Abstract
Sir: We have read with great interest the comments of Drs. Garreffa and Agrawal on our recently published article, “Outcomes of Volume Replacement Oncoplastic Breast-Conserving Surgery Using Chest Wall Perforator Flaps: Comparison with Volume Displacement Oncoplastic Surgery and Total Breast Reconstruction.”1 We thank the authors for their comments and are very grateful to them for giving us the opportunity to further discuss the potential challenges of delivering adjuvant tumor bed boost radiotherapy following this surgery. As the authors point out, whereas an accurate definition of the tumor bed has been well-established for traditional volume displacement oncoplastic breast-conserving surgery, where the cavity walls are apposed,2–5 there has yet to be consensus for volume replacement oncoplastic surgery where the tumor bed is undisplaced, with the cavity walls separated by the perforator flap filling the surgical defect. We agree with the authors that the ideal boost target for such patients should be delineated as a rim of breast tissue adjacent to and surrounding the chest wall perforator flap. It is imperative that surgical cavity clips are placed to allow the tumor bed to be identified on the simulation computed tomography scan, and that there is good communication between the surgeon and radiation oncologist when a chest wall perforator flap has been performed, including delineating the flap on the planning scan where necessary.1–5 An interesting technical question that, in our opinion, remains unanswered is the degree to which current radiation technology could reliably treat this sort of doughnut-shaped target and result in clinically meaningful sparing of the perforator flap. Another option to consider in such cases might be delivery of the boost preoperatively with magnetic resonance imaging guidance, which then confers the distinct advantage of sparing the perforator flap from the boost dose entirely. We believe that these strategies merit further prospective investigation. We are very grateful to the authors for their comments and hope that we have provided further clarity and perspective. DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. Mark V. Schaverien, M.B.Ch.B., M.D., M.Sc., M.Ed.Geoffrey Robb, M.D.Division of SurgeryDepartment of Plastic Surgery Ben Smith, M.D.Department of Radiation OncologyThe University of Texas M. D. Anderson Cancer CenterHouston, Texas
Published Version
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