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Wang Y, Shen J, Gu P, Wang Z. Recent advances progress in radiotherapy for breast cancer after breast-conserving surgery: a review. Front Oncol 2023; 13:1195266. [PMID: 37671064 PMCID: PMC10475720 DOI: 10.3389/fonc.2023.1195266] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 08/07/2023] [Indexed: 09/07/2023] Open
Abstract
Adjuvant radiotherapy after breast-conserving surgery has become an integral part of the treatment of breast cancer. In recent years, the development of radiotherapy technology has made great progress in this field, including the comparison of the curative effects of various radiotherapy techniques and the performance of the segmentation times. The choice of radiotherapy technology needs to be co-determined by clinical evidence practice and evaluated for each individual patient to achieve precision radiotherapy. This article discusses the treatment effects of different radiotherapy, techniques, the risk of second cancers and short-range radiation therapy techniques after breast-conserving surgery such as hypo fractionated whole breast irradiation and accelerated partial breast irradiation. The choice of radiotherapy regimen needs to be based on the individual condition of the patient, and the general principle is to focus on the target area and reduce the irradiation of the normal tissues and organs. Short-range radiotherapy and hypofractionated are superior to conventional radiotherapy and are expected to become the mainstream treatment after breast-conserving surgery.
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Affiliation(s)
- Yun Wang
- Department of Radiation Oncology, Shidong Hospital, Shidong Hospital Affiliated to University of Shanghai for Science and Technology, Shanghai, China
| | - Jingjing Shen
- Department of Radiation Oncology, Shidong Hospital, Shidong Hospital Affiliated to University of Shanghai for Science and Technology, Shanghai, China
- School of Health Science and Engineering, University of Shanghai for Science and Technology, Shanghai, China
| | - Peihua Gu
- Department of Radiation Oncology, Shidong Hospital, Shidong Hospital Affiliated to University of Shanghai for Science and Technology, Shanghai, China
| | - Zhongming Wang
- Department of Radiation Oncology, Shidong Hospital, Shidong Hospital Affiliated to University of Shanghai for Science and Technology, Shanghai, China
- School of Health Science and Engineering, University of Shanghai for Science and Technology, Shanghai, China
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2
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Leonardi MC, Pepa M, Luraschi R, Vigorito S, Dicuonzo S, Isaksson LJ, La Porta MR, Marino L, Ippolito E, Huscher A, Argenone A, De Rose F, Cucciarelli F, De Santis MC, Rossi F, Prisco A, Guarnaccia R, de Fatis PT, Palumbo I, Colangione SP, Mormile M, Ravo V, Fozza A, Aristei C, Orecchia R, Cattani F, Jereczek-Fossa BA. The dosimetric impact of axillary nodes contouring variability in breast cancer radiotherapy: an AIRO multi-institutional study. Radiother Oncol 2022; 168:113-120. [PMID: 35033602 DOI: 10.1016/j.radonc.2022.01.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 01/03/2022] [Accepted: 01/04/2022] [Indexed: 12/01/2022]
Abstract
AIM To quantify the dosimetric impact of contouring variability of axillary lymph nodes (L2, L3, L4) in breast cancer (BC) locoregional radiotherapy (RT). MATERIALS AND METHODS 18 RT centres were asked to plan a locoregional treatment on their own planning target volume (single centre, SC-PTV) which was created by applying their institutional margins to the clinical target volume of the axillary nodes of three BC patients (P1, P2, P3) previously delineated (SC-CTV). The gold standard CTVs (GS-CTVs) of P1, P2 and P3 were developed by BC experts' consensus and validated with STAPLE algorithm. For each participating centre, the GS-PTV of each patient was created by applying the same margins as those used for the SC-CTV to SC-PTV expansion and replaced the SC-PTV in the treatment plan. Datasets were imported into MIM v6.1.7 [MIM Software Inc.], where dose-volume histograms (DVHs) were extracted and differences were analysed. RESULTS 17/18 centres used intensity-modulated RT (IMRT). The CTV to PTV margins ranged from 0 to 10 mm (median 5 mm). No correlation was observed between GS-CTV coverage by 95% isodose and GS-PTV margins width. Doses delivered to 98% (D98) and 95% (D95) of GS-CTVs were significantly lower than those delivered to the SC-CTVs. No significant difference between SC-CTV and GS-CTV was observed in maximum dose (D2), always under 110%. Mean dose ≥ 99% of the SC-CTVs and GS-CTVs was satisfied in 84% and 50%, respectively. In less than one half of plans, GS-CTV V95% was above 90%. Breaking down the GS-CTV into the three nodal levels (L2, L3 and L4), L4 had the lowest probability to be covered by the 95% isodose. CONCLUSIONS Overall, GS-CTV resulted worse coverage, especially for L4. IMRT was largely used and CTV-to-PTV margins did not compensate for contouring issues. The results highlighted the need for delineation training and standardization.
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Affiliation(s)
| | - Matteo Pepa
- Division of Radiation Oncology, IEO, Istituto Europeo di Oncologia, IRCCS, Milano, Italy
| | - Rosa Luraschi
- Unit of Medical Physics, IEO, Istituto Europeo di Oncologia, IRCCS, Milano, Italy
| | - Sabrina Vigorito
- Unit of Medical Physics, IEO, Istituto Europeo di Oncologia, IRCCS, Milano, Italy
| | - Samantha Dicuonzo
- Division of Radiation Oncology, IEO, Istituto Europeo di Oncologia, IRCCS, Milano, Italy.
| | - Lars Johannes Isaksson
- Division of Radiation Oncology, IEO, Istituto Europeo di Oncologia, IRCCS, Milano, Italy
| | | | - Lorenza Marino
- Radiotherapy Unit, REM Radioterapia, Viagrande, (CT), Italy
| | - Edy Ippolito
- Department of Radiotherapy, Campus Bio-Medico University, Roma, Italy
| | | | - Angela Argenone
- Division of Radiation Oncology, Azienda Ospedaliera di Rilievo Nazionale San Pio, Benevento, Italy
| | - Fiorenza De Rose
- Radiotherapy and Radiosurgery Department, Humanitas Clinical and Research Centre IRCCS, Milano, Italy
| | - Francesca Cucciarelli
- Department of Internal Medicine, Radiotherapy Institute, Ospedali Riuniti Umberto I, G.M. Lancisi, G. Salesi, Ancona, Italy
| | - Maria Carmen De Santis
- Radiotherapy Unit 1, Fondazione IRCCS Istituto Nazionale dei Tumori (INT), Milano, Italy
| | - Francesca Rossi
- Radiotherapy Unit, Usl Toscana Centro, Ospedale Santa Maria Annunziata, Firenze, Italy
| | - Agnese Prisco
- Department of Radiotherapy, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy
| | - Roberta Guarnaccia
- Radiotherapy Unit, Ospedale Fatebenefratelli Isola Tiberina, Roma, Italy
| | | | - Isabella Palumbo
- Radiation Oncology Section, University of Perugia and Perugia General Hospital, Perugia, Italy
| | - Sarah Pia Colangione
- Radiotherapy Unit, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Italy
| | - Maria Mormile
- Unit of Medical Physics, ASL Napoli 1 Centro - Ospedale del Mare, Napoli, Italy
| | - Vincenzo Ravo
- Unit of Radiotherapy, Istituto Nazionale Tumori - IRCCS - Fondazione G. Pascale, Napoli, Italy
| | - Alessandra Fozza
- Division of Radiation Oncology, Azienda Ospedaliera Nazionale SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Cynthia Aristei
- Radiation Oncology Section, University of Perugia and Perugia General Hospital, Perugia, Italy
| | - Roberto Orecchia
- Scientific Direction, IEO, Istituto Europeo di Oncologia, IRCCS, Milano, Italy
| | - Federica Cattani
- Unit of Medical Physics, IEO, Istituto Europeo di Oncologia, IRCCS, Milano, Italy
| | - Barbara Alicja Jereczek-Fossa
- Division of Radiation Oncology, IEO, Istituto Europeo di Oncologia, IRCCS, Milano, Italy; Department of Oncology and Hemato-Oncology, University of Milan, Milano, Italy
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- Division of Radiation Oncology, IEO, Istituto Europeo di Oncologia, IRCCS, Milano, Italy; Department of Oncology and Hemato-Oncology, University of Milan, Milano, Italy
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3
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Dicuonzo S, Patti F, Luraschi R, Frassoni S, Rojas DP, Zaffaroni M, Morra A, Gerardi MA, Zerella MA, Emiro F, Cattani F, Bagnardi V, Fodor CI, Veronesi P, Galimberti VE, Orecchia R, Leonardi MC, Jereczek-Fossa BA. Comparing TomoHelical and TomoDirect in postmastectomy hypofractionated radiotherapy after immediate breast reconstruction. Phys Med 2021; 90:66-72. [PMID: 34563833 DOI: 10.1016/j.ejmp.2021.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 09/10/2021] [Accepted: 09/13/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Postmastectomy radiotherapy (PMRT) with TomoHelical™ (TH) or TomoDirect™ (TD) allows a uniform target coverage. In this study, we compare treatment plans using TD and TH in the setting of hypofractionated PMRT and immediate breast reconstruction. MATERIAL AND METHODS The TD-treatment plans of breast cancer patients treated between May 2016 and August 2019 were retrospectively selected. All the TD plans were re-planned on TH with the same prescription dose (40.05 Gy/15 fractions) and according to our dose/volume constraints. Data about the 2 treatment plans were compared with a focus on PTV coverage and all the organs at risk (OARs) constraints. RESULTS Fifty patients for a total number of 100 treatment plans (50 with TD and 50 re-planned with TH) were analyzed. All the median value in the TD PTV CHEST WALL plans fulfilled the predefined planning objectives, even though TH emerged as best for target coverage with statistically significant difference for V90%. TD provided the lowest V95% for the PTV SVC, but the median value was near to the recommended value of 90% (89.8 % vs 98.6% for TD and TH, respectively). Overall, TD reached the best OARs sparing. The main statistically significant differences with TH were for contralateral breast, ipsilateral and contralateral lung. All the other dose values for TH were higher than TD, but they fulfilled the recommended/acceptable predefined planning objectives. CONCLUSIONS In the setting of PMRT, TD compared to TH reached an acceptable target volume coverage, with an optimal sparing of OARs.
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Affiliation(s)
- Samantha Dicuonzo
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Filippo Patti
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Rosa Luraschi
- Unit of Medical Physics, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Samuele Frassoni
- Department of Statistics and Quantitative Methods, University of Milan-Bicocca, Milan, Italy
| | | | - Mattia Zaffaroni
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Anna Morra
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | | | - Maria Alessia Zerella
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, Milan, Italy.
| | - Francesca Emiro
- Unit of Medical Physics, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Federica Cattani
- Unit of Medical Physics, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Vincenzo Bagnardi
- Department of Statistics and Quantitative Methods, University of Milan-Bicocca, Milan, Italy
| | | | - Paolo Veronesi
- Division of Breast Surgery, IEO, European Institute of Oncology IRCCS, Milan, Italy; Department of Oncology and Hemato-oncology, University of Milan, Milan, Italy
| | | | - Roberto Orecchia
- Scientific Directorate, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | | | - Barbara Alicja Jereczek-Fossa
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, Milan, Italy; Department of Oncology and Hemato-oncology, University of Milan, Milan, Italy
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4
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Mastectomy alone for pT1-2 pN0-1 breast cancer patients: when postmastectomy radiotherapy is indicated. Breast Cancer Res Treat 2021; 188:511-524. [PMID: 33905020 DOI: 10.1007/s10549-021-06227-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 04/09/2021] [Indexed: 02/03/2023]
Abstract
PURPOSE To assess outcome of breast cancer (BC) stages pT1-2 N0-1 after mastectomy alone and to identify prognostic factors calling for the need of postmastectomy radiotherapy. METHODS Patients who were not eligible for breast conserving surgery (BCS) were operated on with mastectomy between 1998 and 2008. Locoregional (LRR), distant (DM) control and breast cancer specific survival (BCSS) were retrospectively evaluated. Cumulative incidence (CI) of events was estimated according to Kalbfleisch and Prentice while Gray's test tested difference. Kaplan-Meier method for survival and Cox proportional hazards model for univariable and multivariable analysis were used. A matched pair analysis between mastectomy alone and BCS plus whole breast irradiation (WBI), using the propensity score method, was performed. RESULTS 1281 pT1-2 N0 and 1081 pT1-2 N1 were identified. Median follow-up was 8.2 years (9.2 years for survival). Overall, LRR rate was low for both N0 and N1 subgroups (10-year CI, 8.8% and 10.9%, respectively). Young age, lymphovascular invasion and Ki-67 ≥ 20% were proved to be statistically significant prognostic factors at multivariable analysis. The combination of ≥ 2 risk factors increased LRR rate to ≥ 15%. Risk factors combination weighed on LRR rate more than nodal status itself. DM rate doubled moving from negative to positive nodal status (10-year CI 10.5% versus 20.3%, respectively). BCSS remained high in both N0 and N1 subgroups (10-year CI 92.4% versus 84.5%, respectively). Remarkably, all the molecular subtypes except Luminal A significantly affected DM and BCSS both in the N0 and N1 subgroups. Nodes number significantly impacted on DM and BCSS but not on locoregional control. In the matched pair analysis, WBI decreased nodal recurrence rate and improved distant control, without affecting survival. CONCLUSIONS Selected patients, namely those with at least two additional risk factors, presented high enough LRR risk to support the use of postmastectomy radiotherapy in both N0 and N1 subgroups. Moreover, the observation that radiotherapy may provide benefits that go beyond local control deserves to be further investigated.
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Liang JA, Lee PC, Ku CP, Chen WTL, Chung CY, Kuo YC, Chou SH, Li CC, Chien CR. Effectiveness of Image-Guided Radiotherapy in Adjuvant Radiotherapy on Survival for Localized Breast Cancer: A Population-Based Analysis. Cancer Manag Res 2021; 13:3465-3472. [PMID: 33907469 PMCID: PMC8069678 DOI: 10.2147/cmar.s299975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 03/13/2021] [Indexed: 12/24/2022] Open
Abstract
Purpose Image-guided radiotherapy (IGRT) is an advanced radiotherapy technique to improve the radiotherapy delivery. We aimed to compare the overall survival (OS) for localized breast cancer (LBC) patient treated with adjuvant conventional fractionated radiotherapy (CFRT) using IGRT vs those without IGRT via a population-based analysis. Patients and Methods Eligible LBC patients diagnosed between 2011 and 2013 were identified via the Taiwan Cancer Registry. We used propensity score (PS) weighting to balance observable potential confounders between groups. The hazard ratio (HR) of death and other outcomes were compared between IGRT and non-IGRT. We also evaluated OS in various supplementary analyses. Results Our primary analysis included 6490 patients in whom covariates were well balanced after PS weighing. The HR for death when IGRT was compared with non-IGRT was 1.02 (95% confidence interval 0.80–1.31, P = 0.86). There were also no significant differences in the supplementary analyses. Conclusion We found that OS of LBC patients treated with adjuvant CFRT was not statistically different between those treated with IGRT versus without IGRT. This was the first study in this regard to our knowledge but randomized controlled trials were needed to confirm our finding.
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Affiliation(s)
- Ji-An Liang
- Department of Radiation Oncology, China Medical University Hospital, Taichung, Taiwan.,School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan
| | - Po-Chang Lee
- Department of Surgery, China Medical University Hsinchu Hospital, Hsinchu, Taiwan
| | - Chun-Ping Ku
- Department of Surgery, China Medical University Hsinchu Hospital, Hsinchu, Taiwan
| | - William Tzu-Liang Chen
- School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan.,Department of Surgery, China Medical University Hsinchu Hospital, Hsinchu, Taiwan
| | - Chih-Yuan Chung
- Department of Medical Oncology, China Medical University Hsinchu Hospital, Hsinchu, Taiwan
| | - Yu-Cheng Kuo
- Department of Radiation Oncology, China Medical University Hospital, Taichung, Taiwan.,School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan
| | - Szu-Hsien Chou
- Department of Medical Imaging, China Medical University Hsinchu Hospital, Hsinchu, Taiwan
| | - Chia-Chin Li
- Department of Radiation Oncology, China Medical University Hsinchu Hospital, Hsinchu, Taiwan
| | - Chun-Ru Chien
- Department of Radiation Oncology, China Medical University Hospital, Taichung, Taiwan.,School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan.,Department of Radiation Oncology, China Medical University Hsinchu Hospital, Hsinchu, Taiwan
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6
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Predicting adherence of dose-volume constraints for personalized partial-breast irradiation technique. Brachytherapy 2020; 20:163-170. [PMID: 32741559 DOI: 10.1016/j.brachy.2020.06.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 06/25/2020] [Accepted: 06/25/2020] [Indexed: 11/24/2022]
Abstract
PURPOSE Multicatheter interstitial brachytherapy (MIB) and external-beam (EB) radiotherapy are established partial-breast irradiation (PBI) techniques. Although EB-PBI is widely available, it requires extra irradiated margins for target uncertainties. We examined the impact of EB-PBI on dose-volume constraints as compared to MIB-PBI. METHODS AND MATERIALS Among 653 patients receiving MIB-PBI between October 2008 and April 2020, consequent 159 patients after September 2018 were examined. Clinical target volume (CTV) included the lumpectomy cavity plus 1.0 cm. Planning target volume (PTV) for EB-PBI was defined as CTV with 1.0-cm expansion. Because the ratio of PTV to breast volume (RPB) was related to cosmesis, <25% of RPB was defined as suitable for the ipsilateral breast constraints. Preoperative breast size was classified as very small (<350 cm3), small (350-699 cm3), and medium or large (≥700 cm3). According to each category, the dose-volume constraints of the organs at risk were compared between the two PBI techniques. RESULTS Patients including 84 very small, 59 small, and 16 moderate to large breasts were examined. Although RPB was suitable in all patients receiving MIB-PBI, it was achieved in 74 patients (46.5%) receiving EB-PBI (p < 0.0001). The suitable RPB in patients with very small, small, and moderate to large breast was 32.1%, 55.9%, and 100%, respectively (p < 0.0001). Normal-tissue constraints for the other organs could be satisfied in patients with moderate to large breasts. CONCLUSION Although EB-PBI may be an appropriate option for patients with moderate to large breasts, MIB-PBI could still be a crucial technique, especially for patients with small breasts.
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Lee HH, Chen CH, Luo KH, Chuang HY, Huang CJ, Cheng YK, Chen F, Kuo SH, Huang MY. Five-year survival outcomes of intensity-modulated radiotherapy with simultaneous integrated boost (IMRT-SIB) using forward IMRT or Tomotherapy for breast cancer. Sci Rep 2020; 10:4342. [PMID: 32152428 PMCID: PMC7063050 DOI: 10.1038/s41598-020-61403-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Accepted: 02/24/2020] [Indexed: 12/24/2022] Open
Abstract
Intensity-modulated radiotherapy with simultaneous integrated boost (IMRT-SIB) reduces overall treatment duration and results in less radiotherapy (RT)-induced dermatitis. However, the use of traditional sequential approach or IMRT-SIB is still under debate since there is not enough evidence of long-term clinical outcomes. The present study investigated 216 patients who underwent breast conserving surgery (BCS) between 2010 and 2013. The median age was 51 years (range, 21-81 years). All patients received IMRT-SIB, 50.4 Gy at 1.8 Gy per fraction to the whole breast and 60.2 Gy at 2.15 Gy per fraction to the tumor bed by integral boost. Among 216 patients, 175 patients received post-operative RT with forward IMRT and 41 patients had Tomotherapy. The median follow-up was 6.4 years. Forty patients (97.6%) in the Tomotherapy arm and 147 patients (84%) in the IMRT arm developed grade 0-1 skin toxicity (P = 0.021). For the entire cohort, the 5-year and 7-year overall survival (OS) rates were 94.4% and 93.1% respectively. The 7-year distant metastasis-free survival rates were 100% vs 89.1% in the Tomotherapy and IMRT arm respectively (P = 0.028). In conclusion, Tomotherapy improved acute skin toxicity compared with forward IMRT-SIB. Chronic skin complication was 1.9%. IMRT-SIB resulted in good long-term survival.
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Affiliation(s)
- Hsin-Hua Lee
- Ph.D. Program in Environmental and Occupational Medicine, Kaohsiung Medical University and National Health Research Institutes, Kaohsiung, Taiwan.,Department of Radiation Oncology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Chien-Hung Chen
- Department of Radiation Oncology, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung, Taiwan.,Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Kuei-Hau Luo
- Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Occupational and Environmental Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Hung-Yi Chuang
- Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Occupational and Environmental Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Chih-Jen Huang
- Department of Radiation Oncology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.,Department of Radiation Oncology, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yuan-Kai Cheng
- Department of Radiation Oncology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.,Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Frank Chen
- Department of Radiation Oncology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.,Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Shih-Hsun Kuo
- Department of Radiation Oncology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Ming-Yii Huang
- Ph.D. Program in Environmental and Occupational Medicine, Kaohsiung Medical University and National Health Research Institutes, Kaohsiung, Taiwan. .,Department of Radiation Oncology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan. .,Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan. .,Department of Radiation Oncology, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan. .,Center for Biomarkers and Biotech Drugs, Kaohsiung Medical University, Kaohsiung, Taiwan. .,Center for Cancer Research, Kaohsiung Medical University, Kaohsiung, Taiwan.
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8
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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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Fhoghlú MN, Barrett S. A Review of Radiation-Induced Lymphocyte Apoptosis as a Predictor of Late Toxicity After Breast Radiotherapy. J Med Imaging Radiat Sci 2019; 50:337-344. [PMID: 31176443 DOI: 10.1016/j.jmir.2019.02.004] [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: 08/31/2018] [Revised: 01/28/2019] [Accepted: 02/20/2019] [Indexed: 11/16/2022]
Abstract
BACKGROUND Improved survivorship in patients with breast cancer means many are currently living with the late effects of radiotherapy, particularly fibrosis. Personalized treatment is not currently considered for patients with breast cancer. Radiation-induced lymphocyte apoptosis (RILA), a predictive assay, could offer a novel approach in predicting patients at a higher risk of developing this late toxicity and therefore improving informed decision-making. MATERIALS AND METHODS A systematic search of PubMed and Embase was performed and eight clinical trials were identified that investigate RILA as a predictor of late breast fibrosis after radiotherapy. RESULTS Median RILA scores were lower in patients who experienced ≥ grade 2 fibrosis than in patients who experienced ≥ grade 1. A clear inverse relationship between RILA scores and late toxicity was reported in the literature; however, there were several other confounding factors involved in the development of fibrosis. CD8 lymphocytes were reported to have superior sensitivity and specificity over CD4 lymphocytes. CONCLUSION RILA was reported to be an effective biomarker in predicting fibrosis in breast cancer but other factors also need to be considered before clinical implementation.
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Affiliation(s)
- Meadhbh Ní Fhoghlú
- Applied Radiation Therapy Trinity, Discipline of Radiation Therapy, School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - Sarah Barrett
- Applied Radiation Therapy Trinity, Discipline of Radiation Therapy, School of Medicine, Trinity College Dublin, Dublin, Ireland.
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10
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Leonardi MC, Corrao G, Frassoni S, Vingiani A, Dicuonzo S, Lazzeroni M, Fodor C, Morra A, Gerardi MA, Rojas DP, Dell'Acqua V, Marvaso G, Bassi FD, Galimberti VE, Veronesi P, Miglietta E, Cattani F, Zurrida S, Bagnardi V, Viale G, Orecchia R, Jereczek-Fossa BA. Ductal carcinoma in situ and intraoperative partial breast irradiation: Who are the best candidates? Long-term outcome of a single institution series. Radiother Oncol 2019; 133:68-76. [PMID: 30935584 DOI: 10.1016/j.radonc.2018.12.030] [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: 10/30/2018] [Revised: 12/30/2018] [Accepted: 12/31/2018] [Indexed: 12/27/2022]
Abstract
AIMS To report the long-term outcome of a single institution series of pure ductal carcinoma in situ (DCIS) treated with accelerated partial irradiation using intraoperative electrons (IOERT). METHODS From 2000 to 2010, 180 DCIS patients, treated with quadrantectomy and 21 Gy IOERT, were analyzed in terms of ipsilateral breast recurrences (IBRs) and survival outcomes by stratification in two subgroups. The low-risk group included patients who fulfilled the suitable definition according to American Society of Radiation Oncology (ASTRO) Guidelines (size ≤2.5 cm, grade 1-2 and surgical margins ≥3 mm) (Suitable), while the remaining ones formed the high-risk group (Non-Suitable). RESULTS Eighty-four and 96 patients formed the Suitable and Non-Suitable groups, respectively. In the whole population, the cumulative incidence of IBR at 5, 7 and 10 years was 19%, 21%, and 25%, respectively. In the Suitable group, the cumulative incidence of IBR remained constant at 11% throughout the years, while in the Non-Suitable group increased from 26% at 5 years to 36% at 10 years (p < 0.0001). When hormonal positivity and HER2 absence of expression were added to the selection of the Suitable group, the cumulative incidence of IBR dropped and stabilized at 4% at 10 years. None died of breast cancer. In the whole population, 5-year and 10-year overall survival rate was 98% and 96.5%, respectively, without any difference between the two groups. CONCLUSIONS The overall and by group IBR rates were high and stricter criteria are required for acceptable local control for Suitable DCIS. Because of the concerns raised, IOERT should not be used in clinical practice.
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Affiliation(s)
| | - Giulia Corrao
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, Milan, Italy; Department of Oncology and Hemato-oncology, University of Milan, Italy
| | - Samuele Frassoni
- Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Italy
| | - Andrea Vingiani
- Department of Pathology, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Samantha Dicuonzo
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, Milan, Italy.
| | - Matteo Lazzeroni
- Division of Cancer Prevention and Genetics, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Cristiana Fodor
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Anna Morra
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | | | - Damaris Patricia Rojas
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, Milan, Italy; Department of Oncology and Hemato-oncology, University of Milan, Italy
| | - Veronica Dell'Acqua
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Giulia Marvaso
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Fabio Domenico Bassi
- Division of Breast Surgery, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | | | - Paolo Veronesi
- Department of Oncology and Hemato-oncology, University of Milan, Italy; Division of Breast Surgery, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Eleonora Miglietta
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Federica Cattani
- Unit of Medical Physics, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Stefano Zurrida
- Department of Oncology and Hemato-oncology, University of Milan, Italy
| | - Vincenzo Bagnardi
- Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Italy
| | - Giuseppe Viale
- Department of Oncology and Hemato-oncology, University of Milan, Italy; Department of Pathology, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Roberto Orecchia
- Scientific Direction, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Barbara Alicja Jereczek-Fossa
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, Milan, Italy; Department of Oncology and Hemato-oncology, University of Milan, Italy
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11
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Comparison of Outcome between Invasive Lobular Carcinoma (ILC) and Invasive Ductal Carcinoma (IDC) Patients Treating with Breast Conserving Surgery (BCS) and Radical Dose of Intraoperative Electron Radiotherapy (IOERT). INTERNATIONAL JOURNAL OF CANCER MANAGEMENT 2018. [DOI: 10.5812/ijcm.80985] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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12
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Dosimetric study to assess the feasibility of intraoperative radiotherapy with electrons (ELIOT) as partial breast irradiation for patients with cardiac implantable electronic device (CIED). Breast Cancer Res Treat 2018; 171:693-699. [PMID: 29978418 DOI: 10.1007/s10549-018-4878-8] [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: 06/25/2018] [Accepted: 07/02/2018] [Indexed: 10/28/2022]
Abstract
PURPOSE To report in-vivo dosimetry in the infraclavicular region, a potential site of a cardiac implantable electronic device (CIED) and to evaluate the absorbed dose from intraoperative radiotherapy with electrons (ELIOT). METHODS 27 non-cardiopathic breast cancer (BC) patients without CIED received quadrantectomy and ELIOT as partial breast irradiation. Before delivering ELIOT, two catheters, each containing eight thermoluminescent dosimeters (TLDs), were positioned in the infraclavicular region. TLDs internal catheter was located deep in the tumor bed while the external catheter was placed on patient's skin. RESULTS Data were available for 24/27 patients. The absorbed doses were referred to the dose of 21 Gy. Values measured by the external catheter were low, although statistically significant higher doses were found close to the applicator (mean values 0.26-0.49 Gy). External TLD doses in proximity of the applicator were lower than those detected by their internal counterparts. Values measured by the internal catheter TLDs varied according to the distance from the applicator while no correlation with tumor site and beam energy was found. The distance from the applicator to deliver < 2 Gy to a CIED was 2 cm, while from 2.5 cm the dose measured in all the patients became negligible. CONCLUSIONS This dosimetric study provided data to support the clinical use of ELIOT in BC patients having CIEDs as long as the suggested minimum safe distance of 2.5 cm is taken from the RT field in case of ELIOT single dose of 21 Gy, in the energy range of 6-10 MeV.
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13
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Garibaldi C, Jereczek-Fossa BA, Marvaso G, Dicuonzo S, Rojas DP, Cattani F, Starzyńska A, Ciardo D, Surgo A, Leonardi MC, Ricotti R. Recent advances in radiation oncology. Ecancermedicalscience 2017; 11:785. [PMID: 29225692 PMCID: PMC5718253 DOI: 10.3332/ecancer.2017.785] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Indexed: 12/18/2022] Open
Abstract
Radiotherapy (RT) is very much a technology-driven treatment modality in the management of cancer. RT techniques have changed significantly over the past few decades, thanks to improvements in engineering and computing. We aim to highlight the recent developments in radiation oncology, focusing on the technological and biological advances. We will present state-of-the-art treatment techniques, employing photon beams, such as intensity-modulated RT, volumetric-modulated arc therapy, stereotactic body RT and adaptive RT, which make possible a highly tailored dose distribution with maximum normal tissue sparing. We will analyse all the steps involved in the treatment: imaging, delineation of the tumour and organs at risk, treatment planning and finally image-guidance for accurate tumour localisation before and during treatment delivery. Particular attention will be given to the crucial role that imaging plays throughout the entire process. In the case of adaptive RT, the precise identification of target volumes as well as the monitoring of tumour response/modification during the course of treatment is mainly based on multimodality imaging that integrates morphological, functional and metabolic information. Moreover, real-time imaging of the tumour is essential in breathing adaptive techniques to compensate for tumour motion due to respiration. Brief reference will be made to the recent spread of particle beam therapy, in particular to the use of protons, but also to the yet limited experience of using heavy particles such as carbon ions. Finally, we will analyse the latest biological advances in tumour targeting. Indeed, the effectiveness of RT has been improved not only by technological developments but also through the integration of radiobiological knowledge to produce more efficient and personalised treatment strategies.
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Affiliation(s)
- Cristina Garibaldi
- Unit of Medical Physics, European Institute of Oncology, 20141 Milan, Italy
| | - Barbara Alicja Jereczek-Fossa
- Department of Radiation Oncology, European Institute of Oncology, 20141 Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, 20122 Milan, Italy
| | - Giulia Marvaso
- Department of Radiation Oncology, European Institute of Oncology, 20141 Milan, Italy
| | - Samantha Dicuonzo
- Department of Radiation Oncology, European Institute of Oncology, 20141 Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, 20122 Milan, Italy
| | - Damaris Patricia Rojas
- Department of Radiation Oncology, European Institute of Oncology, 20141 Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, 20122 Milan, Italy
| | - Federica Cattani
- Unit of Medical Physics, European Institute of Oncology, 20141 Milan, Italy
| | - Anna Starzyńska
- Department of Oral Surgery, Medical University of Gdańsk, 80–211 Gdańsk, Poland
| | - Delia Ciardo
- Department of Radiation Oncology, European Institute of Oncology, 20141 Milan, Italy
| | - Alessia Surgo
- Department of Radiation Oncology, European Institute of Oncology, 20141 Milan, Italy
| | | | - Rosalinda Ricotti
- Department of Radiation Oncology, European Institute of Oncology, 20141 Milan, Italy
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14
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Leonardi MC, Maisonneuve P, Mastropasqua MG, Cattani F, Fanetti G, Morra A, Lazzari R, Bazzani F, Caputo M, Rotmensz N, Gerardi MA, Ricotti R, Enrica Galimberti V, Veronesi P, Dicuonzo S, Viale G, Jereczek-Fossa BA, Orecchia R. Comparison of Treatment Outcome Between Invasive Lobular and Ductal Carcinomas in Patients Receiving Partial Breast Irradiation With Intraoperative Electrons. Int J Radiat Oncol Biol Phys 2017; 99:173-181. [DOI: 10.1016/j.ijrobp.2017.04.033] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Revised: 03/16/2017] [Accepted: 04/21/2017] [Indexed: 10/19/2022]
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15
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Abstract
Radiotherapy is able to improve locoregional control in breast cancer patients both after breast conserving surgery or mastectomy, with positive impact in high-risk patients for long-term survival. Recent advances in the precision of radiotherapy were based on the choice of the appropriate fractionation and technique. But the concept of adaptive radiotherapy is not only technical, and includes the biologic characterisation of the breast tumor. The knowledge that different subtypes of breast cancer can have distinct locoregional patterns of recurrence is consisted in the literature data. Luminal A tumor are at the lower risk of locoregional failure, and HER2 positive and triple negative at the higher risk. More evidence in the use of molecular markers for adjuvant radiotherapy can held in choosing the best treatment on individual. The combination of radiotherapy with molecular targeted therapies may enhance radiosensitivity, thus increasing the cytotoxic effects and improving treatment response. The appropriateness of an alternative fractionation, partial breast irradiation, intensification or de-intensification approaches, could be assessed better according the stratification of the risk categories.
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Affiliation(s)
- Roberto Orecchia
- University of Milan, European Institute of Oncology, Milan, Italy.
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Morigi C. Highlights from the 15th St Gallen International Breast Cancer Conference 15-18 March, 2017, Vienna: tailored treatments for patients with early breast cancer. Ecancermedicalscience 2017; 11:732. [PMID: 28491135 PMCID: PMC5406222 DOI: 10.3332/ecancer.2017.732] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Indexed: 01/16/2023] Open
Abstract
The 15th St Gallen International Breast Cancer Conference was held in Vienna for the second time, from 15th–18th March 2017. 4000 people from 105 countries all over the world were invited to take part in the event. The real highlight of the conference was the last day with the International Consensus Session which was chaired by around 50 experts on breast cancer worldwide. With reference to data from scientific research, the consensus panel tried to offer guidelines for the management of breast cancer with the aim of providing patients with optimal treatment. The topics covered focused on the treatment of breast cancer, consideration of surgery, radiotherapy, neo-adjuvant, and adjuvant systemic therapy for breast cancer, as well as genetics and prevention of breast cancer. In particular, in terms of precision medicine, an important topic of the conference was ‘is it possible to think that it could become routine in clinical practice to use immunotherapy and targeted therapy based on genetic signatures?’ In view of personalised therapy, it is important to take into consideration women’s treatment preferences. It is also important not only to offer guidelines which help breast cancer experts all over the world to choose the proper treatment for women with breast cancer but also to discuss the pros and cons of the therapy with the patient. This allows for a better understanding of the disease. ‘From the maximum tolerable to the minimum effective treatment: it is essential to escalate treatment when necessary and to de-escalate when unnecessary’. These few words could summarise the meaning of the 15th St Gallen International Breast Cancer Conference. Prof Martine Piccart-Gebhart was awarded with the St Gallen International Breast Cancer Award 2017 for her fundamental clinical research contribution and Prof Giuseppe Curigliano with the Umberto Veronesi Memorial Award which aims to recognise a physician’s leading role in advancing the science and care of breast cancer patients. Curigliano, in his lecture, spoke about the revolutionary immunotherapy in the clinical management of breast cancer (BC). For the development of these therapies, it is necessary to identify the genetic determinants of BC immune phenotypes in which The Cancer Genome Atlas (TCGA) has contributed towards this. For example, the T helper (Th-1) phenotype (ICR4), which also exhibits upregulation of immune-regulatory transcripts (eg. PDL1, PD1, FOXP3, IDO1, and CTLA4), was associated with prolonged patients’ survival. Chromosome segment 4q21, which includes genes encoding the Th-1 chemokines CXCL9-11, was significantly amplified only in the immune favourable phenotype (ICR4). The mutation and neo-antigen load progressively decreased from ICR4 to ICR1 but could not explain immune phenotypic differences. Mutations of TP53 were enriched in the immune favourable phenotype (ICR4). Instead, the presence of MAP3K1 and MAP2K4 mutations were closely associated with an immune unfavourable phenotype (ICR1). Using both the TCGA and the validation dataset, the degree of MAPK deregulation segregates BC according to their immune disposition. These findings suggest that mutational-driven deregulation of MAPK pathways is linked to the negative regulation of intratumoural immune response in BC. The main themes of this congress were: 1) Surgery of the primary tumour and margins; 2) Surgery of the axilla; 3) Radiotherapy: hypofractionated, ‘boost’ to tumour bed, partial breast, regional node, after mastectomy, advanced technology; 4) Pathology: subtypes, TILs; 5) Multi-gene signatures and therapy; 6) Endocrine therapy: pre- and post-menopausal and duration; 7) Chemotherapy: subtypes, stages; 8) Anti-HER-2 therapy; 9) Neo-adjuvant therapy; 10) Adjuvant bisphosponates; 11) Adjuvant diet and exercise.
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Affiliation(s)
- Consuelo Morigi
- Division of Breast Cancer Surgery, European Institute of Oncology, Via Ripamonti 435, 20146 Milano, Italy
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17
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Lazzeroni M, Dunn BK, Pruneri G, Jereczek-Fossa BA, Orecchia R, Bonanni B, DeCensi A. Adjuvant therapy in patients with ductal carcinoma in situ of the breast: The Pandora's box. Cancer Treat Rev 2017; 55:1-9. [PMID: 28262606 DOI: 10.1016/j.ctrv.2017.01.010] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Revised: 01/26/2017] [Accepted: 01/30/2017] [Indexed: 12/23/2022]
Abstract
Most patients with ductal carcinoma in situ of the breast (DCIS) are eligible for breast conservation treatment. The key management decision is whether to add radiotherapy and/or endocrine therapy to minimize the risk of a subsequent recurrence. Recent analyses indicating a lack of benefit in terms of breast cancer-associated mortality have suggested that more conservative approaches, omitting adjuvant therapy or even surgery, may be advisable in selected patients. These mortality observations are directly influenced by widespread use of mammographic screening which has opened a Pandora's box of subclinical DCIS and early invasive lesions. Confusion as to how aggressively such possibly indolent lesions should be treated has led to misunderstandings among patients and medical professionals. While awaiting further prospective evidence from clinical trials, we endorse an active treatment of DCIS as the standard of care. Our rationale is twofold: invasive recurrences are associated with an increase in breast cancer mortality, which is not the only relevant endpoint for DCIS. The benefit of complete surgical excision, adjuvant radiotherapy and endocrine treatment in preventing recurrence and invasive progression has been demonstrated in DCIS. The challenge now is how to identify DCIS patients who will not progress to invasive carcinoma even without complete excision and, at the other extreme, those patients at the highest risk who require mastectomy for local control. The current controversies over whether and which adjuvant therapy should be implemented can at least in part be addressed by developing effective doctor-patient communications that enable mutual understanding about the management of this biologically heterogeneous disease.
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Affiliation(s)
- Matteo Lazzeroni
- Divisions of Cancer Prevention and Genetics, European Institute of Oncology, Milan, Italy
| | - Barbara K Dunn
- Division of Cancer Prevention, National Cancer Institute, Bethesda, MD 20892, USA
| | - Giancarlo Pruneri
- Pathology, European Institute of Oncology, Milan, Italy; Department of Oncology and Hemato-Oncology, University of Milan, Italy
| | - Barbara Alicja Jereczek-Fossa
- Radiotherapy, European Institute of Oncology, Milan, Italy; Department of Oncology and Hemato-Oncology, University of Milan, Italy
| | - Roberto Orecchia
- Radiotherapy, European Institute of Oncology, Milan, Italy; Department of Oncology and Hemato-Oncology, University of Milan, Italy
| | - Bernardo Bonanni
- Divisions of Cancer Prevention and Genetics, European Institute of Oncology, Milan, Italy
| | - Andrea DeCensi
- Divisions of Cancer Prevention and Genetics, European Institute of Oncology, Milan, Italy; Division of Medical Oncology, E.O. Ospedali Galliera, Genoa, Italy; Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, United Kingdom.
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