Simultaneous Oncoplasty and Intraoperative Radiation: Technical and Clinical Considerations
Arvind U. Gowda, MD, Navid Pourtaheri, MD, PhD, Kitae E. Park, BA, Omar Allam, BS, Seija Maniskas, MD, Derek Steinbacher, MD.
Yale School of Medicine, New Haven, CT, USA.
Introduction: Intraoperative radiation therapy (IORT) is a single-dose radiation alternative delivered at the time of lumpectomy for women with early-stage breast cancer. Compared to traditional whole breast irradiation (WBI), IORT spares healthy breast tissue, reduces treatment time, and maximizes patient convenience. While the concept of simultaneous IORT and oncoplastic reconstructions is not new, there is a paucity of literature on technical considerations and long-term outcomes. Here, we present a proof of concept of successful oncoplastic reconstruction at the time of IORT as a starting point for an IRB-approved, prospective outcomes trial. Methods: A 52-year-old female presented with a T1N0M0 invasive ductal carcinoma in the central right breast, 6 cm deep to the nipple-areolar complex (NAC). She was presented at interdisciplinary tumor board and deemed a candidate for breast conservation therapy, IORT and oncoplasty. The patient underwent right lumpectomy and sentinel lymph node biopsy through a wise pattern incision. Following the completion of IORT, the lumpectomy cavity margins were marked with surgical clips, then painted circumferentially with methylene blue (Figure 1a). Using a superomedial pedicle, the NAC was rotated superiorly to fill the lumpectomy defect without excision of the blue margins. The breast envelope was then closed in layered fashion. Results: At 4-month follow up, the patient demonstrated well-healed incisions with no signs of fibrosis or nodularity (Figure 1b). She remains negative for locoregional recurrence and continues to undergo routine cancer surveillance. Conclusion: Oncoplastic reconstruction at the time of IORT is both feasible and advantageous. A multidisciplinary approach is crucial for successful surgical execution and postoperative monitoring. Following extensive planning with the breast surgeons and radiation oncologists, the above patient underwent successful single-stage cancer treatment and reconstruction without compromise of postoperative cancer surveillance. This case report will serve as the springboard for a prospective trial investigating the long term outcomes (wound healing, aesthetic, locoregional recurrence) and complications of oncoplastic reconstruction during IORT.
Figure 1a. Methylene blue applied to lumpectomy margins of right breast. Figure 1b. 4-month postoperative visit following right breast IORT and oncoplasty with left breast mastopexy.
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