ORIGINAL ARTICLE
Radiation Therapy for Breast Cancer Patients Who Undergo
Oncoplastic Surgery
Localization of the Tumor Bed for the Local Boost
Richard D. Pezner, MD,* Mark C. Tan, MD,w Sharon L. Clancy, MD,w Yi-Jen Chen, MD, PhD,*
Thomas Joseph, CMD,* and Nayana L. Vora, MD*
Introduction: Oncoplastic reconstructive surgery is performed in se-
lect patients with breast cancer to allow conservation treatment when
the lumpectomy would be expected to have a poor cosmetic outcome.
These techniques not only rearrange the breast tissue but may also shift
the position of the tumor bed. The oncoplastic incision may have no
relationship to the tumor bed. Although use of whole-breast radiation
therapy (RT) is straightforward, difficulties in localization of the tumor
bed for the local RT boost have not been investigated.
Materials and Methods: A retrospective review was performed of 25
patients with 26 cancers who received RT after breast conservation
surgery with oncoplastic reconstruction.
Results: Among 11 patients with a minimum of 4 surgical clips placed
at tumor resection, 8 (73%) had the final tumor bed extend beyond the
original breast quadrant or be completely relocated into a different
region. In 3 (27%) cases, the clinical treatment volume was 2 to 3
separated regions within the breast.
Discussion: For breast cancer patients who have had oncoplastic sur-
gery, the tumor bed is frequently more extensive and possibly relocated
compared with original presentation. Placement of surgical clips after
tumor resection and before oncoplastic reconstruction may be the most
accurate method to localize the RT local boost field.
Key Words: breast cancer, radiation therapy, oncoplastic surgery,
postablative mammoplasty
(Am J Clin Oncol 2013;36:535–539)
O ncoplastic breast surgery (postablative mammoplasty)
offers the opportunity for conservation breast cancer
treatment with good cosmetic outcome for patients who would
have otherwise been recommended total mastectomy when the
lumpectomy procedure was expected to yield a very poor
physical appearance.1–3 These techniques allow rearrangement
of the remaining breast parenchyma to create an esthetically
pleasing breast shape. Several different plastic surgery tech-
niques have been used depending on the size of the region to
be resected, size of the breast, and tumor location in the
breast.1,3–6 Adjuvant radiation therapy (RT) is used in these
breast conservation patients.2–4,6,7 Delivery of whole-breast
radiation therapy (WBRT) can be accomplished in routine
From the *Department of Radiation Oncology; and wDivision of Plastic and
Reconstructive Surgery, City of Hope Medical Center, Duarte, CA.
The authors declare no conflicts of interest.
Reprints: Richard D. Pezner, MD, Department of Radiation Oncology, City
of Hope Medical Center, 1500 E. Duarte Rd, Duarte, CA 91010.
E-mail: rpezner@coh.org.
Copyright r 2012 by Lippincott Williams & Wilkins
ISSN: 0277-3732/13/3606-0535
DOI: 10.1097/COC.0b013e318256efba
American Journal of Clinical Oncology  Volume 36, Number 6, December 2013
manner. However, the local RT boost portion of treatment may
be more problematic for the radiation oncologist as the actual
tumor bed may not be easily localized given the rearrangement
of the breast tissue. The oncoplastic incision location may have
no relationship to the tumor bed.1,4,5,8 The presence of a se-
roma pocket palpable on examination or visualized on com-
puted tomography (CT) simulation may be related to the
plastic surgery reconstruction rather than the tumor bed that is
typical in lumpectomy defects. To evaluate this dilemma, we
have performed a review of our RT experience with breast
cancer patients who have undergone oncoplastic surgery.
MATERIALS AND METHODS
An Institutional Review Board-approved retrospective
study was performed of patients who received RT at City of
Hope after conservation breast cancer surgery with oncoplastic
surgical reconstruction. We reviewed all external beam RT
cases treated between April 2005, when oncoplastic surgery
was first performed at our institution, and November 2010.
Oncoplastic surgery was defined as a reconstructive sur-
gical procedure performed in conjunction with a conservation
breast cancer procedure to provide an improved cosmetic
outcome in shape and appearance of the treated breast. The
final surgical incision was placed to minimize potential breast
deformities and to optimize esthetic outcome. Often, this was
accomplished through an “inverted-T” or standard Wise pat-
tern (Fig. 1). This consists of a periareolar incision with a
vertical arm at the 6 o’clock position of the breast extending
from the nipple-areolar complex (NAC) to the inframammary
fold with horizontal arms extending along the inframammary
fold.1,5 Slight modifications may shorten or eliminate the
horizontal component of the incision producing a single ver-
tical extension or an “L” or “J” incision with 1 side arm in the
inframammary fold.1,8 Excluded from analysis were patients
who underwent lumpectomy without oncoplastic surgery,
lumpectomy and simple breast-flap advancement closure,
cosmetic breast reduction surgery with incidental discovery of
cancer in the pathology specimen, and lumpectomy with par-
tial breast RT or brachytherapy.
A broad range of systemic chemotherapy regimens, either
neoadjuvant or adjuvant, were used for patients with invasive
cancer. RT was not given until completion of all chemo-
therapy, although Herceptin alone, when indicated, was con-
tinued during the course of RT. Antiestrogen agents, including
tamoxifen and aromatase inhibitors, were not started until after
the end of RT.
WBRT was delivered through opposed tangential 6 to
10 MV photon beam fields at 1.8 to 2.0 Gy per fraction.
Wedges were used to optimize dose homogeneity. Total
prescribed dose was 50 Gy in 25 fractions or 50.4 Gy in 28
www.amjclinicaloncology.com | 535
Pezner et al American Journal of Clinical Oncology  Volume 36, Number 6, December 2013

TABLE 1. Tumor Characteristics in 25 Oncoplastic Patients With

26 Cancers
Characteristics No. Cases
Treated breast
Left 11
Right 13
Bilateral 1
Primary site quadrant
Upper outer 12
Lower outer 4
Lower inner 4
Upper inner 2
Retroareolar/central 4
Histology
Invasive ductal carcinoma 15
Invasive lobular carcinoma 1
Ductal carcinoma-in-situ 10
Nodal metastases in invasive carcinoma
FIGURE 1. Inverted-T oncoplastic incisions in a patient who un- None 7
derwent conservation surgery for a primary tumor in the upper Axillary 1-2 nodes 6
outer quadrant of the right breast. Axillary > 3 nodes 2
Infraclavicular node 1

fractions. A local boost was used at the discretion of the

treating radiation oncologist, but often depended on whether or
not surgical clips were placed in the tumor bed walls after
tumor resection and before oncoplastic reconstruction. The
local boost dose was 10 Gy in 5 fractions, as all patients had
negative or uninvolved inked pathologic margins. Choice of
local boost technique and method of tumor bed localization
was at the discretion of the radiation oncologist.
For the retrospective study, the CT simulator planning
scans were reviewed for all oncoplastic cases. A new clinical
target volume (CTV) of the tumor bed was created for patients
who had 4 or more surgical clips evident in the breast. Each
clip was contoured with a 3- to 5-mm. margin. The CTV for
the study was defined as a volume that included the outlined
clips with a 1 cm margin expansion. Tumor bed CTV’s and
whole-breast volumes were contoured and measured on the
Eclipse treatment planning system (Varian Medical Systems,
Palo Alto, CA). Primary site and the postoperative tumor bed
locations were defined by breast quadrant (upper outer, upper
inner, lower outer, and lower inner) with regard the NAC, as
well as the region deep to the NAC that was considered the
retroareolar or central region. Primary site quadrant location
was determined on the basis of physical exam and imaging
studies performed before surgery. All tumor bed localizations
and tumor bed and breast volume determinations were per-
formed by the lead author (R.D.P.).
Patients were followed with physical exam every 3 to 6
months and mammography every 12 months. Locoregional
control and survival rates were calculated from the date of start
of cancer treatment, whether that was definitive tumor re-
section or neoadjuvant chemotherapy.
RESULTS
There were 25 women, including 1 with bilateral breast
cancer, who received WBRT after conservation breast cancer
surgery and oncoplastic surgical reconstruction. Their mean
age at diagnosis was 53.2 years (range, 37 to 71 y). Nine of the
25 patients were under 50 years old. Patient weight at diag-
nosis ranged from 119 to 270 pounds with a mean weight of
195 pounds. Breast bra cup size was described for 15 of the
patients, of whom 9 (60%) had size D or greater. Preoperative
imaging studies for the 26 treated breasts included mammo-
graphy in all cases, breast magnetic resonance imaging scans
in 20 (77%) and breast ultrasound in 14 (54%). Tumor char-
acteristics are described in Table 1. Systemic therapy was used
for all 16 patients with invasive cancer, including neoadjuvant
chemotherapy in 5, adjuvant chemotherapy in 7, and anti-
estrogen agent alone in 4. Systemic chemotherapy included
adriamycin-based and/or a taxane-based regimen in the 12
cases. Adjuvant tamoxifen was given to 6 of the 10 patients
with ductal carcinoma-in-situ (DCIS).
Indications for oncoplastic surgery are shown in Table 2.
Oncoplastic surgery was performed by the plastic surgeon for
22 breasts, including the case with bilateral breast cancer, and
by the surgical oncologist for 4. Oncoplastic surgery was
performed in the 25 patients by 6 surgeons, of whom 15 (60%)
were performed by 1 (M.C.T.). Oncoplastic surgery was per-
formed the same day as the tumor resection or tumor bed
reexcision in all except 1 case. Additional tissue was resected
in 12 breasts as part of the oncoplastic procedure. The onco-
plastic incision was an “inverted-T” for 18 breasts, modified
“L” or “J” shape incision for 4, batwing for 1, and other for
3.5,8 Of the 22 cases that did not have prior contralateral RT for
TABLE 2. Indications for Oncoplastic Surgical Reconstruction for
25 Patients Undergoing Conservation Breast Cancer Surgery
No.
Indications Patients
Large multifocal radiographic abnormality 13
Large reexcision for positive margins or residual 6*
microcalcifications
Subareolar primary 2
Planned cosmetic breast reduction with preoperative 2
work-up showing cancer
Large primary tumor 1
Unsatisfactory lumpectomy cosmetic outcome 1
*Including patient with bilateral disease where contralateral surgery was also
oncoplastic to optimize symmetry.

536 | www.amjclinicaloncology.com r 2012 Lippincott Williams & Wilkins

American Journal of Clinical Oncology  Volume 36, Number 6, December 2013 Oncoplastic Breast Surgery

TABLE 3. Tumor Bed Location Shift After Oncoplastic Surgery in Patients With Z4 Surgical Clips Placed at Resection
Case Age Inverted-T No. Surgical Time Interval Surgery to Preoperative Tumor Location of Surgical
Number (y) Incision Clips RT (mo) Location Clips
1 40 No 6 2.5 LI LI
2 42 No 4 5 UO UO
3 71 No 8 1 UO UO, LO
4 44 Yes 8 2 UI UO
5 54 Yes 7 2.5 UO LO
6 45 No 7 2 LI LO, cent.
7 52 Yes 4 2 UO UO
8 40 Yes 5 2 UO UO, UI, cent.
9 65 Yes 6 6 Central Cent., LO,LI
10 50 Yes 6 6 UO UO, UI, cent.
11 62 Yes 7 8 UO UO, LO, cent.
Location (by quadrant): cent., central or retroareolar; LI, lower inner; LO, lower outer; RT, radiation therapy; UI, upper inner; UO, upper outer.

breast cancer (2 patients) or simultaneous bilateral breast breast ptosis, and/or location of the tumor in the breast.1 Al-
cancers (1 patient), contralateral reduction mammoplasty was though the terminology is varied, the oncoplastic concept in-
performed in 11 (50%) cases at the time of oncoplastic surgery volves repair of a partial mastectomy defect utilizing standard
and 9 to 22 months later for 4 (18%) cases. breast reduction techniques. These techniques typically in-
Surgical clips were placed by the surgical oncologist into volve resection of additional breast tissue and repositioning of
the tumor bed cavity walls after resection and before onco- the NAC to minimize potential breast deformity and optimize
plastic reconstruction in 18 of the 26 cases. CT simulation final esthetic outcome. A contralateral breast reduction pro-
scans showed that 7 patients had 1 to 3 clips and 11 had 4 to 8 cedure using an identical surgical procedure is often performed
clips. Among the 11 patients with at least 4 clips, quadrant concurrently or at a subsequent time to improve symmetry and
location of the tumor bed was compared with preoperative cosmetic outcome.1–3,5 This new surgical option has allowed
imaging localization of the primary tumor. The tumor bed many patients to have conservation breast cancer surgery with
extended beyond the original quadrant region or was com- good cosmetic outcome rather than undergoing a total mas-
pletely relocated to a lateral location in 8 of the 11 (73%) cases tectomy. Locoregional tumor control rates and survival rates
(Table 3). In some cases, the location shift was slight, as when are comparable with results of conservation treatment without
a patient with a tumor in the 11 o’clock position had a tumor oncoplastic surgery.2–4,7
bed in the 1 o’clock location. RT details, particularly use of a local boost field, in the
The CTV of the tumor bed for the 11 cases ranged from oncoplastic surgery studies have been minimal.2–4,6,7 Design
43 to 217 cm3, with a mean CTV of 113 cm3. Postoperative and set up of opposed tangential WBRT fields with or without
breast volume for the 11 cases ranged from 540 to 1556 cm3, elective nodal irradiation field(s) is identical to set-ups for
with a mean volume of 911 cm3. CTV as a percentage of the
postoperative breast volume ranged from 6% to 21%, with a
mean of 13%. The CTV was 2 to 3 separated regions within the
breast in 3 of the 11 (27%) cases (Fig. 2).
Follow-up since initiation of cancer treatment for the 25
patients ranged from 9 to 72 months, with a median of 24
months. Two patients, both with locally advanced invasive
cancers, died of metastatic disease. One patient was lost to
follow-up at 9 months when she returned to her native country.
RT was well tolerated with no significant skin acute toxicities
or any type of late toxicities. There have been no locoregional
recurrences. Of note, a local RT boost was not given for 8 of
the 26 treated breasts. The WBRT dose was 50 to 50.4 Gy in
all cases except the patient with bilateral disease who dis-
continued RT at 45 Gy.

DISCUSSION
Oncoplastic surgical reconstruction may pose special
challenges to the delivery of RT as part of a breast con-
servation treatment of early-stage breast cancer and DCIS. It is
usually, but not always, performed by a plastic surgeon spe-
cializing in breast cancer reconstructive procedures. Several
postablative mammoplasty techniques may be utilized when
the lumpectomy is anticipated to produce a poor cosmetic re-
sult because of volume of resection, breast size, degree of
FIGURE 2. Patient with left breast cancer who had a tumor bed
clinical treatment volume (CTV) in 2 distinct regions of the breast
after conservation breast cancer surgery and oncoplastic re-
construction. Purple volume represents the contoured volume of
surgical clips. Green volume represents the CTV based on a 1 cm
expansion around the purple clip zone volume.

r 2012 Lippincott Williams & Wilkins www.amjclinicaloncology.com | 537

Pezner et al American Journal of Clinical Oncology
breast conservation patients who did not have oncoplastic
surgery.9–11 However, localization of the tumor bed for the
local boost is not obvious. Standard methods are based on a
combination of physical exam for a palpable seroma, location
of the lumpectomy scar, review of preoperative radiology
studies, and site of a seroma pocket as visualized on the CT
simulation scan.12 However, with oncoplastic surgery, a pal-
pable seroma pocket may be in the clinically uninvolved breast
reconstruction region rather than the tumor bed. Location of
the scar is only a useful marker when placed over the tumor
site. Oncoplastic incisions, particularly the inverted-T incision,
may have no relationship to the location of the tumor bed
cavity (Fig. 1). Repositioning the NAC during oncoplastic
surgery changes what tissue is located in which quadrant when
quadrants are defined relative the NAC (Table 3).
With lumpectomy alone, placement of surgical clips into
the walls of the surgical cavity at the time of resection has been
studied and recommended as a means to localize the tumor bed
for the local boost.12–16 Typically 4 to 6 clips are placed. The
CTV is then defined as the zone of the clips with uniform
volume expansion of 5 to 15 mm. Skin and chest wall are
excluded from the CTV expansion volume.
Review of the 11 cases in our study who had at least 4
surgical clips found on CT simulation scan showed that the
tumor bed was frequently located in a larger region of the
breast or a completely different region than the initial tumor
bed location based on presenting physical exam findings and
preoperative radiographic studies (Table 3). In 3 of the 11
cases, the clips were in 2 or 3 regions of the breast separated by
at least 1 cm. This suggests that in some but not all cases, the
tumor bed may have been separated into portions and found in
nearby adjacent regions of the breast. Kirova et al16 studied
clip placement in oncoplastic patients and noted that shifts
were often in a left-right axis. As quadrant location is defined
relative to the location of the NAC, different arm, breast, and
torso positioning used for CT simulation and various pre-
operative imaging studies should not influence results.
Use of surgical clips to define the tumor bed in the breast
has limitations. On geometric grounds, determination of a
volume rather than a plane would require a minimum of 4
clips. However, CT simulation may not be able to distinguish
adjacent clips due to metal artifacts, even with a “bone win-
dow” setting. More importantly, clips may not have been
placed equally spaced along resection cavity walls, leading to
underestimation of the tumor bed CTV as portions of the tumor
bed without nearby clips may not have been contoured. Fur-
ther, it may be incorrect to assume that all clips in the breast
represent the CTV, as the plastic surgeon may have placed
clips for hemostatic purposes during the reconstruction phase
of surgery. Contouring such clips would lead to an over-
estimation of the CTV. This might be addressed by use of gold
seed fiducial markers to localize the tumor bed.15 In addition,
Shaikh et al15 observed that benign large calcifications may be
mistaken for surgical clips on CT simulation scans. Finally, our
use of a 1 cm expansion of the clip volume to create the tumor
bed CTV, based on partial breast RT and brachytherapy
studies, may be inappropriate for the types and sizes of breast
cancers treated with oncoplastic reconstruction.
The value of the local RT boost in reducing the frequency
of local recurrences in the breast was demonstrated in the
European Organization for Research and Treatment of Cancer
(EORTC) 22881-10882 trial.17 Patients who received WBRT
and a local boost had fewer ipsilateral breast recurrences
compared with patients who only received WBRT. Its value
for oncoplastic surgery patients is unclear from our study, as
538 | www.amjclinicaloncology.com
 Volume 36, Number 6, December 2013
there have been no locoregional recurrences in our patients,
whether or not they received a boost. However, our patient
group is small and follow-up too short to make definite con-
clusions. All patients received WBRT 45 to 50.4 Gy, a dose
well-recognized to be effective at reducing the risk of local
recurrence.9,11 Patient age is also an important factor in local
control. The EORTC study showed that use of a local boost led
to an absolute improvement in local control rates of only 3% to
4% for patients over 50 years old, a difference too small to be
detected in our study.17 In the EORTC study, the greatest
benefit in improved local control was for patients 40 years old
or younger. In our study, only 3 patients were that young.
Finally, the use of systemic therapy may have had an impact on
locoregional tumor control rates.11,18 All of our patients with
invasive cancer received systemic chemotherapy and/or an
antiestrogen agent. In addition, 6 of our 10 patients with DCIS
received adjuvant tamoxifen. Although use of a local boost
field is considered important to optimize local control rates,
treatment of a small but poorly localized local boost volume
may result in a geographic miss of the tumor bed, whereas
irradiation of a large, generous local boost volume to avoid a
geographic miss may result in a poor cosmetic result.
We conclude that the tumor bed in patients with onco-
plastic reconstruction is often large, irregularly shaped, and/or
split into 2 or 3 regions within the breast. It cannot be de-
pendably localized based on scar location, seroma location,
and/or preoperative radiographic or clinical localization of the
primary tumor. Placement of 6 to 10 surgical clips in the tumor
bed wall after resection and before oncoplastic reconstruction
may be the most accurate method to localize the tumor bed.
The appropriate CTV around the clips cannot be determined
based on our small patient group. Larger patient reviews with
longer follow-up will be needed to determine the relative im-
portance of the local RT boost for breast cancer patients who
have had oncoplastic surgery.
REFERENCES
1. Clough KB, Kaufman GJ, Nos C, et al. Improving breast cancer
surgery: a classification and quadrant per quadrant atlas for
oncoplastic surgery. Ann Surg Oncol. 2010;17:1375–1391.
2. Rietjens M, Urban CA, Rey PC, et al. Long-term oncological
results of breast conservative treatment with oncoplastic surgery.
Breast. 2007;16:387–395.
3. Fitoussi AD, Berry MG, Fama F, et al. Oncoplastic breast surgery
for cancer: analysis of 540 consecutive cases. Plast Reconstr Surg.
2010;125:454–462.
4. Kronowitz SJ, Hunt KK, Kuerer HM, et al. Practical guidelines for
repair of partial mastectomy defects using the breast reduction
technique in patients undergoing breast conservation therapy.
Plast Reconstr Surg. 2007;120:1755–1768.
5. Anderson BO, Masetti R, Silverstein MJ. Oncoplastic approaches
to partial mastectomy; an overview of volume-displacement
techniques. Lancet Oncol. 2005;6:145–157.
6. Song HM, Styblo TM, Carlson GW, et al. The use of oncoplastic
reduction techniques to reconstruct partial mastectomy defects in
women with ductal carcinoma in situ. Breast J. 2010;16:141–146.
7. Regano S, Hernanz F, Ortega E, et al. Oncoplastic techniques
extend breast-conserving surgery to patients with neoadjuvant
chemotherapy response unfit for conventional techniques. World J
Surg. 2009;33:2082–2086.
8. Gainer SM, Lucci A. Oncoplastic techniques for reconstruction of
partial breast defects based on tumor location. J Surg Oncol.
2011;103:341–347.
9. 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;347:1233–1241.
r 2012 Lippincott Williams & Wilkins
American Journal of Clinical Oncology  Volume 36, Number 6, December 2013
10. Veronisi 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;
347:1227–1232.
11. Wapnir IL, Dignam JJ, Fisher B, et al. Long-term outcomes of
invasive ipsilatertal breast tumor recurrences after lumpectomy in
NSABP B-17 and B-24 randomized clinical trials for DCIS. J Natl
Cancer Inst. 2011;103:478–488.
12. Coles CE, Wilson CB, Cumming J, et al. Titanium clip placement
to allow accurate tumour bed localisation following breast
conserving surgery—audit on behalf of the IMPORT Trial
Management Group. EJSO. 2009;35:578–582.
13. Kim LH, DeCesare S, Vicini F, et al. Effect of lumpectomy cavity
volume change on the clinical target volume for accelerated partial
breast irradiation: a deformable registration study. Int J Radiat
Oncol Biol Phys. 2010;78:1121–1126.
14. Dzhugashivilli M, Pichenot C, Dunant A, et al. Surgical clips
assist in the visualization of the lumpectomy cavity in three-
r 2012 Lippincott Williams & Wilkins
Oncoplastic Breast Surgery
dimensional conformal accelerated partial-breast irradiation. Int J
Radiat Oncol Biol Phys. 2010;76:1320–1324.
15. Shaikh T, Chen T, Khan A, et al. Improvement in interobserver
accuracy in delineation of the lumpectomy cavity using fiducial
markers. Int J Radiat Oncol Biol Phys. 2010;78:1127–1134.
16. Kirova YM, Pena PC, Huai T, et al. Improving the definition of
tumor bed boost with the use of surgical clips and image
registration in breast cancer patients. Int J Radiat Oncol Biol Phys.
2010;78:1352–1355.
17. Bartelink H, Horiot J-C, Portmans PM, et al. Impact of a higher
radiation dose on local control and survival in breast-conserving
therapy of early breast cancer: 10-year results of the randomized
boost versus no boost EORTC 22881-10882 trial. J Clin Oncol.
2007;22:3259–3265.
18. Buchholz TA, Tucker SL, Erwin J, et al. Impact of systemic
treatment on local control for patients with lymph node-negative
breast cancer treated with breast-conservation therapy. J Clin
Oncol. 2001;19:2240–2246.
www.amjclinicaloncology.com | 539