):1233-1241.PubMedGoogle ScholarCrossref
3.
Santos  G, Urban  C, Edelweiss  MI,  et al.  Long-term comparison of aesthetical outcomes after oncoplastic surgery and lumpectomy in breast cancer patients.  Ann Surg Oncol. 2015;22(8):2500-2508.PubMedGoogle ScholarCrossref
4.
Crown  A, Wechter  DG, Grumley  JW.  Oncoplastic breast-conserving surgery reduces mastectomy and postoperative re-excision rates.  Ann Surg Oncol. 2015;22(10):3363-3368.PubMedGoogle ScholarCrossref
5.
Vaidya  JS, Wenz  F, Bulsara  M,  et al; TARGIT trialists’ group.  Risk-adapted targeted intraoperative radiotherapy versus whole-breast radiotherapy for breast cancer: 5-year results for local control and overall survival from the TARGIT-A randomised trial.  Lancet. 2014;383(9917):603-613.PubMedGoogle ScholarCrossref
6.
Malter  W, Kirn  V, Mallmann  P,  et al.  Oncoplastic breast reconstruction after IORT.  Transl Cancer Res. 2014;3(1):74-82. doi:10.3978/j.issn.2218-676X.2014.01.04Google Scholar
Research Letter
December 2017

Association of Intraoperative Radiotherapy in the Treatment of Early-Stage Breast Cancer With Minor Surgical Site Complications in Oncoplastic Breast-Conserving Surgery

Author Affiliations
  • 1Department of Surgery, Section of General Thoracic and Vascular Surgery, Virginia Mason Medical Center, Seattle, Washington
JAMA Surg. 2017;152(12):1180-1182. doi:10.1001/jamasurg.2017.3129

Breast-conserving therapy is a standard treatment option for patients with early-stage breast cancer, as large randomized studies have demonstrated equivalent overall and disease-free survival compared with mastectomy.1,2 Currently, breast-conserving therapy consists of surgical removal of the tumor and axillary staging followed by adjuvant whole-breast radiotherapy (WBRT). Through incorporation of plastic surgery techniques, oncoplastic breast-conserving surgery (OBCS) improves oncologic outcomes while improving cosmesis and reducing rates of postoperative reexcision, complications, and mastectomy.3,4 Breast-conserving therapy requires prolonged treatment owing to daily WBRT, which poses logistical impediments for some patients.

Intraoperative radiotherapy (IORT) has emerged as an alternative to WBRT. Intraoperative radiotherapy delivers a single intraoperative dose of radiotherapy to the tumor bed at the time of surgical resection. The Targeted Intraoperative Radiotherapy Versus Whole Breast Radiotherapy for Breast Cancer (TARGIT-A) trial reported similar rates of local recurrence between patients receiving IORT and those receiving WBRT, with low risk of radiotherapy-related complications.5 Radiotherapy raises concern for poor wound healing in the setting of increased complexity associated with OBCS. Studies report low rates of surgical site complications when IORT is performed as a boost during OBCS.6 This study compares the surgical site complications associated with OBCS with IORT and OBCS with WBRT within 6 months of surgery.

Methods

This nested case-control study using data derived from a prospective database includes women undergoing OBCS for treatment of breast cancer between January 1, 2013, and July 31, 2015. Patients with unifocal tumors 3 cm or smaller, no clinical evidence of nodal disease, and lymphovascular invasion were offered partial mastectomy and IORT. The patients were divided into 2 groups: those treated with OBCS and IORT (IORT group) and those treated with OBCS with WBRT (WBRT group). Patients achieving margins less than 2 mm were offered reexcision. Surgical site complications were evaluated. The study was approved by the Benaroya Research Institute Institutional Review Board, which waived patient consent.

Continuous variables were compared using 2-tailed t tests and categorical data were compared using χ2 tests. P < .05 was considered significant. Logistic regression was performed using statistical software (MedCalc, version 12.7.5; MedCalc Software bvba).

Results

A total of 453 patients were evaluated: the IORT group comprised 162 patients, while the WBRT group included 291 patients. Mean patient age (IORT, 62.7 years vs WBRT, 62.3 years; P = .63), body mass index (IORT, 28.6 vs WBRT 28.2 [calculated as weight in kilograms divided by height in meters squared]; P = .60), tumor histologic characteristics, and receptor status were not significantly different between the 2 groups. Tumor size in the IORT group was significantly smaller than in the WBRT group (11.8 vs 17.2 mm; P = .001). No major complications occurred. Reexcision rates were similar between the 2 groups (IORT, 31 [19.1%] vs WBRT, 69 [23.7%]; P = .29). A total of 24 patients (5.3%) who required reexcision underwent mastectomy for inadequate margins, including 3 patients (1.9%) in the IORT group and 21 patients (7.2%) in the WBRT group (P = .02). Minor surgical site complications occurred in 29 patients (17.9%) in the IORT group, compared with 20 patients (6.9%) in the WBRT group (P = .001) (Table 1). The IORT group had a significantly higher rate of superficial wound dehiscence (15 [9.3%] vs 9 [3.1%]; P = .01) and seroma (5 [3.1%] vs 1 [0.3%]; P = .02). When complications occurred, the need for interventions was not different between groups (IORT, 16 of 29 patients [55.2%] vs WBRT, 10 of 20 patients [50.0%]; P = .78) (Table 2). Obesity, smoking, diabetes, chemotherapy, advanced patient age, tumor size, and need for reexcision were not associated with an increased rate of complications on both univariate and multivariate analyses.

Discussion

Overall, OBCS has a low risk of perioperative complications. This study shows that complications associated with IORT are minor and require little intervention. Comorbid factors were not associated with an increased rate of surgical site complications; therefore, these factors should not influence the decision to treat with IORT. Oncoplastic breast surgery with IORT is a safe and reasonable treatment option for patients with early-stage breast cancer.

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Article Information

Corresponding Author: Janie W. Grumley, MD, Department of Surgery, Section of General Thoracic and Vascular Surgery, Virginia Mason Medical Center, 1201 Terry Ave, Mail Stop X11-GS, Seattle, WA 98101 (janie.grumley@virginiamason.org).

Accepted for Publication: May 21, 2017.

Published Online: September 6, 2017. doi:10.1001/jamasurg.2017.3129

Author Contributions: Drs Crown and Grumley had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Both authors.

Acquisition, analysis, or interpretation of data: Both authors.

Drafting of the manuscript: Both authors.

Critical revision of the manuscript for important intellectual content: Both authors.

Statistical analysis: Both authors.

Administrative, technical, or material support: Grumley.

Study supervision: Grumley.

Conflict of Interest Disclosures: None reported.

References
1.
Veronesi  U, Cascinelli  N, Mariani  L,  et al.  Twenty-year follow-up of a randomized study comparing breast-conserving surgery with radical mastectomy for early breast cancer.  N Engl J Med. 2002;347(16):1227-1232.PubMedGoogle ScholarCrossref
2.
Fisher  B, Anderson  S, Bryant  J,  et al.  Twenty-year follow-up of a randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of invasive breast cancer.  N Engl J Med. 2002;347(16):1233-1241.PubMedGoogle ScholarCrossref
3.
Santos  G, Urban  C, Edelweiss  MI,  et al.  Long-term comparison of aesthetical outcomes after oncoplastic surgery and lumpectomy in breast cancer patients.  Ann Surg Oncol. 2015;22(8):2500-2508.PubMedGoogle ScholarCrossref
4.
Crown  A, Wechter  DG, Grumley  JW.  Oncoplastic breast-conserving surgery reduces mastectomy and postoperative re-excision rates.  Ann Surg Oncol. 2015;22(10):3363-3368.PubMedGoogle ScholarCrossref
5.
Vaidya  JS, Wenz  F, Bulsara  M,  et al; TARGIT trialists’ group.  Risk-adapted targeted intraoperative radiotherapy versus whole-breast radiotherapy for breast cancer: 5-year results for local control and overall survival from the TARGIT-A randomised trial.  Lancet. 2014;383(9917):603-613.PubMedGoogle ScholarCrossref
6.
Malter  W, Kirn  V, Mallmann  P,  et al.  Oncoplastic breast reconstruction after IORT.  Transl Cancer Res. 2014;3(1):74-82. doi:10.3978/j.issn.2218-676X.2014.01.04Google Scholar
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