Neoadjuvant radiotherapy and immediate breast reconstruction: A systematic review of literature of the last decade

Background and purpose: Adjuvant radiotherapy (RT) of the chestwall in breast cancer treatment negatively influences complication rates and cosmetic outcomes of breast reconstructions (BR). Neoadjuvant radiotherapy (NART) offers potential advantages, theoretically enabling immediate BR (IBR) with less complications. This comprehensive systematic review provides an overview of patient-reported, complications, and oncological outcomes of NART followed by IBR in breast cancer treatment. Materials and methods: A systematic literature search was conducted on PubMed, Ovid EMBASE and Cochrane library including studies published between 2014–2024. Risk of bias and methodological quality were appraised. Results: Twenty-one articles (16 journal articles, 5 abstracts) involving 1.199 patients (mean follow-up 35 months) were included. Six studies compared NART to adjuvant RT, with majority of patients (98 %) receiving neoadjuvant chemoradiotherapy. Patient-reported outcomes, assessed in three studies, reported excellent-to-good cosmetic outcomes, with one reporting significantly better on cosmetic outcomes for NART compared to adjuvant RT. Complications were reported in eighteen studies. There were no complete flap failures, loss of implant rates were low. Mean incidence of unplanned surgical intervention was 11 % (range: 2–21 %). Grade 3 skin toxicity ranged from 1–17 %, with no Grade 4–5 events. Mastectomy skin necrosis varied from 3-17 %. Pathological complete response after NARCT was achieved in 12–53 % of patients, and locoregional recurrences ranged between 3 %–10 %. Conclusion: This review indicates that NART followed by IBR may result in higher patient satisfaction, lower complication rates and shorter total treatment time compared to adjuvant RT. Randomized trials with head-on comparison between NART and adjuvant RT are needed to confirm this.