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Corso G, Magnoni F, Provenzano E, Girardi A, Iorfida M, De Scalzi AM, Invento A, Colleoni M, Cassano E, Trentin C, Gullo RL, Pravettoni G, Gilardi L, Grana CM, Intra M, Galimberti V, Veronesi P, De Lorenzi F, Leonardi MC. Multicentric breast cancer with heterogeneous histopathology: a multidisciplinary review. Future Oncol 2020; 16:395-412. [PMID: 32026709 DOI: 10.2217/fon-2019-0540] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Multiple synchronous (multifocal or multicentric) ipsilateral breast cancers with heterogeneous histopathology are a rare clinical occurrence, however, their incidence is increasing due to the use of MRI for breast cancer screening and staging. Some studies have demonstrated poorer clinical outcomes for this pattern of breast cancer, but there is no evidence to guide clinical practice. In this multidisciplinary review, we reflect on pathology and molecular characteristics, imaging findings, surgical management including conservation and reconstructive options and approach to the axilla, and the role of chemotherapy and radiotherapy. Multidisciplinary discussions appear decisive in planning an appropriate surgical choice and defining the correct systemic treatment tailored to each clinical condition.
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Affiliation(s)
- Giovanni Corso
- Faculty of Medicine, University of Milan, Milan, Italy.,Division of Breast Surgery, European Institute of Oncology, IRCCS, Milan, Italy
| | - Francesca Magnoni
- Division of Breast Surgery, European Institute of Oncology, IRCCS, Milan, Italy
| | - Elena Provenzano
- NIHR Cambridge Biomedical Research Centre, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Antonia Girardi
- Division of Breast Surgery, European Institute of Oncology, IRCCS, Milan, Italy
| | - Monica Iorfida
- Division of Medical Senology, European Institute of Oncology, IRCCS, Milan, Italy
| | | | - Alessandra Invento
- Division of Breast Surgery, European Institute of Oncology, IRCCS, Milan, Italy
| | - Marco Colleoni
- Division of Medical Senology, European Institute of Oncology, IRCCS, Milan, Italy
| | - Enrico Cassano
- Division of Breast Imaging, European Institute of Oncology, IRCCS, Milan, Italy
| | - Chiara Trentin
- Division of Breast Imaging, European Institute of Oncology, IRCCS, Milan, Italy
| | - Roberto Lo Gullo
- Division of Breast Imaging, European Institute of Oncology, IRCCS, Milan, Italy
| | - Gabriella Pravettoni
- Faculty of Medicine, University of Milan, Milan, Italy.,Applied Research Division for Cognitive & Psychological Science, European Institute of Oncology, IRCCS, Milan, Italy
| | - Laura Gilardi
- Division of Nuclear Medicine, European Institute of Oncology, IRCCS, Milan, Italy
| | - Chiara Maria Grana
- Division of Nuclear Medicine, European Institute of Oncology, IRCCS, Milan, Italy
| | - Mattia Intra
- Division of Breast Surgery, European Institute of Oncology, IRCCS, Milan, Italy
| | - Viviana Galimberti
- Division of Breast Surgery, European Institute of Oncology, IRCCS, Milan, Italy
| | - Paolo Veronesi
- Faculty of Medicine, University of Milan, Milan, Italy.,Division of Breast Surgery, European Institute of Oncology, IRCCS, Milan, Italy
| | - Francesca De Lorenzi
- Division of Plastic & Reconstructive Surgery, European Institute of Oncology, IRCCS, Milan, Italy
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A literature review of the role of brachytherapy in the management of early-stage breast cancer. JOURNAL OF RADIOTHERAPY IN PRACTICE 2019. [DOI: 10.1017/s1460396919000700] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AbstractBackground:This review evaluates whether brachytherapy can be considered as an alternative to whole breast irradiation (WBI) using criteria such as local recurrence rates, overall survival rates and quality of life (QoL) factors. This is an important issue because of a decline in local recurrence rates, suggesting that some women at very low risk of recurrence may be incurring the negative long-term side effects of WBI without benefitting from a reduction in local recurrence and greater overall survival. As such, the purpose of this literature review is to evaluate whether brachytherapy is a credible alternative to external beam radiation with a particular focus on the impact it has on patient QoL.Methods:The search terms used were devised by using the Population Intervention Comparison Outcome framework, and a literature search was carried out using Boolean connectors and Medical Subject Headings in the PubMed database. The resultant articles were manually assessed for relevance and appraised using the Scottish Intercollegiate Guidelines Network tool. Additional papers were sourced from the citations of articles found using the search strategy. Government guidelines and regulations were also used following a manual search on the National Institute for Health and Care Excellence website. This process resulted in a total of 30 sources being included as part of the review.Results:Three types of brachytherapy were the foundation for the majority of the papers found: interstitial multi-catheter brachytherapy, intra-cavity brachytherapy and permanent seed implantation. The key themes that arose from the literature were that brachytherapy is equivalent to WBI both in terms of 5-year local recurrence rates and overall survival rates at 10–12 years. The findings showed that brachytherapy was superior to WBI for some QoL factors such as being less time-consuming and equal in terms of others such as breast cosmesis. The results did also show that brachytherapy does come with its own local toxicities that could impact upon QoL such as the poor breast cosmesis associated with some brachytherapy techniques.Conclusion:In conclusion, brachytherapy was deemed a safe or acceptable alternative to WBI, but there is a need for further research on the long-term local recurrence rates, survival rates and quality of life issues as the volume of evidence is still significantly smaller for brachytherapy than for WBI. Specifically, there needs to be further investigation as to which patients will benefit from being offered brachytherapy and the influence that factors such as co-morbidities, performance status and patient choice play in these decisions.
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Dundas KL, Pogson EM, Batumalai V, Boxer MM, Yap ML, Delaney GP, Metcalfe P, Holloway L. Australian survey on current practices for breast radiotherapy. J Med Imaging Radiat Oncol 2015; 59:736-42. [PMID: 26269376 DOI: 10.1111/1754-9485.12348] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2015] [Accepted: 06/21/2015] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Detailed, published surveys specific to Australian breast radiotherapy practice were last conducted in 2002. More recent international surveys specific to breast radiotherapy practice include a European survey conducted in 2008/2009 and a Spanish survey conducted in 2009. Radiotherapy techniques continue to evolve, and the utilisation of new techniques, such as intensity-modulated radiation therapy (IMRT), is increasing. This survey aimed to determine current breast radiotherapy practices across Australia. METHOD An online survey was completed by 50 of the 69 Australian radiation therapy treatment centres. RESULTS Supine tangential beam whole breast irradiation remains the standard of care for breast radiotherapy in Australia. A growing number of institutions are exploring prone positioning and IMRT utilisation. This survey demonstrated a wide variation in the benchmarks used to limit and report organ at risk doses, prescribed dose regimen, and post-mastectomy bolus practices. This survey also indicated, when compared with international literature, that there may be less interest in or uptake of external beam partial breast irradiation, prone positioning, simultaneous integrated boost and breath hold techniques. These are areas where further review and research may be warranted to ensure Australian patients are receiving the best care possible based on the best evidence available. CONCLUSION This survey provides insight into the current radiotherapy practice for breast cancer in Australia.
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Affiliation(s)
- Kylie L Dundas
- Centre for Medical Radiation Physics, University of Wollongong, Wollongong, New South Wales, Australia.,Liverpool and Macarthur Cancer Therapy Centres, Sydney, New South Wales, Australia.,Ingham Institute for Applied Medical Research, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Elise M Pogson
- Centre for Medical Radiation Physics, University of Wollongong, Wollongong, New South Wales, Australia.,Liverpool and Macarthur Cancer Therapy Centres, Sydney, New South Wales, Australia.,Ingham Institute for Applied Medical Research, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Vikneswary Batumalai
- Liverpool and Macarthur Cancer Therapy Centres, Sydney, New South Wales, Australia.,South Western Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Miriam M Boxer
- Liverpool and Macarthur Cancer Therapy Centres, Sydney, New South Wales, Australia.,South Western Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Mei Ling Yap
- Liverpool and Macarthur Cancer Therapy Centres, Sydney, New South Wales, Australia.,Ingham Institute for Applied Medical Research, Liverpool Hospital, Sydney, New South Wales, Australia.,South Western Clinical School, University of New South Wales, Sydney, New South Wales, Australia.,School of Medicine, University of Western Sydney, Sydney, New South Wales, Australia
| | - Geoff P Delaney
- Liverpool and Macarthur Cancer Therapy Centres, Sydney, New South Wales, Australia.,Ingham Institute for Applied Medical Research, Liverpool Hospital, Sydney, New South Wales, Australia.,South Western Clinical School, University of New South Wales, Sydney, New South Wales, Australia.,School of Medicine, University of Western Sydney, Sydney, New South Wales, Australia
| | - Peter Metcalfe
- Centre for Medical Radiation Physics, University of Wollongong, Wollongong, New South Wales, Australia.,Liverpool and Macarthur Cancer Therapy Centres, Sydney, New South Wales, Australia.,Ingham Institute for Applied Medical Research, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Lois Holloway
- Centre for Medical Radiation Physics, University of Wollongong, Wollongong, New South Wales, Australia.,Liverpool and Macarthur Cancer Therapy Centres, Sydney, New South Wales, Australia.,Ingham Institute for Applied Medical Research, Liverpool Hospital, Sydney, New South Wales, Australia.,South Western Clinical School, University of New South Wales, Sydney, New South Wales, Australia.,Institute of Medical Physics, School of Physics, University of Sydney, Sydney, New South Wales, Australia
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Moser EC, Vrieling C. Accelerated partial breast irradiation: the need for well-defined patient selection criteria, improved volume definitions, close follow-up and discussion of salvage treatment. Breast 2012; 21:707-15. [PMID: 23127279 DOI: 10.1016/j.breast.2012.09.014] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2012] [Revised: 08/17/2012] [Accepted: 09/23/2012] [Indexed: 12/24/2022] Open
Abstract
Breast-conserving therapy, including whole breast irradiation, has become a well-established alternative to mastectomy in early-stage breast cancer patients, with similar survival rates and better cosmetic outcome. However, many women are still treated with mastectomy, due to logistical issues related to the long course of radiotherapy (RT). To reduce mastectomy rates and/or omission of RT after breast-conserving surgery, shorter, hypofractionated RT treatments have been introduced. More recently, the necessity of routinely treating the entire breast in all patients has been questioned, leading to the development of partial breast radiotherapy. With accelerated partial breast irradiation (APBI) these two approaches have been combined: the tumor bed with a 1-2 cm margin is irradiated either intra-operatively (single fraction) or postoperatively over 5-15 days. Different techniques have been developed, including interstitial brachytherapy, intra-cavity brachytherapy, intra-operative radiotherapy and external beam radiotherapy. These techniques are being evaluated in several ongoing phase III studies. Since its introduction, APBI has been the subject of continuous debate. ASTRO and GEC-ESTRO have published guidelines for patient selection for APBI, and strongly recommend that APBI be carried out within ongoing clinical trials. Recently, the patient selection criteria for APBI have also been up for debate, following the publication of results from different groups that do/do not confirm a difference in recurrence risk among the ASTRO defined risk groups. This paper reviews the different APBI techniques, current recommendations for patient selection, available clinical data and ongoing clinical trials. A case report is included to illustrate the need for careful follow-up of patients treated with APBI.
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Affiliation(s)
- Elizabeth C Moser
- Breast Unit/Department of Radiotherapy, Champalimaud Cancer Centre, Lisbon, Portugal.
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Shah AP, Dvorak T, Curry MS, Buchholz DJ, Meeks SL. Clinical evaluation of interfractional variations for whole breast radiotherapy using 3-dimensional surface imaging. Pract Radiat Oncol 2012; 3:16-25. [PMID: 24674259 DOI: 10.1016/j.prro.2012.03.002] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2011] [Revised: 03/01/2012] [Accepted: 03/07/2012] [Indexed: 10/28/2022]
Abstract
PURPOSE To evaluate the impact of 3-dimensional (3D) surface imaging on daily patient setup for breast radiotherapy. MATERIALS AND METHODS Fifty patients undergoing treatment for whole breast radiotherapy were setup daily using an AlignRT system (VisionRT, London, UK) for 3D surface-based alignment. Daily alignments were performed against a reference surface topogram and shifts from skin marks were recorded daily. This investigation evaluated the following: (1) the performance of the surface-based imaging system for daily breast alignment; (2) the absolute displacements between setup with skin marks and setup with the surface-based imaging system; and (3) the dosimetric effect of daily alignments with skin marks versus surface-based alignments. RESULTS Displacements from 1258 treatment fractions were analyzed. Sixty percent of those fractions (749) were reviewed against MV portal imaging in order to assess the performance of the AlignRT system. Daily setup errors were given as absolute displacements, comparing setup marks against shifts determined using the surface-based imaging system. Averaged over all patients, the mean displacements were 4.1 ± 2.6 mm, 2.7 ± 1.4 mm, and 2.6 ± 1.2 mm in the anteroposterior (AP), superoinferior (S/I), and left-right (L/R) directions, respectively. Furthermore, the standard deviation of the random error (σ) was 3.2 mm, 2.2 mm, and 2.2 mm in the A/P, S/I, and L/R directions, respectively. CONCLUSIONS Daily alignment with 3D surface imaging was found to be valuable for reducing setup errors when comparing with patient alignment from skin marks. The result of the surface-based alignments specifically showed that alignment with skin marks was noticeably poor in the anteroposterior directions. The overall dosimetric effect of the interfractional variations was small, but these variations showed a potential for increased dose deposition to both the heart and lung tissues. Although these interfractional variations would not negatively affect the quality of patient care for whole breast radiotherapy, it may require an increase in PTV margin, especially in cases of partial breast irradiation.
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Affiliation(s)
- Amish P Shah
- Department of Radiation Oncology, MD Anderson Cancer Center Orlando, Orlando, Florida.
| | - Tomas Dvorak
- Department of Radiation Oncology, MD Anderson Cancer Center Orlando, Orlando, Florida
| | - Michael S Curry
- Department of Radiation Oncology, MD Anderson Cancer Center Orlando, Orlando, Florida
| | - Daniel J Buchholz
- Department of Radiation Oncology, MD Anderson Cancer Center Orlando, Orlando, Florida
| | - Sanford L Meeks
- Department of Radiation Oncology, MD Anderson Cancer Center Orlando, Orlando, Florida
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Abstract
This article examines the effects of radiation on prosthetic breast reconstruction when human dermal allograft is used in the reconstruction. A brief review of radiation terminology and techniques as applied to the breast is given, followed by a review of the effects of radiation on wound healing in human tissue. The effects of radiation on prosthetic breast reconstruction before the advent of dermal allografting are reviewed. The addition of dermal allograft in reconstruction has led to a reduced number of complications. An algorithm for surgical treatment of irradiated prosthetic breast reconstructions is presented, with a discussion of the authors technique.
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Guedea F, López Torrecilla J, Londres B, Ventura M, Bilbao P, Borràs JM. Patterns of care for brachytherapy in Europe: updated results for Spain. Clin Transl Oncol 2012; 14:36-42. [DOI: 10.1007/s12094-012-0759-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Njeh CF, Saunders MW, Langton CM. Accelerated partial breast irradiation using external beam conformal radiation therapy: A review. Crit Rev Oncol Hematol 2012; 81:1-20. [PMID: 21376625 DOI: 10.1016/j.critrevonc.2011.01.011] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2010] [Revised: 01/03/2011] [Accepted: 01/25/2011] [Indexed: 01/03/2023] Open
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Sautter-Bihl ML, Souchon R, Gerber B. Adjuvant therapy for women over age 65 with breast cancer. DEUTSCHES ARZTEBLATT INTERNATIONAL 2011; 108:365-71. [PMID: 21691560 PMCID: PMC3117173 DOI: 10.3238/arztebl.2011.0365] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/21/2010] [Accepted: 09/06/2010] [Indexed: 11/27/2022]
Abstract
BACKGROUND Women over age 65 with breast cancer are often not treated in accordance with current guidelines as far as adjuvant therapy is concerned, because of the lack of adequate scientific evidence. METHODS This article is based on a selective review of pertinent literature retrieved by a PubMed search, as well as on the German S3 guidelines for the diagnosis, treatment, and follow-up care of breast cancer, the treatment recommendations of the German Working Group on Gynecological Oncology (Arbeitsgemeinschaft Gynäkologische Onkologie, AGO) and the German Society of Radiation Oncology (Deutsche Gesellschaft für Radioonkologie), US National Comprehensive Cancer Network, and the Cochrane database. RESULTS Women over age 65 are underrepresented in randomized trials of treatments for breast cancer. Geriatric assessment is essential for therapeutic decision-making. Endocrine treatment is feasible for nearly all patients with hormone-sensitive tumors. In selected patients over age 65, chemotherapy significantly improves overall survival. The best evidence regarding toxicity is available for anthracycline monotherapy and for combined therapy with doxorubicin/cyclophosphamide or taxane/doxorubicin. Women without cardiac disease can be given trastuzumab, which may lead to reversible cardiotoxicity. Adjuvant radiotherapy significantly improves local tumor control and survival. Adjuvant radiotherapy that is carried out with modern treatment planning, as recommended by the current guidelines, is no more toxic to older patients than to younger ones; thus, it should always be given, unless there is a special reason not to. CONCLUSION Women with breast cancer over age 65 whose life expectancy is greater than 5 years, and who are not otherwise too ill, should be given chemotherapy, trastuzumab, and radiotherapy as standard adjuvant treatment. Adjuvant therapy can be reduced or omitted in frail patients. Patients over age 65 should be given the opportunity to enroll in clinical trials.
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Njeh CF, Saunders MW, Langton CM. Accelerated Partial Breast Irradiation (APBI): A review of available techniques. Radiat Oncol 2010; 5:90. [PMID: 20920346 PMCID: PMC2958971 DOI: 10.1186/1748-717x-5-90] [Citation(s) in RCA: 144] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2010] [Accepted: 10/04/2010] [Indexed: 01/08/2023] Open
Abstract
Breast conservation therapy (BCT) is the procedure of choice for the management of the early stage breast cancer. However, its utilization has not been maximized because of logistics issues associated with the protracted treatment involved with the radiation treatment. Accelerated Partial Breast Irradiation (APBI) is an approach that treats only the lumpectomy bed plus a 1-2 cm margin, rather than the whole breast. Hence because of the small volume of irradiation a higher dose can be delivered in a shorter period of time. There has been growing interest for APBI and various approaches have been developed under phase I-III clinical studies; these include multicatheter interstitial brachytherapy, balloon catheter brachytherapy, conformal external beam radiation therapy and intra-operative radiation therapy (IORT). Balloon-based brachytherapy approaches include Mammosite, Axxent electronic brachytherapy and Contura, Hybrid brachytherapy devices include SAVI and ClearPath. This paper reviews the different techniques, identifying the weaknesses and strength of each approach and proposes a direction for future research and development. It is evident that APBI will play a role in the management of a selected group of early breast cancer. However, the relative role of the different techniques is yet to be clearly identified.
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Affiliation(s)
- Christopher F Njeh
- Radiation Oncology Department, Texas Oncology Tyler, 910 East Houston Street, Tyler, Texas, USA
| | - Mark W Saunders
- Radiation Oncology Department, Texas Oncology Tyler, 910 East Houston Street, Tyler, Texas, USA
| | - Christian M Langton
- Physics, Faculty of Science and Technology, Queensland University of Technology, Brisbane, Australia
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