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Bosma SCJ, Leij F, Vreeswijk S, Maaker MD, Wesseling J, Vijver MVD, Scholten A, Rivera S, Bourgier C, Auzac G, Foukakis T, Lekberg T, Bongard D, Loo C, Rutgers E, Bartelink H, Elkhuizen PHM. Five-Year Results of the Preoperative Accelerated Partial Breast Irradiation (PAPBI) Trial. Int J Radiat Oncol Biol Phys 2020; 106:958-967. [PMID: 31987957 DOI: 10.1016/j.ijrobp.2019.12.037] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Revised: 12/12/2019] [Accepted: 12/16/2019] [Indexed: 01/19/2023]
Abstract
PURPOSE In this multicenter phase 2 feasibility study, we investigated the impact of preoperative accelerated partial breast irradiation (PAPBI) on local control, breast fibrosis, and cosmetic outcome. METHODS AND MATERIALS Women aged >60 years with an invasive, unifocal (mammography and magnetic resonance imaging), nonlobular adenocarcinoma of the breast were treated with PAPBI. Six weeks after radiation therapy, a wide local excision was performed. Radiation therapy consisted of 10 × 4 Gy (2010-2013) or 5 × 6 Gy (after 2013) to the tumor (gross target volume) with a 25 mm margin (20 mm from gross target volume to clinical target volume, 5 mm planning target volume). RESULTS One hundred thirty-three patients treated between 2010 and 2016 were analyzed with a median follow-up of 5.0 years (0.9-8.8 years). Seventy-eight (59%) patients were treated with 10 × 4 Gy in 2 weeks and 55 (41%) patients with 5 × 6 Gy in 1 week. Eighteen postoperative complications (14%) occurred in 15 patients (11%). The proportion of patients with no to mild fibrosis in the treated part of the breast at 2 years and later time points was around 90%. Cosmesis improved over time in several patients: excellent to good cosmetic score as rated by the physician was 68% at 6 months and 92% at 5 years. Seventy-seven percent (6 months) to 82% (5 years) of patients were "satisfied" or "very satisfied" with their cosmetic outcome. Three recurrences were detected in the biopsy track and 1 recurrence in the ipsilateral breast. CONCLUSIONS PAPBI is a feasible method with a low postoperative complication rate, limited fibrosis, and good to excellent cosmetic outcome. The local recurrence rate was 3% at 5 years; however, no local recurrences were observed since removal of the needle biopsy track.
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Affiliation(s)
- Sophie C J Bosma
- Department of Radiation Oncology, the Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Femke Leij
- Department of Radiation Oncology, the Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Sandra Vreeswijk
- Department of Radiation Oncology, the Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Michiel de Maaker
- Division of Molecular Pathology, the Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Jelle Wesseling
- Division of Molecular Pathology, the Netherlands Cancer Institute, Amsterdam, The Netherlands
| | | | - Astrid Scholten
- Department of Radiation Oncology, the Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Sofia Rivera
- Department of Radiation Oncology, Gustave Roussy, Villejuif, France
| | - Celine Bourgier
- Department of Radiation Oncology, Institut du Cancer de Montpellier Val d'Aurelle, Montpellier, France
| | - Guillaume Auzac
- Department of Radiation Oncology, Gustave Roussy, Villejuif, France
| | - Theodoros Foukakis
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
| | - Tobias Lekberg
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
| | - Desiree Bongard
- Department of Radiation Oncology, University Medical Center, Utrecht, The Netherlands
| | - Claudette Loo
- Department of Radiology, the Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Emiel Rutgers
- Department of Surgical Oncology, the Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Harry Bartelink
- Department of Radiation Oncology, the Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Paula H M Elkhuizen
- Department of Radiation Oncology, the Netherlands Cancer Institute, Amsterdam, The Netherlands.
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202
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Fastner G, Sedlmayer F, Widder J, Metz M, Geinitz H, Kapp K, Fesl C, Sölkner L, Greil R, Jakesz R, Kwasny W, Heck D, Bjelic-Radisic V, Balic M, Stöger H, Wieder U, Zwrtek R, Semmler D, Horvath W, Melbinger-Zeinitzer E, Wiesholzer M, Wette V, Gnant M. Endocrine therapy with or without whole breast irradiation in low-risk breast cancer patients after breast-conserving surgery: 10-year results of the Austrian Breast and Colorectal Cancer Study Group 8A trial. Eur J Cancer 2020; 127:12-20. [PMID: 31962198 DOI: 10.1016/j.ejca.2019.11.024] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 11/16/2019] [Accepted: 11/21/2019] [Indexed: 11/25/2022]
Abstract
PURPOSE To investigate long-term results of patients with hormonal receptor-positive breast cancer treated with breast-conserving surgery (BCS) and consecutive endocrine therapy (ET) with or without whole breast irradiation (WBI). METHODS AND MATERIALS Within the 8 A trial of the Austrian Breast and Colorectal Cancer Study Group, a total of 869 patients received ET after BCS which was randomly followed by WBI (n = 439, group 1) or observation (n = 430, group 2). WBI was applied up to a mean total dosage of 50 Gy (+/- 10 Gy boost) in conventional fractionation. RESULTS After a median follow-up of 9.89 years, 10 in-breast recurrences (IBRs) were observed in group 1 and 31 in group 2, resulting in a 10-year local recurrence-free survival (LRFS) of 97.5% and 92.4%, respectively (p = 0.004). This translated into significantly higher rates for disease-free survival (DFS): 94.5% group 1 vs 88.4% group 2, p = 0.0156. For distant metastases-free survival (DMFS) and overall survival (OS), respective 10-year rates amounted 96.7% and 86.6% for group 1 versus 96.4% and 87.6%, for group 2 (ns). WBI (hazard ratio [HR]: 0.27, p < 0.01) and tumour grading (HR: 3.76, p = 0.03) were found as significant predictors for IBR in multiple cox regression analysis. CONCLUSIONS After a median follow-up of 10 years, WBI resulted in a better local control and DFS compared with ET alone. The omission of WBI and tumour grading, respectively, were the only negative predictors for LRFS.
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Affiliation(s)
- Gerd Fastner
- Department of Radiotherapy and Radio-Oncology, Paracelsus Medical University, University Hospital Salzburg, Landeskrankenhaus, Salzburg, Austria.
| | - Felix Sedlmayer
- Department of Radiotherapy and Radio-Oncology, Paracelsus Medical University, University Hospital Salzburg, Landeskrankenhaus, Salzburg, Austria.
| | - Joachim Widder
- Department of Radiation Oncology, Medical University of Vienna, Vienna, Austria.
| | - Martina Metz
- Department of Radiooncology and Radiotherapy, Wiener Neustadt Hospital, Wiener Neustadt, Austria.
| | - Hans Geinitz
- Department of Radiation Oncology, Ordensklinikum Linz Barmherzige Schwestern, Linz, Austria.
| | - Karin Kapp
- Department of Therapeutic Radiology and Oncology, Comprehensive Cancer Center (CCC), Medical University of Graz, Graz, Austria.
| | - Christian Fesl
- Austrian Breast and Colorectal Cancer Study Group, Vienna, Austria.
| | - Lidija Sölkner
- Austrian Breast and Colorectal Cancer Study Group, Vienna, Austria.
| | - Richard Greil
- Department of Medical Oncology, Paracelsus Medical University, Salzburg, Austria.
| | - Raimund Jakesz
- Department of Medical Oncology, Paracelsus Medical University, Salzburg, Austria.
| | - Werner Kwasny
- Department of Surgery, Wiener Neustadt Hospital, Wiener Neustadt, Austria.
| | - Dietmar Heck
- Department of Surgery, Ordensklinikum Linz Barmherzige Schwestern, Linz, Austria.
| | - Vesna Bjelic-Radisic
- Breast Unit, Universtiy Hospital Wuppertal, University Witten/Herdecke, Witten, Germany.
| | - Marija Balic
- Department of Internal Medicine, Division of Oncology, Medical University of Graz, Graz, Austria.
| | - Herbert Stöger
- Department of Internal Medicine, Division of Oncology, Medical University of Graz, Graz, Austria.
| | - Ursula Wieder
- Department of Surgery, Hanusch Spital, Vienna, Austria.
| | - Ronald Zwrtek
- Department of Surgery, Mistelbach Hospital, Mistelbach, Austria.
| | - Dagmar Semmler
- Department of Surgery, Mistelbach Hospital, Mistelbach, Austria.
| | | | | | - Martin Wiesholzer
- Department of Internal Medicine I, Division of Nephrology and Hematology, University Hospital St. Poelten, Karl Landsteiner University of Health Sciences, St. Pölten, Austria.
| | - Viktor Wette
- Department of Surgery, Krankenhaus der Barmherzigen Brüder St Veit an der Glan, St. Veit an der Glan, Austria.
| | - Michael Gnant
- Austrian Breast and Colorectal Cancer Study Group, Vienna, Austria; Department of Surgery and Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria.
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203
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New Palpable Mass in the Right Breast. Surgery 2020. [DOI: 10.1007/978-3-030-05387-1_6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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204
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Intraoperative Radiotherapy. Pract Radiat Oncol 2020. [DOI: 10.1007/978-981-15-0073-2_14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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205
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Dutta SW, Aliotta E, Alonso CE, Bliley RC, Romano KD, Libby B, Showalter TN, Showalter SL, Janowski EM. Normal tissue dose and risk estimates from whole and partial breast radiation techniques. Breast J 2019; 26:1308-1315. [PMID: 31876106 DOI: 10.1111/tbj.13735] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 12/03/2019] [Accepted: 12/05/2019] [Indexed: 11/29/2022]
Abstract
PURPOSE To compare radiation dose to organs at risk in patients with early-stage breast cancer treated with lumpectomy and intraoperative radiation therapy with CT-guided HDR brachytherapy (precision breast IORT; PB-IORT) and those treated with external beam whole breast irradiation (WB-DIBH) or partial breast irradiation (PB-DIBH) with deep inspiratory breath hold. METHODS We retrospectively identified 52 consecutive patients with left-sided breast cancers treated with either PB-IORT (n = 17, 76% outer breast) on a phase I clinical trial, adjuvant PB-DIBH (n = 18, 56% outer breast, 6% cavity boost), or WB-DIBH (n = 17, 76% outer breast, 53% with lumpectomy cavity boost). Conventional (2 Gy/fraction) or moderate hypofractionation (2.66 Gy/fraction) was prescribed for the external beam cohorts and 12.5 Gy in 1 fraction to 1 cm from the balloon surface was prescribed to the HDR brachytherapy cohort. CT-based planning was used for all patients. Organ at risk doses and excess risk ratios (ERR) for secondary lung cancers, contralateral breast cancers, and cardiac toxicity were compared between treatment techniques. RESULTS Compared to WB-DIBH and PB-DIBH, PB-IORT resulted in lower ipsilateral lung V5, V10, V20, mean, and max dose (P < .05). Mean ipsilateral lung BED3Gy was as follows: 1.32 Gy for PB-IORT, 4.33 Gy for WB-DIBH, 3.35 Gy for PB-DIBH. The ERR for lung cancer was lowest for PB-IORT (P < .001). There was significantly higher contralateral breast max dose but lower mean BED3Gy for WB-DIBH compared with PB-IORT (P = .012, P = .011, respectively). Mean contralateral breast BED3Gy was as follows: 0.10 Gy for PB-IORT, 0.06 Gy for WB-DIBH, and 0.08 Gy for PB-DIBH. The ERR for contralateral breast cancer was low for all breast techniques, but WB-DIBH showed lower ERR compared to PB-IORT (P = .019). Mean heart BED2Gy was higher with PB-IORT at 1.26 Gy compared to 0.48 Gy and 0.24 Gy for WB-DIBH and PB-DIBH, respectively (P < .001). CONCLUSIONS Patients with early-stage breast cancer treated with PB-IORT and with tissue-sparing external beam techniques all received low organ at risk doses, but PB-IORT resulted in far lower ipsilateral lung dose compared with external beam techniques. Our data indicate the lowest mean contralateral breast BED in the WB-DIBH group, likely due to the simplicity of the field design in low-risk patients using tangential whole breast radiation. External beam using DIBH results in lowest heart dose, but all techniques were well within recommended heart constraints.
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Affiliation(s)
- Sunil W Dutta
- Department of Radiation Oncology, University of Virginia, Charlottesville, VA, USA
| | - Eric Aliotta
- Department of Radiation Oncology, University of Virginia, Charlottesville, VA, USA
| | - Clayton E Alonso
- Department of Radiation Oncology, University of Virginia, Charlottesville, VA, USA
| | - Roy C Bliley
- Department of Radiation Oncology, University of Virginia, Charlottesville, VA, USA
| | - Kara D Romano
- Department of Radiation Oncology, University of Virginia, Charlottesville, VA, USA
| | - Bruce Libby
- Department of Radiation Oncology, University of Virginia, Charlottesville, VA, USA
| | - Timothy N Showalter
- Department of Radiation Oncology, University of Virginia, Charlottesville, VA, USA
| | | | - Einsley M Janowski
- Department of Radiation Oncology, University of Virginia, Charlottesville, VA, USA
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206
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Melnik I, Yerushalmi R, Sobol Y, Magen A, Givon‐Madhala O, Birinbaum Y, Fenig E, Sharon E. Intraoperative radiation therapy for breast cancer—Immediate and 30‐month oncological outcomes. Breast J 2019; 26:946-951. [DOI: 10.1111/tbj.13708] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 10/28/2019] [Accepted: 11/21/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Idit Melnik
- Department of Surgery B Rabin Medical Center – Hasharon Hospital Petach Tikva Israel
| | - Rinat Yerushalmi
- Department of Oncology Rabin Medical Center – Beilinson Hospital Petach Tikva Israel
- Sackler Faculty of Medicine Tel Aviv University Tel Aviv Israel
| | - Yael Sobol
- Department of Surgery Rabin Medical Center – Beilinson Hospital Petach Tikva Israel
| | - Ada Magen
- Department of Surgery Rabin Medical Center – Beilinson Hospital Petach Tikva Israel
| | - Osnat Givon‐Madhala
- Department of Surgery Rabin Medical Center – Beilinson Hospital Petach Tikva Israel
| | - Yehudit Birinbaum
- Department of Surgery Rabin Medical Center – Beilinson Hospital Petach Tikva Israel
| | - Eyal Fenig
- Department of Oncology Rabin Medical Center – Beilinson Hospital Petach Tikva Israel
- Sackler Faculty of Medicine Tel Aviv University Tel Aviv Israel
| | - Eran Sharon
- Sackler Faculty of Medicine Tel Aviv University Tel Aviv Israel
- Department of Surgery Rabin Medical Center – Beilinson Hospital Petach Tikva Israel
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207
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Citron F, Segatto I, Vinciguerra GLR, Musco L, Russo F, Mungo G, D'Andrea S, Mattevi MC, Perin T, Schiappacassi M, Massarut S, Marchini C, Amici A, Vecchione A, Baldassarre G, Belletti B. Downregulation of miR-223 Expression Is an Early Event during Mammary Transformation and Confers Resistance to CDK4/6 Inhibitors in Luminal Breast Cancer. Cancer Res 2019; 80:1064-1077. [PMID: 31862778 DOI: 10.1158/0008-5472.can-19-1793] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 11/19/2019] [Accepted: 12/17/2019] [Indexed: 11/16/2022]
Abstract
miR-223 is an anti-inflammatory miRNA that in cancer acts either as an oncosuppressor or oncopromoter, in a context-dependent manner. In breast cancer, we demonstrated that it dampens the activation of the EGF pathway. However, little is known on the role of miR-223 during breast cancer onset and progression. miR-223 expression was decreased in breast cancer of luminal and HER2 subtypes and inversely correlated with patients' prognosis. In normal luminal mammary epithelial cells, miR-223 acted cell autonomously in the control of their growth and morphology in three-dimensional context. In the MMTV-Δ16HER2 transgenic mouse model, oncogene transformation resulted in a timely abrogation of miR-223 expression, likely due to activation of E2F1, a known repressor of miR-223 transcription. Accordingly, treatment with CDK4/6 inhibitors, which eventually results in restraining E2F1 activity, restored miR-223 expression and miR-223 ablation induced luminal breast cancer resistance to CDK4/6 inhibition, both in vitro and in vivo. Notably, miR-223 expression was lost in microdissected ductal carcinoma in situ (DCIS) from patients with luminal and HER2-positive breast cancer. Altogether, these results identify downmodulation of miR-223 as an early step in luminal breast cancer onset and suggest that it could be used to identify aggressive DCIS and predict the response to targeted therapy. SIGNIFICANCE: miR-223 may represent a predictive biomarker of response to CDK4/6 inhibitors and its loss could identify DCIS lesions that are likely to progress into invasive breast cancer.
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Affiliation(s)
- Francesca Citron
- Molecular Oncology Unit, Centro di Riferimento Oncologico di Aviano (CRO), IRCCS, National Cancer Institute, Aviano, Italy
| | - Ilenia Segatto
- Molecular Oncology Unit, Centro di Riferimento Oncologico di Aviano (CRO), IRCCS, National Cancer Institute, Aviano, Italy
| | - Gian Luca Rampioni Vinciguerra
- Molecular Oncology Unit, Centro di Riferimento Oncologico di Aviano (CRO), IRCCS, National Cancer Institute, Aviano, Italy.,Faculty of Medicine and Psychology, Department of Clinical and Molecular Medicine, University of Rome "Sapienza" Sant'Andrea Hospital, Rome, Italy
| | - Lorena Musco
- Molecular Oncology Unit, Centro di Riferimento Oncologico di Aviano (CRO), IRCCS, National Cancer Institute, Aviano, Italy
| | - Francesca Russo
- Molecular Oncology Unit, Centro di Riferimento Oncologico di Aviano (CRO), IRCCS, National Cancer Institute, Aviano, Italy
| | - Giorgia Mungo
- Molecular Oncology Unit, Centro di Riferimento Oncologico di Aviano (CRO), IRCCS, National Cancer Institute, Aviano, Italy
| | - Sara D'Andrea
- Molecular Oncology Unit, Centro di Riferimento Oncologico di Aviano (CRO), IRCCS, National Cancer Institute, Aviano, Italy
| | - Maria Chiara Mattevi
- Molecular Oncology Unit, Centro di Riferimento Oncologico di Aviano (CRO), IRCCS, National Cancer Institute, Aviano, Italy
| | - Tiziana Perin
- Pathology Unit, Centro di Riferimento Oncologico di Aviano (CRO), IRCCS, National Cancer Institute, Aviano, Italy
| | - Monica Schiappacassi
- Molecular Oncology Unit, Centro di Riferimento Oncologico di Aviano (CRO), IRCCS, National Cancer Institute, Aviano, Italy
| | - Samuele Massarut
- Breast Surgery Unit, Centro di Riferimento Oncologico di Aviano (CRO), IRCCS, National Cancer Institute, Aviano, Italy
| | - Cristina Marchini
- Department of Biosciences and Veterinary Medicine, University of Camerino, Camerino, Italy
| | - Augusto Amici
- Department of Biosciences and Veterinary Medicine, University of Camerino, Camerino, Italy
| | - Andrea Vecchione
- Faculty of Medicine and Psychology, Department of Clinical and Molecular Medicine, University of Rome "Sapienza" Sant'Andrea Hospital, Rome, Italy
| | - Gustavo Baldassarre
- Molecular Oncology Unit, Centro di Riferimento Oncologico di Aviano (CRO), IRCCS, National Cancer Institute, Aviano, Italy.
| | - Barbara Belletti
- Molecular Oncology Unit, Centro di Riferimento Oncologico di Aviano (CRO), IRCCS, National Cancer Institute, Aviano, Italy.
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208
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Ohri N, Haffty BG. The evolution of adjuvant radiation therapy for early-stage and locally advanced breast cancer. Breast J 2019; 26:59-64. [PMID: 31854499 DOI: 10.1111/tbj.13715] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Accepted: 10/14/2019] [Indexed: 11/27/2022]
Abstract
Adjuvant radiation therapy is often delivered after breast cancer surgery, both in the post-lumpectomy and post-mastectomy settings. Standard fractionation whole breast irradiation (SF-WBI), which is typically delivered over 5-7 weeks, was previously considered the standard of care. More recent data has helped to establish hypofractionated whole breast irradiation (HF-WBI), which consists of a 3-4 week regimen, as a new standard of care. This article provides an overview of the major randomized trials that support the routine use of HF-WBI for the majority of patients undergoing breast-conserving surgery for early-stage breast cancer. Newer data on the use of a hypofractionated approach in the post-mastectomy setting, as well as ongoing randomized trials addressing this topic, are also discussed.
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Affiliation(s)
- Nisha Ohri
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
| | - Bruce G Haffty
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
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209
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Kulcenty K, Piotrowski I, Wróblewska JP, Wasiewicz J, Suchorska WM. The Composition of Surgical Wound Fluids from Breast Cancer Patients is Affected by Intraoperative Radiotherapy Treatment and Depends on the Molecular Subtype of Breast Cancer. Cancers (Basel) 2019; 12:cancers12010011. [PMID: 31861498 PMCID: PMC7016654 DOI: 10.3390/cancers12010011] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 12/10/2019] [Accepted: 12/12/2019] [Indexed: 11/16/2022] Open
Abstract
Invasive oncological procedures affect the remaining tumor cells by increasing their survival, proliferation, and migration through the induction of wound healing response. The phenomena of local relapse after breast-conserving surgery (BCS) has resulted in a series of research and clinical trials with the aim of assessing whether localized intraoperative radiotherapy (IORT), may be beneficial in inhibiting local recurrences. Therefore, it is essential to assess the impact of intraoperative radiotherapy in modulating the immunological response and wound healing process. Thus, we decided to perform a quantitative analysis of the composition of surgical wound fluids (SWF) in two groups of breast cancer (BC) patients: those treated with BCS followed by IORT, and those who underwent BCS alone. We found that several cytokines, which are believed to have anti-tumor properties, were highly expressed in the luminal A breast cancer subtype in the IORT treatment group. Interestingly, we also found significant differences between IORT patients with tumors of different molecular subtypes. Based on these findings, we hypothesized that IORT treatment might be beneficial in changing the tumor bed microenvironment, making it less favorable for tumor recurrence due to decreased concentration of tumor-facilitating cytokines, especially in the luminal A subtype of BC.
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Affiliation(s)
- Katarzyna Kulcenty
- Radiobiology Lab, Department of Medical Physics, Greater Poland Cancer, 61-866 Poznań, Poland; (I.P.); (W.M.S.)
- Department of Electroradiology, Poznan University of Medical Sciences, ul. Garbary 15, 61-866 Poznan, Poland
- Correspondence:
| | - Igor Piotrowski
- Radiobiology Lab, Department of Medical Physics, Greater Poland Cancer, 61-866 Poznań, Poland; (I.P.); (W.M.S.)
- Department of Electroradiology, Poznan University of Medical Sciences, ul. Garbary 15, 61-866 Poznan, Poland
| | - Joanna Patrycja Wróblewska
- Department of Pathology, Poznan University of Medical Sciences and Greater Poland Cancer Center, ul. Garbary 15, 61-866 Poznan, Poland;
| | - Janusz Wasiewicz
- Department of Breast Cancer Surgery, Greater Poland Cancer Centre, ul. Garbary 15, 61-866 Poznań, Poland;
| | - Wiktoria Maria Suchorska
- Radiobiology Lab, Department of Medical Physics, Greater Poland Cancer, 61-866 Poznań, Poland; (I.P.); (W.M.S.)
- Department of Electroradiology, Poznan University of Medical Sciences, ul. Garbary 15, 61-866 Poznan, Poland
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210
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Chua BH. Individualised target volume selection and dose prescription after conservative surgery, mastectomy and reconstruction. Breast 2019; 48 Suppl 1:S69-S75. [PMID: 31839165 DOI: 10.1016/s0960-9776(19)31128-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Progress in radiotherapy (RT) for early breast cancer, driven by advances in radiobiology and radiation techniques is enabling individualised target volume and dose-fractionation according to recurrence risk. Conventionally fractionated WBI (CF-WBI) has been justified on the basis that it spares dose-limiting late-responding normal tissues more than breast cancer. However, randomised clinical trials (RCTs) testing hypofractionated WBI (HF-WBI) showed equivalent tumour control, improved acute toxicity and similar late toxicity between selected HF-WBI schedules and CF-WBI. RCTs showed that tumour bed boost (TBB) after WBI improved local control but increased breast fibrosis compared to no TBB. RCT comparing sequential TBB and simultaneous integrated TBB using dose intensity modulation showed similar toxicity. Partial breast irradiation (PBI) limits target volume to the tumour bed, which permits safe treatment acceleration. RCTs showed that PBI resulted in low local relapse rates but in some RCTs, higher rates of late toxicity and adverse cosmetic outcome than WBI. Given heterogeneity of PBI techniques, target volumes and dose-fractionation schedules used in RCTs, interpretation of results to distinguish whether outcome variations are caused by target volume or dose-fractionation effect is challenging. RCTs demonstrating efficacy of post-mastectomy RT (PMRT) included the chest wall and regional nodes but did not distinguish relative contributions of nodal target sub-volumes. In patients with smaller axillary tumour burden, IMC irradiation is controversial. RCTs were not powered for comparison between CF-PMRT and HF-PMRT. No increase in arm or shoulder dysfunction with HF-PMRT was observed. No RCT data exist on HF-PMRT in patients with breast reconstruction.
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Affiliation(s)
- Boon H Chua
- Faculty of Medicine, University of New South Wales, UNSW Sydney, NSW, Australia; Nelune Comprehensive Cancer Centre, Prince of Wales Hospital, Randwick, NSW, Australia.
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211
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Tom MC, Joshi N, Vicini F, Chang AJ, Hong TS, Showalter TN, Chao ST, Wolden S, Wu AJ, Martin D, Husain Z, Badiyan SN, Kolar M, Sherertz T, Mourtada F, Cohen GN, Shah C. The American Brachytherapy Society consensus statement on intraoperative radiation therapy. Brachytherapy 2019; 18:242-257. [PMID: 31084904 DOI: 10.1016/j.brachy.2019.01.015] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2018] [Accepted: 01/30/2019] [Indexed: 12/12/2022]
Abstract
PURPOSE Although radiation therapy has traditionally been delivered with external beam or brachytherapy, intraoperative radiation therapy (IORT) represents an alternative that may shorten the course of therapy, reduce toxicities, and improve patient satisfaction while potentially lowering the cost of care. At this time, there are limited evidence-based guidelines to assist clinicians with patient selection for IORT. As such, the American Brachytherapy Society presents a consensus statement on the use of IORT. METHODS Physicians and physicists with expertise in intraoperative radiation created a site-directed guideline for appropriate patient selection and utilization of IORT. RESULTS Several IORT techniques exist including radionuclide-based high-dose-rate, low-dose-rate, electron, and low-energy electronic. In breast cancer, IORT as monotherapy should only be used on prospective studies. IORT can be considered in the treatment of sarcomas with close/positive margins or recurrent sarcomas. IORT can be considered in conjunction with external beam radiotherapy for retroperitoneal sarcomas. IORT can be considered for colorectal malignancies with concern for positive margins and in the setting of recurrent gynecologic cancers. For thoracic, head and neck, and central nervous system malignancies, utilization of IORT should be evaluated on a case-by-case basis. CONCLUSIONS The present guidelines provide clinicians with a summary of current data regarding IORT by treatment site and guidelines for the appropriate patient selection and safe utilization of the technique. High-dose-rate, low-dose-rate brachytherapy methods are appropriate when IORT is to be delivered as are electron and low-energy based on the clinical scenario.
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Affiliation(s)
- Martin C Tom
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland, OH
| | - Nikhil Joshi
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland, OH
| | - Frank Vicini
- 21st Century Oncology, Michigan Healthcare Professionals, Farmington Hills, MI
| | | | - Theodore S Hong
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA
| | - Timothy N Showalter
- Department of Radiation Oncology, University of Virginia, Charlottesville, VA
| | - Samuel T Chao
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland, OH
| | - Suzanne Wolden
- Departments of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Abraham J Wu
- Departments of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Douglas Martin
- Department of Radiation Oncology, Ohio State University, Columbus, OH
| | - Zain Husain
- Department of Therapeutic Radiology, Yale University, New Haven, CT
| | - Shahed N Badiyan
- Department of Radiation Oncology, Washington University, St. Louis, MO
| | - Matthew Kolar
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland, OH
| | - Tracy Sherertz
- Department of Radiation Oncology, Kaiser Capitol Hill, Seattle, WA
| | - Firas Mourtada
- Helen F. Graham Cancer Center & Research Institute, Christiana Care Health System, Newark, DE
| | - Gilad N Cohen
- Department Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Chirag Shah
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland, OH.
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212
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Whelan TJ, Julian JA, Berrang TS, Kim DH, Germain I, Nichol AM, Akra M, Lavertu S, Germain F, Fyles A, Trotter T, Perera FE, Balkwill S, Chafe S, McGowan T, Muanza T, Beckham WA, Chua BH, Gu CS, Levine MN, Olivotto IA. External beam accelerated partial breast irradiation versus whole breast irradiation after breast conserving surgery in women with ductal carcinoma in situ and node-negative breast cancer (RAPID): a randomised controlled trial. Lancet 2019; 394:2165-2172. [PMID: 31813635 DOI: 10.1016/s0140-6736(19)32515-2] [Citation(s) in RCA: 263] [Impact Index Per Article: 52.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Revised: 09/24/2019] [Accepted: 10/01/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND Whole breast irradiation delivered once per day over 3-5 weeks after breast conserving surgery reduces local recurrence with good cosmetic results. Accelerated partial breast irradiation (APBI) delivered over 1 week to the tumour bed was developed to provide a more convenient treatment. In this trial, we investigated if external beam APBI was non-inferior to whole breast irradiation. METHODS We did this multicentre, randomised, non-inferiority trial in 33 cancer centres in Canada, Australia and New Zealand. Women aged 40 years or older with ductal carcinoma in situ or node-negative breast cancer treated by breast conserving surgery were randomly assigned (1:1) to receive either external beam APBI (38·5 Gy in ten fractions delivered twice per day over 5-8 days) or whole breast irradiation (42·5 Gy in 16 fractions once per day over 21 days, or 50 Gy in 25 fractions once per day over 35 days). Patients and clinicans were not masked to treatment assignment. The primary outcome was ipsilateral breast tumour recurrence (IBTR), analysed by intention to treat. The trial was designed on the basis of an expected 5 year IBTR rate of 1·5% in the whole breast irradiation group with 85% power to exclude a 1·5% increase in the APBI group; non-inferiority was shown if the upper limit of the two-sided 90% CI for the IBTR hazard ratio (HR) was less than 2·02. This trial is registered with ClinicalTrials.gov, NCT00282035. FINDINGS Between Feb 7, 2006, and July 15, 2011, we enrolled 2135 women. 1070 were randomly assigned to receive APBI and 1065 were assigned to receive whole breast irradiation. Six patients in the APBI group withdrew before treatment, four more did not receive radiotherapy, and 16 patients received whole breast irradiation. In the whole breast irradiation group, 16 patients withdrew, and two more did not receive radiotherapy. In the APBI group, a further 14 patients were lost to follow-up and nine patients withdrew during the follow-up period. In the whole breast irradiation group, 20 patients were lost to follow-up and 35 withdrew during follow-up. Median follow-up was 8·6 years (IQR 7·3-9·9). The 8-year cumulative rates of IBTR were 3·0% (95% CI 1·9-4·0) in the APBI group and 2·8% (1·8-3·9) in the whole breast irradiation group. The HR for APBI versus whole breast radiation was 1·27 (90% CI 0·84-1·91). Acute radiation toxicity (grade ≥2, within 3 months of radiotherapy start) occurred less frequently in patients treated with APBI (300 [28%] of 1070 patients) than whole breast irradiation (484 [45%] of 1065 patients, p<0·0001). Late radiation toxicity (grade ≥2, later than 3 months) was more common in patients treated with APBI (346 [32%] of 1070 patients) than whole breast irradiation (142 [13%] of 1065 patients; p<0·0001). Adverse cosmesis (defined as fair or poor) was more common in patients treated with APBI than in those treated by whole breast irradiation at 3 years (absolute difference, 11·3%, 95% CI 7·5-15·0), 5 years (16·5%, 12·5-20·4), and 7 years (17·7%, 12·9-22·3). INTERPRETATION External beam APBI was non-inferior to whole breast irradiation in preventing IBTR. Although less acute toxicity was observed, the regimen used was associated with an increase in moderate late toxicity and adverse cosmesis, which might be related to the twice per day treatment. Other approaches, such as treatment once per day, might not adversely affect cosmesis and should be studied. FUNDING Canadian Institutes for Health Research and Canadian Breast Cancer Research Alliance.
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Affiliation(s)
- Timothy J Whelan
- Department of Oncology, McMaster University and Juravinski Cancer Centre, Hamilton, ON, Canada.
| | - Jim A Julian
- Department of Oncology, McMaster University and Juravinski Cancer Centre, Hamilton, ON, Canada
| | - Tanya S Berrang
- Radiation Therapy Program, BC Cancer - Victoria, University of British Columbia, Vancouver, BC, Canada
| | - Do-Hoon Kim
- Department of Oncology, McMaster University and Juravinski Cancer Centre, Hamilton, ON, Canada
| | - Isabelle Germain
- Department of Radiation Oncology, CHU de Québec - Université Laval, Québec, QC, Canada
| | - Alan M Nichol
- Division of Radiation Oncology, University of British Columbia and BC Cancer - Vancouver, BC, Canada
| | - Mohamed Akra
- Department of Radiation Oncology, University of Manitoba, Winnipeg, MB, Canada
| | - Sophie Lavertu
- Department of Radiation Oncology, Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada
| | - Francois Germain
- Department of Radiation Oncology, CHU de Québec - Université Laval, Québec, QC, Canada; Division of Radiation Oncology, University of British Columbia and BC Cancer - Kelowna, BC, Canada
| | - Anthony Fyles
- Department of Radiation Oncology, University of Toronto and Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | | | - Francisco E Perera
- Department of Oncology, Western University and London Regional Cancer Program, London, ON, Canada
| | | | - Susan Chafe
- Department of Oncology, Division of Radiation Oncology, University of Alberta and Cross Cancer Institute, Edmonton, AB, Canada
| | - Thomas McGowan
- Trillium Health Partners Credit Valley Hospital, Mississauga, ON, Canada
| | - Thierry Muanza
- Department of Oncology, McGill University and Jewish General Hospital Segal Cancer Centre, Montreal, QC, Canada
| | - Wayne A Beckham
- Department of Physics and Astronomy, University of Victoria and BC Cancer - Victoria, BC, Canada
| | - Boon H Chua
- University of New South Wales and Prince of Wales Hospital, Sydney, NSW, Australia
| | - Chu Shu Gu
- Department of Oncology, McMaster University and Juravinski Cancer Centre, Hamilton, ON, Canada
| | - Mark N Levine
- Department of Oncology, McMaster University and Juravinski Cancer Centre, Hamilton, ON, Canada
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Coles CE, Bliss JM, Poortmans PM. Accelerated partial breast irradiation: more questions than answers? Lancet 2019; 394:2127-2129. [PMID: 31813634 DOI: 10.1016/s0140-6736(19)32959-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 11/28/2019] [Indexed: 11/21/2022]
Affiliation(s)
- Charlotte E Coles
- Department of Oncology, University of Cambridge, Cambridge CB2 0QQ, UK.
| | - Judith M Bliss
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, UK
| | - Philip M Poortmans
- Department of Radiation Oncology, Institut Curie, Paris, France; Université Paris Sciences et Lettres, Paris, France
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Hannoun-Lévi JM, Lam Cham Kee D, Gal J, Schiappa R, Hannoun A, Fouche Y, Gautier M, Boulahssass R, Chand ME. Accelerated partial breast irradiation in the elderly: 5-Year results of the single fraction elderly breast irradiation (SiFEBI) phase I/II trial. Brachytherapy 2019; 19:90-96. [PMID: 31767533 DOI: 10.1016/j.brachy.2019.10.007] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Revised: 10/25/2019] [Accepted: 10/25/2019] [Indexed: 12/12/2022]
Abstract
PURPOSE To evaluate the clinical outcomes of a very-accelerated partial breast irradiation (vAPBI) in the elderly based on a single fraction of multicatheter interstitial high-dose rate brachytherapy (MIB). Mature results with a median follow-up of 5 years. METHODS AND MATERIALS From November 2012 to September 2014, 26 patients (pts) (≥70) with early breast cancer were enrolled in a prospective phase II trial (NCT01727011). After lumpectomy, intraoperative catheter implant was performed for postoperative APBI (single fraction 16 Gy). Surveillance was performed twice a year after APBI. Oncologic outcome (local [LRFS], metastasis-free survival, cancer-specific survival, and overall survival [OS]) as well as late toxicity and cosmetic outcome were investigated. RESULTS Median age was 77 years [69-89]. After a median follow-up of 63 months [60-68], 5-year LRFS, metastasis-free survival, cancer-specific survival, and overall survival rates were 100%, 95.5%, 100%, and 88.5%, respectively. Late toxicity was observed in 5 pts (19.2%) with a total of five events: 3 pts G1 (60%); and 2 pts G2 (40%). The observed late side effects were breast pain in 1 pt (G2 cytosteatonecrosis with occasional acetaminophen consumption), hypopigmentation (puncture site) in 2 pts (G1) and breast fibrosis in 2 pts (G1: 1 pt; G2: 1 pt). Cosmetic evaluation was excellent for 21 pts (81%) and good for 2 pts (19%). CONCLUSION For elderly with early breast cancer, a vAPBI using a single fraction of postoperative MIB (16 Gy) provides excellent oncologic results, mainly in terms of local control and cancer death. Late toxicity and cosmetic profile are acceptable.
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Affiliation(s)
- Jean-Michel Hannoun-Lévi
- Department of Radiation Oncology, Antoine Lacassagne Cancer Center, University of Cote d'Azur, Nice, France.
| | - Daniel Lam Cham Kee
- Department of Radiation Oncology, Antoine Lacassagne Cancer Center, University of Cote d'Azur, Nice, France
| | - Jocelyn Gal
- Biostatistic Unit, Antoine Lacassagne Cancer Center, University of Cote d'Azur, Nice, France
| | - Renaud Schiappa
- Biostatistic Unit, Antoine Lacassagne Cancer Center, University of Cote d'Azur, Nice, France
| | | | - Yves Fouche
- Department of Breast Surgery, Antoine Lacassagne Cancer Center, University of Cote d'Azur, Nice, France
| | - Mathieu Gautier
- Department of Radiation Oncology, Antoine Lacassagne Cancer Center, University of Cote d'Azur, Nice, France
| | - Rabia Boulahssass
- Geriatric Unit, CHU de NICE, FHU ONCOAGE, University of Cote d'Azur, Nice, France
| | - Marie-Eve Chand
- Department of Radiation Oncology, Antoine Lacassagne Cancer Center, University of Cote d'Azur, Nice, France
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215
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Crown A, Rocha FG, Grumley JW. Intraoperative radiation therapy in early-stage breast cancer: Presence of lobular features is not associated with increased rate of requiring additional therapy. Am J Surg 2019; 220:161-164. [PMID: 31839176 DOI: 10.1016/j.amjsurg.2019.11.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 10/25/2019] [Accepted: 11/05/2019] [Indexed: 11/16/2022]
Abstract
BACKGROUND There is a paucity of data regarding the application of IORT to the treatment of carcinomas with lobular features. METHODS This study includes women with invasive breast cancer who underwent breast conservation in combination with IORT from February 2011 to October 2016. Patients whose final pathology did not satisfy inclusion criteria or had inadequate margins were recommended to undergo additional therapy (AT) with WBRT as well as re-excision of inadequate margins. RESULTS 243 invasive breast cancers were treated with IORT. The lobular features (LF) group comprised 62 patients and the invasive ductal carcinoma (IDCA) group consisted of 172 patients. Rate of AT was similar between groups (LF 19 patients, 30.6%, vs IDCA 56 patients, 32.6%, p = 0.87) groups. Lobular histology was not associated with a need for AT. Local recurrence rate for the cohort was 1.2% with a median follow up of 46 months. There was no difference in recurrence or survival after 46 months of follow-up. CONCLUSIONS IORT is an effective treatment option for well-selected patients with early breast cancer and can be considered for patients with lobular histology.
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Affiliation(s)
- Angelena Crown
- Department of General, Thoracic and Vascular Surgery, Virginia Mason Medical Center, 1100 Ninth Avenue, H8-GME, Seattle, WA, USA.
| | - Flavio G Rocha
- Department of General, Thoracic and Vascular Surgery, Virginia Mason Medical Center, 1100 Ninth Avenue, H8-GME, Seattle, WA, USA.
| | - Janie W Grumley
- Department of General, Thoracic and Vascular Surgery, Virginia Mason Medical Center, 1100 Ninth Avenue, H8-GME, Seattle, WA, USA.
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216
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Intraoperative radiotherapy (IORT) versus whole-breast external beam radiotherapy (EBRT) in early stage breast cancer: results from SEER database. Jpn J Radiol 2019; 38:85-92. [PMID: 31691091 DOI: 10.1007/s11604-019-00891-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Accepted: 10/15/2019] [Indexed: 01/09/2023]
Abstract
PURPOSE Intraoperative radiotherapy (IORT) has emerged as an alternative to whole-breast external beam radiotherapy (EBRT) for early breast cancer. This study aimed to investigate the risk factors for survival after IORT or whole-breast EBRT in breast cancer patients. MATERIALS AND METHODS Breast cancer patients undergoing IORT or whole-breast EBRT were included from the surveillance, epidemiology, and end results database. Risk factors for overall survival (OS) and cancer-specific survival (CSS) were identified by Cox proportional hazards regression analysis. RESULTS The IORT and EBRT groups did not differ significantly in OS and CSS. T2 stage (tumor size > 2 cm) was associated with poorer OS (aHR 3.49, 95% CI 1.05-11.62, P = 0.042), whereas ER-positive tumors were associated with better OS (aHR 0.26, 95% CI 0.09-0.76, P = 0.014). CONCLUSION IORT was not inferior than EBRT considering the OS and CSS in the short-term follow-up of early breast cancer. It may be a reasonable alternative to EBRT for early breast cancer in select patients with favorable tumor size and receptor status, given the need for long-term monitoring of local control and radiation toxicity.
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217
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Randomized trials in accelerated partial breast irradiation: “Two wrongs don’t make a right!!”. Rep Pract Oncol Radiother 2019; 24:695-696. [DOI: 10.1016/j.rpor.2019.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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218
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Mi Y, Lv P, Wang F, Li L, Zhu M, Cao Q, Liu J, Dong M, Shi Y, Fan R. Efficacy, late complications, and cosmetic outcomes of targeted intraoperative radiotherapy in breast-conserving surgery for early-stage breast cancer: a single-centre study in China. Jpn J Clin Oncol 2019; 49:1120-1125. [PMID: 31665413 DOI: 10.1093/jjco/hyz128] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Accepted: 07/30/2019] [Indexed: 11/14/2022] Open
Abstract
Abstract
Objective
The purpose of this study was to evaluate the efficacy, late complications, and cosmetic outcomes of targeted intraoperative radiotherapy for the treatment of Chinese patients with early-stage breast cancer.
Methods
Between September 2014 and May 2017, breast cancer patients undergoing targeted intraoperative radiotherapy at our facility were retrospectively recruited for this study. Intraoperative radiotherapy was performed with a 50-kV X-ray source in an Intrabeam system (Carl Zeiss Meditec, Oberkochen, Germany). The one-time prescribed irradiation dose to the tumour bed was 20 Gy. Recurrence, death, late complications, and cosmetic outcomes were recorded. Late radiotoxicity was assessed based on the grading criteria of the Radiation Therapy Oncology Group.
Results
A total of 77 patients who were treated with targeted intraoperative radiotherapy only were recruited. The cohort had a mean age of 58 years; patients with T1, N0, and invasive ductal carcinoma accounted for 75.3, 89.6, and 84.4%, respectively; the median follow-up duration was 40 months; there were 2 patients of recurrence and 2 patients of death. There were no patients of cardiac toxicity or skin or lung radiotoxicity of grade 2 or above. The main complications were breast oedema (18.2%), seroma (15.6%), chromatosis (9.1%), induration (7.8%), pain (5.2%), skin depression (2.6%), mild dry cough (2.6%), delayed wound healing (1.3%), and wound infection (1.3%). Seventy-three patients participated in the cosmetic outcome evaluation, which yielded an excellent or good rate of 95.9%.
Conclusions
Due to its low recurrence rates, lack of high-grade late radiotoxicity, and excellent cosmetic outcomes, targeted intraoperative radiotherapy may be a suitable treatment for select early-stage breast cancer patients in China.
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Affiliation(s)
- Yin Mi
- Department of Radiation Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Pengwei Lv
- Department of Breast Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Fang Wang
- Department of Breast Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Lin Li
- Department of Breast Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Mingzhi Zhu
- Department of Breast Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Qinchen Cao
- Department of Radiation Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Junqi Liu
- Department of Radiation Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Meilian Dong
- Department of Radiation Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yonggang Shi
- Department of Radiation Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Ruitai Fan
- Department of Radiation Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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Gondim GRM, Makdissi FBA, Fogaroli RC, Collins JBD, Iyeyasu H, de Castro DG, Silva MLG, Chen MJ, Coelho TM, Ramos H, Pellizzon ACA. Intraoperative breast radiotherapy: survival, local control and risk factors for recurrence. Rep Pract Oncol Radiother 2019; 24:551-555. [PMID: 31660047 DOI: 10.1016/j.rpor.2019.09.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2019] [Revised: 06/27/2019] [Accepted: 09/21/2019] [Indexed: 10/25/2022] Open
Abstract
Background Whole breast irradiation reduces loco-regional recurrence and risk of death in patients submitted to breast-conserving treatment. Data show that radiation to the index quadrant alone may be enough in selected patients. Aim To report the experience with intra-operative radiotherapy (IORT) with Electron-beam Cone in Linear Accelerator (ELIOT) and the results in overall survival, local control and late toxicity of patients submitted to this treatment. Materials and Methods 147 patients treated with a median follow up of 6.9 years (0.111.5 years). The actuarial local control and overall survival probabilities were estimated using the Kaplan Meier method. All tests were two-sided and p 0.05 was considered statistically significant. Results Overall survival of the cohort in 5 years, in the median follow up and in 10 years was of 98.3%, 95.1% and 95.1%, respectively, whereas local control in 5 years, in the median follow up and in 10 years was of 96%, 94.9% and 89.5%, respectively. Two risk groups were identified for local recurrence depending on the estrogen or progesterone receptors, axillary or margin status and lymphovascular invasion (LVI) (p = 0.016). Conclusions IORT is a safe and effective treatment. Rigorous selection is important to achieve excellent local control results.
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Affiliation(s)
| | | | - Ricardo Cesar Fogaroli
- AC Camargo Cancer Center R. Prof. Antônio Prudente, 211 - Liberdade, São Paulo, Brazil
| | | | - Hirofumi Iyeyasu
- AC Camargo Cancer Center R. Prof. Antônio Prudente, 211 - Liberdade, São Paulo, Brazil
| | | | | | - Michael Jenwei Chen
- AC Camargo Cancer Center R. Prof. Antônio Prudente, 211 - Liberdade, São Paulo, Brazil
| | | | - Henderson Ramos
- AC Camargo Cancer Center R. Prof. Antônio Prudente, 211 - Liberdade, São Paulo, Brazil
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Abstract
A series of landmark studies have increasingly emphasized the role of adjuvant radiotherapy for the definitive management of breast cancer. Although regional nodal irradiation, including the internal mammary nodes, was typically reserved for high-risk patients, there is now evidence of benefit to this approach even for those with a limited nodal disease burden. Similarly, low-risk disease has historically been treated with whole-breast tangents, although contemporary studies now support accelerated partial breast irradiation or the omission of radiotherapy in select cases. This article presents recent data informing these contemporary developments in the radiotherapeutic management of breast cancer.
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Affiliation(s)
- Lior Z Braunstein
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue Box 22, New York, NY 10065, USA
| | - Jennifer R Bellon
- Department of Radiation Oncology, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA 02115, USA.
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221
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Hypofractionated radiation therapy for invasive breast cancer: From moderate to extreme protocols. Cancer Radiother 2019; 23:874-882. [PMID: 31611051 DOI: 10.1016/j.canrad.2019.09.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Accepted: 09/04/2019] [Indexed: 11/22/2022]
Abstract
Adjuvant irradiation is the standard treatment after breast conservative surgery. Normofractionated regimen with an overall treatment time of 5 to 6 weeks is often considered as a limiting factor for irradiation compliance. In order to answer this issue, moderate and more recently extreme hypofractionated protocols appeared. We report here oncological outcomes and toxicity of hypofractionated breast irradiation. After defining the frame of moderate and extreme hypofractionated breast irradiations based on overall treatment time, patient selection criteria were listed. According to their levels of proof, the results of moderate and extreme hypofractionated breast irradiation were analysed. Overall treatment time for moderate hypofractionated breast irradiation ranged from 3 to 4 weeks, while for extreme hypofractionated breast irradiation, it was less than 1 week. For moderate hypofractionated breast irradiation, whole breast irradiation was currently performed with or without lymph node irradiation. Moderate hypofractionated breast irradiation has proven to be as safe and as efficient as normofractionated breast irradiation with level IA evidence. For extreme hypofractionated breast irradiation, phase III randomized trials confirmed that accelerated partial breast irradiation was non-inferior in terms of local control compared to normofractionated whole breast irradiation (with external beam radiation therapy and multicatheter brachytherapy), with similar acute and late toxicity. While the use of intraoperative breast irradiation remains under debate, new very accelerated partial breast irradiation (overall treatment time not exceeding 2 days) protocols emerged with encouraging results. Accelerated partial breast irradiation is warranted for extreme hypofractionated breast irradiation and is indicated for low-risk breast cancers. Moderate and extreme hypofractionated breast irradiation regimens are validated and can be routinely proposed according to patient selection criteria.
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222
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Shah C, Tendulkar RD. Revisiting TARGIT-A and intraoperative radiation therapy for breast cancer. Breast J 2019; 26:831-832. [PMID: 31549437 DOI: 10.1111/tbj.13629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2019] [Accepted: 09/06/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Chirag Shah
- Department of Radiation Oncology, Cleveland Clinic, Taussig Cancer Institute, Cleveland, OH
| | - Rahul D Tendulkar
- Department of Radiation Oncology, Cleveland Clinic, Taussig Cancer Institute, Cleveland, OH
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223
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Harbeck N, Penault-Llorca F, Cortes J, Gnant M, Houssami N, Poortmans P, Ruddy K, Tsang J, Cardoso F. Breast cancer. Nat Rev Dis Primers 2019; 5:66. [PMID: 31548545 DOI: 10.1038/s41572-019-0111-2] [Citation(s) in RCA: 1450] [Impact Index Per Article: 290.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/22/2019] [Indexed: 12/24/2022]
Abstract
Breast cancer is the most frequent malignancy in women worldwide and is curable in ~70-80% of patients with early-stage, non-metastatic disease. Advanced breast cancer with distant organ metastases is considered incurable with currently available therapies. On the molecular level, breast cancer is a heterogeneous disease; molecular features include activation of human epidermal growth factor receptor 2 (HER2, encoded by ERBB2), activation of hormone receptors (oestrogen receptor and progesterone receptor) and/or BRCA mutations. Treatment strategies differ according to molecular subtype. Management of breast cancer is multidisciplinary; it includes locoregional (surgery and radiation therapy) and systemic therapy approaches. Systemic therapies include endocrine therapy for hormone receptor-positive disease, chemotherapy, anti-HER2 therapy for HER2-positive disease, bone stabilizing agents, poly(ADP-ribose) polymerase inhibitors for BRCA mutation carriers and, quite recently, immunotherapy. Future therapeutic concepts in breast cancer aim at individualization of therapy as well as at treatment de-escalation and escalation based on tumour biology and early therapy response. Next to further treatment innovations, equal worldwide access to therapeutic advances remains the global challenge in breast cancer care for the future.
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Affiliation(s)
- Nadia Harbeck
- LMU Munich, University Hospital, Department of Obstetrics and Gynecology, Breast Center and Comprehensive Cancer Center (CCLMU), Munich, Germany.
| | - Frédérique Penault-Llorca
- Department of Pathology and Biopathology, Jean Perrin Comprehensive Cancer Centre, UMR INSERM 1240, University Clermont Auvergne, Clermont-Ferrand, France
| | - Javier Cortes
- IOB Institute of Oncology, Quironsalud Group, Madrid and Barcelona, Spain.,Vall d´Hebron Institute of Oncology, Barcelona, Spain
| | - Michael Gnant
- Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Nehmat Houssami
- Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Philip Poortmans
- Department of Radiation Oncology, Institut Curie, Paris, France.,Université PSL, Paris, France
| | - Kathryn Ruddy
- Department of Oncology, Mayo Clinic, Rochester, MN, USA
| | - Janice Tsang
- Hong Kong Breast Oncology Group, The University of Hong Kong, Hong Kong, China
| | - Fatima Cardoso
- Breast Unit, Champalimaud Clinical Center/Champalimaud Foundation, Lisbon, Portugal
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Frasson AL, Filho AB, Lichtenfels M, de Souza ABA, Vollbrecht B, Zerwes F. Effect of intraoperative radiotherapy for early breast cancer on 10-year recurrence rates and overall survival. Breast J 2019; 26:427-432. [PMID: 31538696 DOI: 10.1111/tbj.13502] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 07/09/2019] [Accepted: 07/10/2019] [Indexed: 01/24/2023]
Abstract
The aim of this study was to evaluate 10-year local control and overall survival of IORT for early breast cancer treatment. We analyzed 68 patients submitted to breast conservative surgery and IORT, in the accelerator room of the Radiotherapy Service in South Brazil. In the long-term follow-up, we had 17.6% of patients with ipsilateral breast cancer recurrence, 2.9% with regional recurrence, 2.9% with contralateral breast recurrence, and 5.9% with distant metastasis. The 10-year overall survival was 82.8%. Our data show high local recurrence rates, however, good overall survival in early breast cancer patients treated with breast-conserving surgery and intraoperative radiotherapy with electron beams in the long-term follow-up.
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Affiliation(s)
- Antônio Luiz Frasson
- Breast Cancer Center, Hospital São Lucas, Pontifical Catholic University of Rio Grande do Sul (PUCRS), Porto Alegre, Brazil.,Breast Cancer Group, Albert Einstein Hospital, São Paulo, Brazil.,Brazilian Society of Mastology, São Paulo, Brazil
| | - Aroldo Braga Filho
- Radiotherapy Department, Hospital São Lucas, Pontifical Catholic University of Rio Grande do Sul (PUCRS), Porto Alegre, Brazil
| | - Martina Lichtenfels
- Breast Cancer Center, Hospital São Lucas, Pontifical Catholic University of Rio Grande do Sul (PUCRS), Porto Alegre, Brazil
| | | | - Betina Vollbrecht
- Breast Cancer Center, Hospital São Lucas, Pontifical Catholic University of Rio Grande do Sul (PUCRS), Porto Alegre, Brazil
| | - Felipe Zerwes
- Breast Cancer Center, Hospital São Lucas, Pontifical Catholic University of Rio Grande do Sul (PUCRS), Porto Alegre, Brazil
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225
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Crown A, Rocha FG, Grumley JW. Oncoplastic Central Partial Mastectomy and Neoareolar Reduction Mammoplasty with Immediate Nipple Reconstruction: An Initial Report of a Novel Option for Breast Conservation in Patients with Subareolar Tumors. Ann Surg Oncol 2019; 26:4284-4293. [DOI: 10.1245/s10434-019-07731-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Indexed: 11/18/2022]
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Abstract
OBJECTIVE The aim of this study was to evaluate the long-term oncologic outcome after oncoplastic surgery (OPS). BACKGROUND OPS combines wide tumor excision with reduction mammoplasty techniques thus extending breast conserving surgery to large tumors that might else be proposed a mastectomy. Little data are available about the oncologic results for breast conserving surgery of these larger tumors. METHODS From January 2004 until March 2016, a total of 350 oncoplastic breast reductions were prospectively entered into a database. Patients were included if their breast reshaping included a reduction mammoplasty with skin excision (Level 2 oncoplastic techniques). RESULTS Histologic subtypes were: invasive ductal carcinoma in 219 cases (62.6%), ductal carcinoma in situ (DCIS) in 88 cases (25.1%), and invasive lobular carcinoma in 43 (12.3%) cases. Seventy-three of the invasive cancers (27.9%) received neoadjuvant chemotherapy. The mean resection weight was 177 grams. The mean pathological tumor size was 26 mm (range 0-180 mm) and varied from 23 mm (4-180 mm) for invasive cancers to 32 mm (0-100 mm) for DCIS. Specimen margins were involved in 12.6% of the cases; 10.5% of invasive ductal, 14.7% of DCIS, and 20.9% of invasive lobular. The overall breast conservation rate was 92% and varied from 87.4% for DCIS to 93.5% for the invasive cancers. Thirty-one patients (8.9%) developed one or more postoperative complications, inducing a delay in postoperative treatments in 4.6% of patients. The median follow up was 55 months. The cumulative 5-year incidences for local, regional, and distant recurrences were 2.2%, 1.1%, and 12.4%, respectively. CONCLUSIONS Oncoplastic breast reductions allow wide resections with free margins and can be used for large cancers as an alternative to mastectomy.
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Chargari C, Deutsch E, Blanchard P, Gouy S, Martelli H, Guérin F, Dumas I, Bossi A, Morice P, Viswanathan AN, Haie-Meder C. Brachytherapy: An overview for clinicians. CA Cancer J Clin 2019; 69:386-401. [PMID: 31361333 DOI: 10.3322/caac.21578] [Citation(s) in RCA: 135] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Brachytherapy is a specific form of radiotherapy consisting of the precise placement of radioactive sources directly into or next to the tumor. This technique is indicated for patients affected by various types of cancers. It is an optimal tool for delivering very high doses to the tumor focally while minimizing the probability of normal tissue complications. Physicians from a wide range of specialties may be involved in either the referral to or the placement of brachytherapy. Many patients require brachytherapy as either primary treatment or as part of their oncologic care. On the basis of high-level evidence from randomized controlled trials, brachytherapy is mainly indicated: 1) as standard in combination with chemoradiation in patients with locally advanced cervical cancer; 2) in surgically treated patients with uterine endometrial cancer for decreasing the risk of vaginal vault recurrence; 3) in patients with high-risk prostate cancer to perform dose escalation and improve progression-free survival; and 4) in patients with breast cancer as adjuvant, accelerated partial breast irradiation or to boost the tumor bed. In this review, the authors discuss the clinical relevance of brachytherapy with a focus on indications, levels of evidence, and results in the overall context of radiation use for patients with cancer.
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Affiliation(s)
- Cyrus Chargari
- Department of Radiation Oncology, Gustave Roussy Comprehensive Cancer Center, Villejuif, France
- French Military Health Academy, Paris, France
| | - Eric Deutsch
- Department of Radiation Oncology, Gustave Roussy Comprehensive Cancer Center, Villejuif, France
- Faculty of Medicine, Paris-South University/Paris Saclay, Paris, France
- Molecular Radiotherapy Unit 1030, National Institute of Health and Medical Research (INSERM), Paris, France
| | - Pierre Blanchard
- Department of Radiation Oncology, Gustave Roussy Comprehensive Cancer Center, Villejuif, France
| | - Sebastien Gouy
- Department of Surgery, Gustave Roussy Comprehensive Cancer Center, Villejuif, France
| | - Hélène Martelli
- Department of Pediatric Surgery, Kremlin Bicetre University Hospital, Kremlin Bicetre, France
| | - Florent Guérin
- Department of Pediatric Surgery, Kremlin Bicetre University Hospital, Kremlin Bicetre, France
| | - Isabelle Dumas
- Department of Radiation Oncology, Gustave Roussy Comprehensive Cancer Center, Villejuif, France
| | - Alberto Bossi
- Department of Radiation Oncology, Gustave Roussy Comprehensive Cancer Center, Villejuif, France
| | - Philippe Morice
- Department of Surgery, Gustave Roussy Comprehensive Cancer Center, Villejuif, France
- Paris-South University/Paris Saclay, Paris, France
| | - Akila N Viswanathan
- Department of Radiation Oncology, Johns Hopkins Medicine, Baltimore, Maryland
| | - Christine Haie-Meder
- Department of Radiation Oncology, Gustave Roussy Comprehensive Cancer Center, Villejuif, France
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A skin dose prediction model based on in vivo dosimetry and ultrasound skin bridge measurements during intraoperative breast radiation therapy. Brachytherapy 2019; 18:720-726. [DOI: 10.1016/j.brachy.2019.05.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2019] [Revised: 05/07/2019] [Accepted: 05/28/2019] [Indexed: 11/19/2022]
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229
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Near-Miss Event With the Xoft Breast Intraoperative Radiation Therapy System. Pract Radiat Oncol 2019; 9:e443-e446. [DOI: 10.1016/j.prro.2019.04.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Revised: 04/14/2019] [Accepted: 04/29/2019] [Indexed: 11/22/2022]
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230
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Moving incision for covert breast-conserving surgery may prevent early wound complications in brachytherapy-based partial-breast irradiation. Brachytherapy 2019; 18:645-650. [DOI: 10.1016/j.brachy.2019.05.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Revised: 05/06/2019] [Accepted: 05/09/2019] [Indexed: 12/25/2022]
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231
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Williams VL, Bhandari T, Chen LJ, Wagman LD, Carpenter M, Harness JK, Khanijou R, Gobran M, Olaya W, Carandang MI, Ash RB. Recurrence rates for patients with early-stage breast cancer treated with IOERT at a community hospital per the ASTRO consensus statement for APBI. Brachytherapy 2019; 18:651-657. [DOI: 10.1016/j.brachy.2019.04.270] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2018] [Revised: 04/14/2019] [Accepted: 04/29/2019] [Indexed: 10/26/2022]
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Wersal C, Keller A, Weiss C, Giordano FA, Abo-Madyan Y, Tuschy B, Sütterlin M, Wenz F, Sperk E. Long-term changes in blood counts after intraoperative radiotherapy for breast cancer-single center experience and review of the literature. Transl Cancer Res 2019; 8:1882-1903. [PMID: 35116939 PMCID: PMC8799206 DOI: 10.21037/tcr.2019.09.05] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Accepted: 08/26/2019] [Indexed: 01/04/2023]
Abstract
Background Intraoperative radiotherapy (IORT) for breast cancer is used as an upfront boost or as accelerated partial breast irradiation (APBI). To date, no description of blood count changes after IORT are available. Our analysis shows blood count changes in breast cancer patients up to 5 years after IORT ± whole breast radiotherapy (WBRT). Methods IORT was given as APBI in 58 patients (IORT/APBI-group) and as a boost in 198 patients (IORT/WBRT-group). A median dose of 20 Gy was given intraoperatively with low energy X-rays [INTRABEAM (TM) System] and additionally 46 Gy/2 Gy per fraction to the whole breast, if WBRT was added. Blood counts were collected preoperatively, after 90 days and through year 1–5 of follow-up. Dunnett’s tests were used to calculate changes in blood counts over time. Additionally, platelet-to-lymphocyte ratio (PLR), neutrophil-to-lymphocyte ratio (NLR) and derived neutrophil-to-lymphocyte ratio (dNLR) were calculated for each time point. Results Significantly decreases in the IORT/WBRT-group were seen for erythrocytes, hemoglobin, platelets and leucocytes and an increase for lymphocytes for the total follow-up period. In the IORT/APBI-group significantly decreases were seen for erythrocytes and hemoglobin for the total follow-up period. Regarding changes during follow-up compared to the preoperative value, much more significant changes were seen in the IORT/WBRT-group compared to IORT/APBI-group without any relevant impact of chemotherapy. Regarding PLR-, NLR- and dNLR-values the rate of patients over the range improved over time in both groups. Conclusions IORT/APBI seems to have a smaller effect on blood counts compared to IORT/WBRT. Furthermore, PLR-, NLR- and dNLR-values improved over time, suggesting a positive effect on outcome after IORT in general.
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Affiliation(s)
- Cornelia Wersal
- Department of Radiation Oncology, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Anke Keller
- Department of Radiation Oncology, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Christel Weiss
- Department of Clinical Statistics, Biomathematics, Information Processing, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Frank A Giordano
- Department of Radiation Oncology, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Yasser Abo-Madyan
- Department of Radiation Oncology, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Benjamin Tuschy
- Department of Gynecology and Obstetrics, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Marc Sütterlin
- Department of Gynecology and Obstetrics, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | | | - Elena Sperk
- Department of Radiation Oncology, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
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Finazzi T, Nguyen VT, Zimmermann F, Papachristofilou A. Impact of patient and treatment characteristics on heart and lung dose in adjuvant radiotherapy for left-sided breast cancer. Radiat Oncol 2019; 14:153. [PMID: 31462267 PMCID: PMC6714299 DOI: 10.1186/s13014-019-1364-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 08/21/2019] [Indexed: 12/25/2022] Open
Abstract
PURPOSE The heart and lungs are routinely exposed to incidental irradiation during adjuvant radiotherapy (RT) of breast cancer. We analyzed the impact of patient and treatment characteristics on heart and lung dose in left-sided breast RT. METHODS We analyzed 332 female patients treated with left-sided breast RT between 2013 and 2018. Mean heart dose (MHD), left mean lung dose (MLD) and heart / lung V20Gy were collected from treatment plans. Patients were stratified by RT technique (3D-conformal RT, 3DCRT; intensity-modulated RT, IMRT; volumetric modulated arc therapy, VMAT) and target volumes, including lymph node RT (LN-RT). Patient characteristics (body mass index (BMI), heart and lung volume) were assessed using correlation analyses. RESULTS LN-RT was performed in 111 patients with increased MHD (median 4.6 vs. 3.3 Gy; p < .01), left MLD (14.8 vs. 7.7 Gy; p < .01) and left lung V20Gy (30.0% vs. 14.4%; p < .01) compared to treatment without LN-RT. Internal mammary LN-RT further increased organ doses compared to RT involving only supraclavicular +/- axillary LN (p < .01 for all values; MHD 6.9 vs. 4.2 Gy). In 221 patients treated without LN-RT, IMRT/VMAT was associated with higher left lung doses (MLD 9.1 vs. 7.4 Gy, p < .01; V20Gy 18.8% vs. 14.0%, p < .01) compared to 3DCRT. A negative correlation between total lung volume and both MHD (r = - 0.38; p < .01) and heart V20Gy (r = - 0.37; p < .01), as well as a weak positive correlation of BMI and MHD (r = 0.27; p < .01) were observed. CONCLUSIONS In adjuvant RT for left-sided breast cancer, LN-RT is associated with a marked increase in heart and lung doses, particularly with internal mammary LN-RT. Potential advantages of IMRT/VMAT for breast or chest wall RT need to be weighed against a moderately increased lung dose.
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Affiliation(s)
- Tobias Finazzi
- Clinic of Radiotherapy and Radiation Oncology, University Hospital Basel, Petersgraben 4, 4031 Basel, Switzerland
| | - Van-Trinh Nguyen
- Clinic of Radiotherapy and Radiation Oncology, University Hospital Basel, Petersgraben 4, 4031 Basel, Switzerland
| | - Frank Zimmermann
- Clinic of Radiotherapy and Radiation Oncology, University Hospital Basel, Petersgraben 4, 4031 Basel, Switzerland
| | - Alexandros Papachristofilou
- Clinic of Radiotherapy and Radiation Oncology, University Hospital Basel, Petersgraben 4, 4031 Basel, Switzerland
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Bourgier C, Lemanski C, Draghici R, Castan F, Fenoglietto P, Bons F, Farcy-Jacquet MP, Brengues M, Gourgou S, Ozsahin M, Azria D. [Individual modification of the dose, volume and fractionation of breast radiotherapy]. Cancer Radiother 2019; 23:778-783. [PMID: 31378461 DOI: 10.1016/j.canrad.2019.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Accepted: 06/26/2019] [Indexed: 11/26/2022]
Abstract
Randomized trials demonstrated similar overall survival between mastectomy and breast-conservative surgery followed by adjuvant radiation therapy. Breast-conservative surgery, with adjuvant radiation therapy, with or without neoadjuvant systemic therapy has become the standard of care for women with early or locally advanced breast cancer. Nevertheless, certain cardiac, lung or cutaneous toxicities may alter the long-term body image and the quality of life of a limited number of patients who consider having had "overtreatment" or treatment outside the best knowledge of science. In case of low-risk breast cancer, several trials have evaluated the carcinologic outcome in absence of radiation therapy after breast-conservative surgery. Local recurrences increased in case of breast-conservative surgery alone but without impact on overall survival. Multiple debates have emerged in order to select the most appropriate evaluation criteria. Finally, a large consensus has considered that reducing local recurrences is important but with modern technologies and after identifying patients of individual radiosensitivity. Indeed, in case of a low absolute risk of local recurrence, radiation therapy techniques have been developed to allow a focal treatment especially for patients with high risk of developing late effects. This kind of compromise takes into account the reduction risk of local recurrences but also the probability of developing radiation-induced cutaneous sequelae. In the same way, for patients considered at high risk of recurrence, the huge volumes need specific techniques to better cover the targets while protecting the surrounding critic organs such as heart and lung. Intensity-modulated radiation therapy and the local high boost may help to decrease local recurrences of these more extended and aggressive diseases while considering the individual radiosensitivity that paves the way of long-term sequelae. In this article, we detail a personalized approach of breast radiation therapy considering the absolute risk of local recurrences and the probability of radiation-induced toxicity appearance.
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Affiliation(s)
- C Bourgier
- Institut de recherche en cancérologie de Montpellier (IRCM), rue Croix-Verte, 34298 Montpellier, cedex 5, France; Inserm U1194, rue Croix-Verte, 34298 Montpellier, cedex 5, France; Université de Montpellier, avenue des Apothicaires, 34298 Montpellier cedex 05, France; Fédération universitaire d'oncologie radiothérapie, Institut régional du cancer de Montpellier (ICM), rue Croix-Verte, 34298 Montpellier, cedex 5, France
| | - C Lemanski
- Institut de recherche en cancérologie de Montpellier (IRCM), rue Croix-Verte, 34298 Montpellier, cedex 5, France; Inserm U1194, rue Croix-Verte, 34298 Montpellier, cedex 5, France; Université de Montpellier, avenue des Apothicaires, 34298 Montpellier cedex 05, France; Fédération universitaire d'oncologie radiothérapie, Institut régional du cancer de Montpellier (ICM), rue Croix-Verte, 34298 Montpellier, cedex 5, France
| | - R Draghici
- Institut de recherche en cancérologie de Montpellier (IRCM), rue Croix-Verte, 34298 Montpellier, cedex 5, France; Inserm U1194, rue Croix-Verte, 34298 Montpellier, cedex 5, France; Université de Montpellier, avenue des Apothicaires, 34298 Montpellier cedex 05, France; Fédération universitaire d'oncologie radiothérapie, Institut régional du cancer de Montpellier (ICM), rue Croix-Verte, 34298 Montpellier, cedex 5, France
| | - F Castan
- Unité de biométrie, Institut régional du cancer Montpellier (ICM), rue Croix-Verte, 34298 Montpellier cedex 05, France
| | - P Fenoglietto
- Fédération universitaire d'oncologie radiothérapie, Institut régional du cancer de Montpellier (ICM), rue Croix-Verte, 34298 Montpellier, cedex 5, France
| | - F Bons
- Fédération universitaire d'oncologie radiothérapie, institut de cancérologie du Gard, CHU de Nîmes, rue Henri-Pujol, 30000 Nîmes, France
| | - M-P Farcy-Jacquet
- Fédération universitaire d'oncologie radiothérapie, institut de cancérologie du Gard, CHU de Nîmes, rue Henri-Pujol, 30000 Nîmes, France
| | - M Brengues
- Institut de recherche en cancérologie de Montpellier (IRCM), rue Croix-Verte, 34298 Montpellier, cedex 5, France; Inserm U1194, rue Croix-Verte, 34298 Montpellier, cedex 5, France; Université de Montpellier, avenue des Apothicaires, 34298 Montpellier cedex 05, France
| | - S Gourgou
- Unité de biométrie, Institut régional du cancer Montpellier (ICM), rue Croix-Verte, 34298 Montpellier cedex 05, France
| | - M Ozsahin
- Service de radio-oncologie, Centre hospitalier universitaire vaudois, rue du Bugnon 46, 1011 Lausanne, Suisse
| | - D Azria
- Institut de recherche en cancérologie de Montpellier (IRCM), rue Croix-Verte, 34298 Montpellier, cedex 5, France; Inserm U1194, rue Croix-Verte, 34298 Montpellier, cedex 5, France; Université de Montpellier, avenue des Apothicaires, 34298 Montpellier cedex 05, France; Fédération universitaire d'oncologie radiothérapie, Institut régional du cancer de Montpellier (ICM), rue Croix-Verte, 34298 Montpellier, cedex 5, France; Fédération universitaire d'oncologie radiothérapie, institut de cancérologie du Gard, CHU de Nîmes, rue Henri-Pujol, 30000 Nîmes, France.
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Sawaki M, Miyamoto T, Fujisawa T, Itoh Y, Ebara T, Tachibana H, Kodaira T, Kikumori T, Yanagita Y, Iwata H. Multicenter Phase II Study of Intraoperative Radiotherapy of Early Breast Cancer: Ipsilateral Tumor Recurrence. Ann Surg Oncol 2019; 26:2428-2434. [PMID: 30993410 DOI: 10.1245/s10434-019-07350-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2018] [Indexed: 07/03/2024]
Abstract
BACKGROUND We performed a multicenter phase II study on the efficacy and safety of intraoperative radiotherapy (IORT) as partial breast irradiation using multiple devices. METHODS The primary endpoint was ipsilateral breast tumor recurrence (IBTR). Key inclusion criteria were T < 2.5 cm, age > 50 years, surgical margin > 1 cm, intraoperative pathologically free margins, and sentinel node negative. After resection of the tumor, radiation at 21 Gy was delivered directly to the mammary gland employing an electron linear accelerator in the operating room, otherwise the patient was transported from the surgical suite to the radiation room. RESULTS Overall, 142 patients were enrolled in this study and 129 underwent IORT. Stage 0: n = 4 (3.1%); stage I: n = 98 (76.0%); and stage IIA: n = 27 (20.9%). Luminal type: n = 116 (89.9%); triple-negative: n = 9 (7.0%); and human epidermal growth factor receptor 2: n = 4 (3.1%). Median follow-up time was 59.5 months (range 27.5-99.0), and the rate of IBTR was 3.1% (95% confidence interval 0.9-7.8). The toxicities included fibrosis in deep-connective tissue: grade 1, 78.1%; wound infection: grade 3, 1.6% and grade 2, 1.6%; and soft tissue necrosis: grade 3, 0.8% and grade 2, 0.8%. Recurrence in the breast occurred in four cases; the site of recurrence was just under the skin near the primary tumor site, with similar histology and subtype. CONCLUSIONS In this multicenter phase II study, the rate of IBTR was low and IORT at 21 Gy was feasible in properly selected patients. It is important to use a careful surgical technique to reduce local recurrence because the skin is not included in the radiation field of IORT.
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MESH Headings
- Adenocarcinoma, Mucinous/pathology
- Adenocarcinoma, Mucinous/radiotherapy
- Adenocarcinoma, Mucinous/surgery
- Aged
- Breast Neoplasms/pathology
- Breast Neoplasms/radiotherapy
- Breast Neoplasms/surgery
- Carcinoma, Ductal, Breast/pathology
- Carcinoma, Ductal, Breast/radiotherapy
- Carcinoma, Ductal, Breast/surgery
- Carcinoma, Lobular/pathology
- Carcinoma, Lobular/radiotherapy
- Carcinoma, Lobular/surgery
- Combined Modality Therapy
- Female
- Follow-Up Studies
- Humans
- Incidence
- Intraoperative Care
- Japan/epidemiology
- Mastectomy, Segmental/methods
- Middle Aged
- Neoplasm Invasiveness
- Neoplasm Recurrence, Local/epidemiology
- Neoplasm Recurrence, Local/pathology
- Prognosis
- Radiotherapy, Adjuvant/methods
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Affiliation(s)
- Masataka Sawaki
- Department of Breast Oncology, Aichi Cancer Center Hospital, Nagoya, Japan.
| | - Takeshi Miyamoto
- Department of Breast Oncology, Gunma Prefectural Cancer Center, Ota, Gunma, Japan
| | - Tomomi Fujisawa
- Department of Breast Oncology, Gunma Prefectural Cancer Center, Ota, Gunma, Japan
| | - Yoshiyuki Itoh
- Department of Radiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Takeshi Ebara
- Department of Radiation Oncology, Gunma Prefectural Cancer Center, Ota, Gunma, Japan
| | - Hiroyuki Tachibana
- Department of Radiation Oncology, Aichi Cancer Center Hopsital, Nagoya, Japan
| | - Takeshi Kodaira
- Department of Radiation Oncology, Aichi Cancer Center Hopsital, Nagoya, Japan
| | - Toyone Kikumori
- Department of Breast and Endocrine Surgery, Nagoya University School of Medicine, Nagoya, Japan
| | - Yasuhiro Yanagita
- Department of Breast Oncology, Gunma Prefectural Cancer Center, Ota, Gunma, Japan
| | - Hiroji Iwata
- Department of Breast Oncology, Aichi Cancer Center Hospital, Nagoya, Japan
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Outcomes of selective whole breast irradiation following lumpectomy with intraoperative radiation therapy for hormone receptor positive breast cancer. Am J Surg 2019; 218:749-754. [PMID: 31345502 DOI: 10.1016/j.amjsurg.2019.07.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 04/16/2019] [Accepted: 07/16/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND For low risk breast cancer, the TARGIT-A randomized trial supported lumpectomy with intraoperative radiation therapy (IORT) and selective whole breast radiation (WBXRT). Selection criteria for WBXRT vary. METHODS Women with hormone-receptor positive, clinically node-negative breast cancer were categorized retrospectively as suitable for IORT alone or also needing WBXRT by TARGIT-A or expanded TARGIT criteria (TARGIT-MCC). We evaluated local recurrence (LR) by selection criteria and receipt of WBXRT. RESULTS Among 194 cases followed a median of 44 months, 54 (27.8%) met TARGIT-MCC criteria for WBXRT (34 met TARGIT-A criteria). Thirty patients were recommended and 21 (10.8%) received WBXRT. Of 13 patients with LR, none received WBXRT. LR was 10.5% in patients meeting TARGIT-MCC criteria who did not receive WBXRT versus 0% after WBXRT (p = 0.299). CONCLUSIONS Selective WBXRT may have mitigated LR. Nearly all LR were in patients not recommended WBXRT. Further work should refine criteria for WBXRT after IORT. SUMMARY Prior work among women with early breast cancer supported lumpectomy with intraoperative radiation therapy and selective adjuvant radiation using a risk-adapted approach. An expanded set of criteria for adjuvant radiation appear to further mitigate local recurrence risk. Local recurrence after lumpectomy with IORT could be further minimized by identification of additional high-risk features, as well as greater adherence to adjuvant endocrine therapy.
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Pondé NF, Zardavas D, Piccart M. Progress in adjuvant systemic therapy for breast cancer. Nat Rev Clin Oncol 2019; 16:27-44. [PMID: 30206303 DOI: 10.1038/s41571-018-0089-9] [Citation(s) in RCA: 151] [Impact Index Per Article: 30.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The prognosis of patients with early stage breast cancer has greatly improved in the past three decades. Following the first adjuvant endocrine therapy and chemotherapy trials, continuous improvements of clinical outcomes have been achieved through intense therapeutic escalation, albeit with increased health-care costs and treatment-related toxicities. In contrast to the advances achieved in surgery or radiotherapy, the identification of the patient subgroups that will derive clinical benefit from therapeutic escalation has proved to be a daunting process hindered by a lack of collaboration between scientific groups and by the pace of drug development. In the past few decades, initiatives towards de-escalation of systemic adjuvant treatment have achieved success. Herein, we summarize attempts to escalate and de-escalate adjuvant systemic treatment for patients with breast cancer and argue that new, creative trial designs focused on patients' actual needs rather than on maximizing drug market size are needed. Ultimately, the adoption of effective treatments that do not needlessly expose patients and health-care systems to harm demands extensive international collaboration between academic groups, governments, and pharmaceutical companies.
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Affiliation(s)
- Noam F Pondé
- Research Department, Institut Jules Bordet, Academic Promoting Team, Brussels, Belgium
| | | | - Martine Piccart
- Research Department, Institut Jules Bordet, Brussels, Belgium.
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Six-Year Results From a Phase I/II Trial for Hypofractionated Accelerated Partial Breast Irradiation Using a 2-Day Dose Schedule. Am J Clin Oncol 2019; 41:986-991. [PMID: 28787281 DOI: 10.1097/coc.0000000000000402] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND To report 6-year outcomes from a phase I/II trial using balloon-based brachytherapy to deliver APBI in 2 days. METHODS A total of 45 patients with early-stage breast cancer received adjuvant APBI in 2 days with high-dose rate (HDR) brachytherapy totaling 2800 cGy in 4 fractions (700 cGy BID) using a balloon-based applicator as part of a prospective phase I/II clinical trial. All patients had negative margins and skin spacing ≥8 mm. We evaluated toxicities (CTCAE v3) as well as ipsilateral breast tumor recurrence (IBTR), regional nodal failure (RNF), distant metastasis, disease-free survival, cause-specific survival, and overall survival. RESULTS Median age and tumor size were 66 years old (48 to 83) and 0.8 cm (0.2 to 2.3 cm), respectively. Four percent of patients were N1 (n=2) and 73% were estrogen receptor (ER) positive (n=32). Median follow-up was 6.2 years (2.4 to 8.0 y). Nearly all toxicities at 6 years were grade 1 to 2 except 1 instance of grade 3 telangiectasia (2%). Eleven percent (n=5) of patients had chronic asymptomatic fat necrosis whereas asymptomatic seromas were noted on mammogram in 13% of cases (n=6). Cosmesis at last follow-up was good or excellent in 91% of cases (n=40) and fair in 9% (n=4). Two of the previously reported rib fractures healed with conservative measures. There were no IBTR or RNF (6 y IBTR/RNF rate 0%); however, 2 patients experienced distant metastasis (4% at 6 y). The 6-year actuarial disease-free survival, cause-specific survival, and overall survival were 96%, 100%, and 93%, respectively. CONCLUSIONS Hypofractionated 2-day APBI using brachytherapy resulted in excellent clinical outcomes with acceptable chronic toxicities.
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239
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Haque W, Verma V, Hsiao KY, Hatch S, Arentz C, Szeja S, Schwartz M, Niravath P, Bonefas E, Miltenburg D, Brian Butler E, Teh BS. Omission of radiation therapy following breast conservation in older (≥70 years) women with T1-2N0 triple-negative breast cancer. Breast J 2019; 25:1126-1133. [PMID: 31273872 DOI: 10.1111/tbj.13443] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Revised: 01/08/2019] [Accepted: 01/09/2019] [Indexed: 12/23/2022]
Abstract
BACKGROUND Although randomized data support omitting adjuvant radiotherapy (RT) following breast conservation for T1-2N0 estrogen receptor positive breast cancer in ≥70-year-old women, there remains a knowledge gap regarding its omission for triple-negative BC (TNBC). METHODS AND MATERIALS The National Cancer Database (NCDB) was queried for ≥70-year-old females with newly diagnosed T1-2N0M0 TNBC treated with breast conservation. Multivariable logistic regression ascertained factors associated with adjuvant RT administration. Overall survival (OS) between patients treated with or without adjuvant RT was estimated using the Kaplan-Meier method. Cox proportional hazards modeling determined variables associated with OS. RESULTS Of 8526 patients, 6283 (74%) patients received adjuvant RT, and 2243 (26%) did not. RT was more frequently withheld in older patients, those with higher comorbidities, lower income, pT2 disease, following margin-positive resection, receipt of chemotherapy, and at academic centers (P < 0.05 for all). Median follow-up was 38.0 months. Five-year OS was greater in the adjuvant RT group (77.2% vs 55.3%, P < 0.001); these differences persisted when stratifying for age, T stage, and chemotherapy utilization (P < 0.001 for all). Omission of RT was also independently associated with poorer OS on multivariate analysis (P < 0.001). CONCLUSIONS This investigation, the largest known such study to date, observed that omission of adjuvant RT for elderly women with T1-2N0 TNBC was associated with poorer OS; this was observed across a range of age groups, as well as following stratification by T stage and chemotherapy usage. Although these results do not imply causation, caution must be exercised when considering omission of adjuvant RT in node-negative TNBC patients.
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Affiliation(s)
- Waqar Haque
- Department of Radiation Oncology, Houston Methodist Hospital, Houston, Texas, USA
| | - Vivek Verma
- Department of Radiation Oncology, Allegheny General Hospital, Pittsburgh, Pennsylvania, USA
| | - Kuan-Yin Hsiao
- Department of Radiation Oncology, Houston Methodist Hospital, Houston, Texas, USA
| | - Sandra Hatch
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Candy Arentz
- Department of Surgery, Houston Methodist Hospital, Houston, Texas, USA
| | - Sean Szeja
- Department of Radiation Oncology, City of Hope, Duarte, California, USA
| | - Mary Schwartz
- Department of Pathology, Houston Methodist Hospital, Houston, Texas, USA
| | - Polly Niravath
- Department of Medical Oncology, Houston Methodist Hospital, Houston, Texas, USA
| | - Elizabeth Bonefas
- Department of Surgery, Houston Methodist Hospital, Houston, Texas, USA
| | | | - Edward Brian Butler
- Department of Radiation Oncology, Houston Methodist Hospital, Houston, Texas, USA
| | - Bin S Teh
- Department of Radiation Oncology, Houston Methodist Hospital, Houston, Texas, USA
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240
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Rana S, Naik A, Pillai S, Vetto J, Pommier R, Kubicky CD. Outcomes of intraoperative radiotherapy for early-stage breast cancer: Experience from a multidisciplinary breast oncology program. Am J Surg 2019; 219:655-659. [PMID: 31242962 DOI: 10.1016/j.amjsurg.2019.06.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2019] [Revised: 06/03/2019] [Accepted: 06/08/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Intraoperative radiotherapy (IORT) was implemented at our institution for early stage breast cancer patients including those with geographic or medical co-morbidity limitations to whole breast radiation therapy (WBRT). METHODS Retrospective review of patients (n = 127) who underwent IORT from 2009 to 2016 for breast cancer. Demographics, pathology, toxicity, and recurrences were ascertained. RESULTS The median age was 67 years (interquartile range: 62-73). At median follow-up (49.6 months), 5 patients (4%) had ipsilateral breast tumor recurrence with median time to recurrence of 36.8 months. Acute and late grade ≥3 skin toxicities were observed in 3.1% and 4.7% of patients, respectively. A subset (n = 7) who received prior ipsilateral WBRT was found to have no subsequent local recurrence, one case of acute grade 3 skin toxicity, and no late toxicity. CONCLUSIONS IORT is a safe and effective alternative to whole breast radiotherapy, and serves as a suitable alternative to completion mastectomy in locally recurrent breast cancer.
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Affiliation(s)
- Shushan Rana
- Oregon Health & Science University, 3181 SW Sam Jackson Rd, Portland, OR, 97239, USA.
| | - Arpana Naik
- Oregon Health & Science University, 3181 SW Sam Jackson Rd, Portland, OR, 97239, USA
| | - Susha Pillai
- Oregon Health & Science University, 3181 SW Sam Jackson Rd, Portland, OR, 97239, USA
| | - John Vetto
- Oregon Health & Science University, 3181 SW Sam Jackson Rd, Portland, OR, 97239, USA
| | - Rodney Pommier
- Oregon Health & Science University, 3181 SW Sam Jackson Rd, Portland, OR, 97239, USA
| | - Charlotte Dai Kubicky
- Oregon Health & Science University, 3181 SW Sam Jackson Rd, Portland, OR, 97239, USA
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241
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Tang JY, Shu CW, Wang CL, Wang SC, Chang MY, Lin LC, Chang HW. Sulfonyl chromen-4-ones (CHW09) shows an additive effect to inhibit cell growth of X-ray irradiated oral cancer cells, involving apoptosis and ROS generation. Int J Radiat Biol 2019; 95:1226-1235. [PMID: 31141432 DOI: 10.1080/09553002.2019.1625490] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Purpose: This study evaluates the growth inhibiting potential of our previously described sulfonyl chromen-4-ones (CHW09) compound in X-ray irradiated oral cancer cells. Materials and methods: The growth inhibiting effect and mechanism of combined CHW09/X-ray treatment was examined by analyzing cell viability, cell cycle, apoptosis, reactive oxygen species (ROS), and DNA damage. Results: Individual treatments of CHW09 (10 μg/mL) and X-ray irradiation (12 Gy) slightly decreased cell viability of oral cancer Ca9-22 (87.25% and 86.54%) and CAL 27 (80.00% and 74.01%) cells and normal oral HGF-1 cells (92.76% and 87.56%) at 24 h-MTS assay, respectively. In a combined treatment (CHW09/X-ray), the cell viability in Ca9-22 and CAL 27 cells was significantly decreased to 73.48% and 59.07%, whereas HGF-1 cells maintained 84.97% viability in 24 h-MTS assay. For CAL 27 cells, both 72 h-MTS assay and clonogenic assay showed that CHW09/X-ray resulted in more growth inhibition than other treatments. Intracellular ROS levels of CHW09/X-ray were higher than for CHW09, X-ray and control. CHW09/X-ray and X-ray alone had higher G2/M arrest than the control and CHW09 alone. Moreover, flow cytometry and western blotting showed that CHW09/X-ray treatment caused higher apoptosis levels. Levels of H2A histone family member X (γH2AX)-based DNA damage and 8-oxo-2'-deoxyguanosine (8-oxodG)-oxidative DNA damage of CHW09/X-ray were higher than for CHW09, X-ray and control. Conclusion: CHW09/X-ray treatment had additive growth inhibiting effects against X-ray irradiated oral cancer cells, partly attributing to apoptosis and ROS generation.
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Affiliation(s)
- Jen-Yang Tang
- Department of Radiation Oncology, Faculty of Medicine, College of Medicine, Kaohsiung Medical University , Kaohsiung , Taiwan.,Department of Radiation Oncology, Kaohsiung Medical University Hospital , Kaohsiung , Taiwan
| | - Chih-Wen Shu
- School of Medicine for International Students, I-Shou University , Kaohsiung , Taiwan
| | - Chun-Lin Wang
- Food Industry Research and Development Institute, Bioresource Collection and Research Center , Hsinchu , Taiwan
| | - Sheng-Chieh Wang
- PhD Program in Life Sciences, College of Life Science, Kaohsiung Medical University , Kaohsiung , Taiwan
| | - Meng-Yang Chang
- Department of Medicinal and Applied Chemistry, Kaohsiung Medical University , Kaohsiung , Taiwan
| | - Li-Ching Lin
- Department of Radiation Oncology, Chi-Mei Foundation Medical Center , Tainan , Taiwan.,School of Medicine, Taipei Medical University , Taipei , Taiwan.,Chung Hwa University of Medical Technology , Tainan , Taiwan
| | - Hsueh-Wei Chang
- Regenerative Medicine and Cell Therapy Research Center, Kaohsiung Medical University , Kaohsiung , Taiwan.,Institute of Medical Science and Technology, National Sun Yat-sen University , Kaohsiung , Taiwan.,Cancer Center, Kaohsiung Medical University Hospital, Kaohsiung Medical University , Kaohsiung , Taiwan.,Department of Biomedical Science and Environmental Biology, Kaohsiung Medical University , Kaohsiung , Taiwan
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242
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Corradini S, Krug D, Meattini I, Fastner G, Matuschek C, Cutuli B. Challenges in Radiotherapy. Breast Care (Basel) 2019; 14:152-158. [PMID: 31316313 DOI: 10.1159/000500847] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 05/07/2019] [Indexed: 01/06/2023] Open
Affiliation(s)
- Stefanie Corradini
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - David Krug
- Klinik für Strahlentherapie, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Icro Meattini
- Department of Biomedical, Experimental and Clinical Sciences, University of Florence, Florence, Italy.,Radiation Oncology Unit, Oncology Department, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Gerd Fastner
- Department of Radiotherapy and Radio-Oncology, Paracelsus Medical University, University Hospital Salzburg, Landeskrankenhaus, Salzburg, Austria
| | - Christiane Matuschek
- Department of Radiation Oncology, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
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243
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Wound fluids collected postoperatively from patients with breast cancer induce epithelial to mesenchymal transition but intraoperative radiotherapy impairs this effect by activating the radiation-induced bystander effect. Sci Rep 2019; 9:7891. [PMID: 31133667 PMCID: PMC6536501 DOI: 10.1038/s41598-019-44412-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Accepted: 05/16/2019] [Indexed: 02/07/2023] Open
Abstract
Wound fluids (WF) are believed to play a role in the local recurrences by inducing an inflammatory process in scar tissue area. Given that most local relapse in primary breast cancer patients occur within the scar tissue area, researchers have investigated whether localized radiotherapy, such as intraoperative radiotherapy (IORT), could be more effective than postoperative RT in inhibiting local tumor recurrence. The epithelial-mesenchymal transition (EMT) program plays a critical role in promoting metastasis in epithelium-derived carcinoma. Given this background the main aim of the present study was to determine the mechanisms by which IORT decreases the tumorigenic potential of WF. We assumed that postoperative fluids from patients would activate the radiation-induced bystander effect (RIBE) in treated cells, thus altering the tumor microenvironment. To confirm this hypothesis, WF collected from patients after breast conserving surgery (BCS) alone, after BCS followed by IORT treatment or WF from BCS patients together with RIBE medium were incubated with MCF7 and MDA-MB-468 cells. Changes in the CSC phenotype, in EMT program and potential to migrate were performed to determine the possible role of WF on the migration of breast cancer cells. Our findings show that wound fluids stimulate the CSC phenotype and EMT program in breast cancer cell lines. This effect was partially abrogated when the cells were incubated in wound fluids collected from patients after breast-conserving surgery followed by IORT. Additionally, we confirmed the role of radiation-induced bystander effect in altering the properties of the WF to induce the CSC phenotype and EMT program.
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244
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Pan L, Wan M, Zheng W, Wu R, Tang W, Zhang X, Yang T, Ye C. Intrabeam Radiation Inhibits Proliferation, Migration, and Invasiveness and Promotes Apoptosis of MCF-7 Breast Cancer Cells. Technol Cancer Res Treat 2019; 18:1533033819840706. [PMID: 30929609 PMCID: PMC6444775 DOI: 10.1177/1533033819840706] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Intraoperative radiotherapy differs from the more commonly used external beam radiation
with respect to fractionation, radiation energy, dose rate, and target volume, which may
influence the irradiated cells in a complex manner. However, experimental studies of
intraoperative radiotherapy are limited. Intrabeam is a frequently used intraoperative
radiotherapy device; we evaluated its effects on the proliferation, apoptosis, migration,
and invasion of MCF-7 human breast cancer cells. We performed colony formation assays for
cells irradiated with single radiation doses of 0 to 16 Gy. Other cells were irradiated
with single radiation doses of 0 to 6 Gy and then continued to be cultured. We measured
cell-cycle distributions and apoptosis rates 24 hours later, using flow cytometry, and
performed wound-healing assays, Transwell tests, and terminal deoxynucleotidyl
transferase–mediated 2′-deoxyuridine 5′-triphosphate nick-end labeling staining 4 weeks
later. Colony formation assays showed no positive colonies from cells irradiated with
doses of ≥6 Gy. In flow cytometry, the experimental groups had higher
late-apoptosis/necrosis rates (P < .01) and higher percentages of
cells arrested in G1 phase (P < .01). Experimental groups
also had much lower scratch-repair rates in the wound healing assay (P
< .001) and higher apoptosis rates in the terminal deoxynucleotidyl
transferase–mediated 2′-deoxyuridine 5′-triphosphate nick-end labeling assay (P
< .05). In Transwell tests, the 4 Gy and 6 Gy groups had fewer invading
cells than the control group (P < .05). Single-dose irradiation of 6
Gy with the Intrabeam device can effectively inhibit proliferation, migration, and
invasiveness and promote apoptosis in MCF-7 cells with long-lasting effects.
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Affiliation(s)
- Lingxiao Pan
- 1 Breast Center, Nanfang Hospital, Southern Medical University, Guangzhou, China.,2 Department of Breast Surgery, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Minghui Wan
- 3 Department of Radiation Oncology, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Wenbo Zheng
- 2 Department of Breast Surgery, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Rui Wu
- 4 Department of Radiotherapy, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Wei Tang
- 2 Department of Breast Surgery, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Xiaoshen Zhang
- 2 Department of Breast Surgery, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Tong Yang
- 5 Department of Pathology, the Second Affiliated Hospital (Panyu branch) of Guangzhou Medical University, Guangzhou, China
| | - Changsheng Ye
- 1 Breast Center, Nanfang Hospital, Southern Medical University, Guangzhou, China
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245
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Crown A, Grumley JW. Association of Intraoperative Radiotherapy in the Treatment of Early-Stage Breast Cancer With Minor Surgical Site Complications in Oncoplastic Breast-Conserving Surgery. JAMA Surg 2019; 152:1180-1182. [PMID: 28877298 DOI: 10.1001/jamasurg.2017.3129] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Affiliation(s)
- Angelena Crown
- Department of Surgery, Section of General Thoracic and Vascular Surgery, Virginia Mason Medical Center, Seattle, Washington
| | - Janie W Grumley
- Department of Surgery, Section of General Thoracic and Vascular Surgery, Virginia Mason Medical Center, Seattle, Washington
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246
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Meattini I, Lambertini M, Desideri I, De Caluwé A, Kaidar-Person O, Livi L. Radiation therapy for young women with early breast cancer: Current state of the art. Crit Rev Oncol Hematol 2019; 137:143-153. [DOI: 10.1016/j.critrevonc.2019.02.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Revised: 02/26/2019] [Accepted: 02/28/2019] [Indexed: 12/14/2022] Open
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247
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The American Brachytherapy Society consensus statement for electronic brachytherapy. Brachytherapy 2019; 18:292-298. [DOI: 10.1016/j.brachy.2018.10.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 10/31/2018] [Indexed: 11/21/2022]
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248
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Risk analysis of electronic intraoperative radiation therapy for breast cancer. Brachytherapy 2019; 18:271-276. [DOI: 10.1016/j.brachy.2018.10.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Revised: 10/29/2018] [Accepted: 10/31/2018] [Indexed: 11/22/2022]
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249
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Catheter-based delineation of lumpectomy cavity for accurate target definition in partial-breast irradiation with multicatheter interstitial brachytherapy. J Contemp Brachytherapy 2019; 11:108-115. [PMID: 31139218 PMCID: PMC6536147 DOI: 10.5114/jcb.2019.84504] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Accepted: 03/03/2019] [Indexed: 11/17/2022] Open
Abstract
Purpose In partial-breast irradiation (PBI), accurate lumpectomy cavity (LC) delineation is critical. Seroma-based delineation (SBD) using computed tomography (CT) with clips remains uncertain, causing an expansion of the LC and planning target volume (PTV). In catheter-based delineation (CBD), the implanted catheters were used as reference markers for LC delineation in multicatheter interstitial brachytherapy (MIB). Material and methods Between October 2008 and October 2018, 513 patients who underwent MIB-PBI were examined. In CBD, anatomical relations of LC to catheters were recorded. In randomly selected 22 CBD cases, the LC volume and PTV were retrospectively recontoured on SBD, and the relationship between the contribution of CBD and cavity visuality was evaluated. The LC volume and PTV before and after the introduction of CBD were compared. Results The mean LC volumes based on SBD and CBD were 19.1 cm3 and 14.1 cm3, respectively (p < 0.001). The mean PTVs based on SBD and CBD were 47.9 cm3 and 35.7 cm3, respectively (p < 0.0001). More reductions in the LC volume (5.1 cm3) (p < 0.05) and PTV (7.7 cm3) (p = 0.13) were observed in the poorly visible LC than in the visible LC. The LC volume and PTV before the introduction of CBD (n = 411) were compared with those after introduction (n = 102). Significant reductions were observed in the LC volume (5.9 cm3) (p < 0.0001) after the introduction of CBD; moreover, PTV tended to be reduced (3.9 cm3) (p = 0.17). Conclusions CBD may help to establish the standardized procedure for MIB-PBI and prevent unnecessary radiation exposure to the normal breast tissue.
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250
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Jacobs DHM, Horeweg N, Straver M, Roeloffzen EMA, Speijer G, Merkus J, van der Sijp J, Mast ME, Fisscher U, Petoukhova AL, Zwanenburg AG, Marijnen CAM, Koper PCM. Health-related quality of life of breast cancer patients after accelerated partial breast irradiation using intraoperative or external beam radiotherapy technique. Breast 2019; 46:32-39. [PMID: 31075670 DOI: 10.1016/j.breast.2019.04.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2018] [Revised: 03/13/2019] [Accepted: 04/23/2019] [Indexed: 11/26/2022] Open
Abstract
PURPOSE To compare health-related quality of life (HRQL) in elderly breast cancer patients between two types of Accelerated Partial Breast Irradiation: intraoperative radiotherapy (IORT) and external beam APBI (EB-APBI). METHODS Between 2011 and 2016 women ≥60 years undergoing breast conserving therapy for early stage breast cancer were included in a prospective multi-centre cohort study. Patients were treated with electron IORT (1 × 23.3 Gy) or photon EB-APBI (10 × 3.85 Gy daily). HRQL was measured by the EORTC-QLQ C30 and BR23 questionnaires before surgery and at several time points until 1 year. RESULTS HRQoL data was available of 204 IORT and 158 EB-APBI patients. In longitudinal analyses emotional functioning and future perspective were significantly, but not clinically relevantly, worse in IORT-treated patients, and improved significantly during follow-up in both groups. All other aspects of HRQL slightly worsened after treatment and recovered within 3 months with an improvement until 1 year. Cross-sectional analysis showed that postoperatively fatigue and role functioning were significantly worse in IORT patients compared to EB-APBI patients who were not yet irradiated, but the difference was not clinically relevant. At other timepoints there were no significant differences. Multivariable analysis at 1 year identified comorbidity and systemic therapy as risk factors for a worse global health score (GHS). CONCLUSIONS EB-APBI and IORT were well tolerated. Despite a temporary deterioration after treatment, all HRQL scales recovered within 3 months resulting in no clinically relevant differences until 1 year between groups nor compared to baseline levels.
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Affiliation(s)
- D H M Jacobs
- Department of Radiation Oncology, Haaglanden Medical Centre, The Hague, the Netherlands; Department of Radiation Oncology, Leiden University Medical Centre, Leiden, the Netherlands.
| | - N Horeweg
- Department of Radiation Oncology, Leiden University Medical Centre, Leiden, the Netherlands
| | - M Straver
- Department of Surgery, Haaglanden Medical Centre, The Hague, the Netherlands
| | - E M A Roeloffzen
- Department of Radiation Oncology, Isala, Zwolle, the Netherlands
| | - G Speijer
- Department of Radiation Oncology, Haga Hospital, The Hague, the Netherlands
| | - J Merkus
- Department of Surgery, Haga Hospital, The Hague, the Netherlands
| | - J van der Sijp
- Department of Surgery, Haaglanden Medical Centre, The Hague, the Netherlands
| | - M E Mast
- Department of Radiation Oncology, Haaglanden Medical Centre, The Hague, the Netherlands
| | - U Fisscher
- Department of Radiation Oncology, Haaglanden Medical Centre, The Hague, the Netherlands
| | - A L Petoukhova
- Department of Radiation Oncology, Haaglanden Medical Centre, The Hague, the Netherlands
| | - A G Zwanenburg
- Department of Radiation Oncology, Isala, Zwolle, the Netherlands
| | - C A M Marijnen
- Department of Radiation Oncology, Leiden University Medical Centre, Leiden, the Netherlands
| | - P C M Koper
- Department of Radiation Oncology, Haaglanden Medical Centre, The Hague, the Netherlands
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