1
|
Rothschild HT, Clelland EN, Mujir F, Record H, Wong J, Esserman LJ, Alvarado M, Ewing C, Mukhtar RA. Predictors of Early Versus Late Recurrence in Invasive Lobular Carcinoma of the Breast: Impact of Local and Systemic Therapy. Ann Surg Oncol 2023; 30:5999-6006. [PMID: 37464134 PMCID: PMC10495501 DOI: 10.1245/s10434-023-13881-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 06/04/2023] [Indexed: 07/20/2023]
Abstract
BACKGROUND Invasive lobular carcinoma (ILC) of the breast is known for high risk of late recurrence, yet some patients still recur within 5 years of diagnosis. Determining factors associated with early/late recurrence could help tailor treatment and surveillance strategies. METHODS Using an institutional database, we evaluated patients with ILC and ≥ 5 years of follow-up or recurrence within 5 years. We used multivariate logistic regression and the Kaplan-Meier method to evaluate which clinicopathologic features and treatment strategies were associated with recurrence < 5 years since diagnosis versus recurrence ≥ 5 years since diagnosis. Additionally, we explored the association between Clinical Treatment Score 5 (CTS5) with early versus late recurrence. RESULTS Among 513 cases of stage I-III ILC, there were 75 early and 54 late recurrences during a median follow-up period of 9.4 years. Early recurrence was associated with larger tumors (mean 4.2 cm vs. 2.9 cm, p < 0.0001), higher incidence of > 3 positive nodes (32.4% vs. 9.11%, p > 0.0001), and more aggressive tumor biology (low/negative progesterone receptor expression, higher grade, and higher Ki67). Late recurrence was associated with younger age (mean 55.6 vs. 59.2 years, p = 0.037) and elevated body mass index (BMI > 25 kg/m2 in 60.1.0% vs. 45.4%, p = 0.021). Omission of adjuvant endocrine therapy or radiotherapy after lumpectomy conferred increased risk of early rather than late recurrence. CONCLUSION Factors related to tumor aggressiveness and treatment were associated with early recurrence, whereas patient related factors were related to late recurrence. These data may help guide treatment strategies and surveillance approaches for patients with ILC.
Collapse
Affiliation(s)
| | - Elle N Clelland
- School of Medicine, University of California San Francisco, San Francisco, USA
| | - Firdows Mujir
- Department of Surgery, Division of Surgical Oncology, University of California San Francisco, San Francisco, CA, USA
| | - Helena Record
- School of Medicine, University of California San Francisco, San Francisco, USA
| | - Jasmine Wong
- School of Medicine, University of California San Francisco, San Francisco, USA
| | - Laura J Esserman
- School of Medicine, University of California San Francisco, San Francisco, USA
| | - Michael Alvarado
- School of Medicine, University of California San Francisco, San Francisco, USA
| | - Cheryl Ewing
- School of Medicine, University of California San Francisco, San Francisco, USA
| | - Rita A Mukhtar
- Department of Surgery, Division of Surgical Oncology, University of California San Francisco, San Francisco, CA, USA.
| |
Collapse
|
2
|
Recent Advances in Optimizing Radiation Therapy Decisions in Early Invasive Breast Cancer. Cancers (Basel) 2023; 15:cancers15041260. [PMID: 36831598 PMCID: PMC9954587 DOI: 10.3390/cancers15041260] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 02/07/2023] [Accepted: 02/10/2023] [Indexed: 02/18/2023] Open
Abstract
Adjuvant whole breast irradiation after breast-conserving surgery is a well-established treatment standard for early invasive breast cancer. Screening, early diagnosis, refinement in surgical techniques, the knowledge of new and specific molecular prognostic factors, and now the standard use of more effective neo/adjuvant systemic therapies have proven instrumental in reducing the rates of locoregional relapses. This underscores the need for reliably identifying women with such low-risk disease burdens in whom elimination of radiation from the treatment plan would not compromise oncological safety. This review summarizes the current evidence for radiation de-intensification strategies and details ongoing prospective clinical trials investigating the omission of adjuvant whole breast irradiation in molecularly defined low-risk breast cancers and related evidence supporting the potential for radiation de-escalation in HER2+ and triple-negative clinical subtypes. Furthermore, we discuss the current evidence for the de-escalation of regional nodal irradiation after neoadjuvant chemotherapy. Finally, we also detail the current knowledge of the clinical value of stromal tumor-infiltrating lymphocytes and liquid-based biomarkers as prognostic factors for locoregional relapse.
Collapse
|
3
|
Kunkler IH, Williams LJ, Jack WJL, Cameron DA, Dixon JM. Breast-Conserving Surgery with or without Irradiation in Early Breast Cancer. N Engl J Med 2023; 388:585-594. [PMID: 36791159 DOI: 10.1056/nejmoa2207586] [Citation(s) in RCA: 122] [Impact Index Per Article: 122.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
BACKGROUND Limited level 1 evidence is available on the omission of radiotherapy after breast-conserving surgery in older women with hormone receptor-positive early breast cancer receiving adjuvant endocrine therapy. METHODS We performed a phase 3 randomized trial of the omission of irradiation; the trial population included women 65 years of age or older who had hormone receptor-positive, node-negative, T1 or T2 primary breast cancer (with tumors ≤3 cm in the largest dimension) treated with breast-conserving surgery with clear excision margins and adjuvant endocrine therapy. Patients were randomly assigned to receive whole-breast irradiation (40 to 50 Gy) or no irradiation. The primary end point was local breast cancer recurrence. Regional recurrence, breast cancer-specific survival, distant recurrence as the first event, and overall survival were also assessed. RESULTS A total of 1326 women were enrolled; 658 were randomly assigned to receive whole-breast irradiation and 668 to receive no irradiation. The median follow-up was 9.1 years. The cumulative incidence of local breast cancer recurrence within 10 years was 9.5% (95% confidence interval [CI], 6.8 to 12.3) in the no-radiotherapy group and 0.9% (95% CI, 0.1 to 1.7) in the radiotherapy group (hazard ratio, 10.4; 95% CI, 4.1 to 26.1; P<0.001). Although local recurrence was more common in the group that did not receive radiotherapy, the 10-year incidence of distant recurrence as the first event was not higher in the no-radiotherapy group than in the radiotherapy group, at 1.6% (95% CI, 0.4 to 2.8) and 3.0% (95% CI, 1.4 to 4.5), respectively. Overall survival at 10 years was almost identical in the two groups, at 80.8% (95% CI, 77.2 to 84.3) with no radiotherapy and 80.7% (95% CI, 76.9 to 84.3) with radiotherapy. The incidence of regional recurrence and breast cancer-specific survival also did not differ substantially between the two groups. CONCLUSIONS Omission of radiotherapy was associated with an increased incidence of local recurrence but had no detrimental effect on distant recurrence as the first event or overall survival among women 65 years of age or older with low-risk, hormone receptor-positive early breast cancer. (Funded by the Chief Scientist Office of the Scottish Government and the Breast Cancer Institute, Western General Hospital, Edinburgh; ISRCTN number, ISRCTN95889329.).
Collapse
Affiliation(s)
- Ian H Kunkler
- From the University of Edinburgh (I.H.K., L.J.W., D.A.C., J.M.D.) and Western General Hospital (W.J.L.J.) - both in Edinburgh
| | - Linda J Williams
- From the University of Edinburgh (I.H.K., L.J.W., D.A.C., J.M.D.) and Western General Hospital (W.J.L.J.) - both in Edinburgh
| | - Wilma J L Jack
- From the University of Edinburgh (I.H.K., L.J.W., D.A.C., J.M.D.) and Western General Hospital (W.J.L.J.) - both in Edinburgh
| | - David A Cameron
- From the University of Edinburgh (I.H.K., L.J.W., D.A.C., J.M.D.) and Western General Hospital (W.J.L.J.) - both in Edinburgh
| | - J Michael Dixon
- From the University of Edinburgh (I.H.K., L.J.W., D.A.C., J.M.D.) and Western General Hospital (W.J.L.J.) - both in Edinburgh
| |
Collapse
|
4
|
Smolanka II, Movchan OV, Bagmut IY, Sheremet MI, Kolisnyk IL, Dosenko IV, Lyashcnko AO, Ivankova OM, Loboda AD, Shidlovskyi OV. Breast cancer relapses considering molecular biological characteristics. J Med Life 2023; 16:70-75. [PMID: 36873133 PMCID: PMC9979183 DOI: 10.25122/jml-2022-0189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 07/28/2022] [Indexed: 03/07/2023] Open
Abstract
We aimed to analyze the frequency of breast cancer relapses and their relationship with molecular and biological tumor characteristics. We studied 6,136 breast cancer patients, including 146 with relapses (Group 1) and 455 without relapses (Group 2). We divided the patients based on age, menstrual function, disease stage, histology form and grade, and molecular-biological subtype. The 5-year relapse-free rate for Group 1 was longer for Lum A and TN subtypes (60% and 40%, respectively) but shorter for Lum B and HER-2/neu-amplified subtypes (38% and 31%, respectively). Disease stage, tumor histology, and grade did not significantly affect relapse frequency in these patients. Relapses were more common in premenopausal patients and the Lum B subtype.
Collapse
|
5
|
Meattini I, Kim K, Livi L. Accelerated Partial Breast Irradiation: Florence Phase 3 Trial Experience and Future Perspectives. Am J Clin Oncol 2023; 46:10-15. [PMID: 36472353 DOI: 10.1097/coc.0000000000000968] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Accelerated partial breast irradiation Florence phase 3 trial is a single-center study comparing intensity-modulated based accelerated partial breast irradiation (PBI, 30 Gy in 5 fractions) and whole breast irradiation (50 Gy in 25 fractions) followed by a tumor bed boost (10 Gy in 5 fractions). This easy-to-deliver PBI approach showed excellent long-term disease control with favorable safety and cosmetic outcome profiles. A plateau has been probably reached concerning the reduction of the number of fractions in the postoperative PBI setting. A 5-fraction schedule is the standard regimen and probably the appropriate compromise in terms of efficacy, safety, and quality of life, also considering the negative results of most intraoperative single-fraction PBI trials. A new frontier is now open on the potential benefit of preoperative PBI delivery, although concerns remain on the optimal dose, fractionation, and technique. Hereby we report the accelerated PBI Florence phase 3 trial experience and future perspectives.
Collapse
Affiliation(s)
- Icro Meattini
- Department of Experimental and Clinical Biomedical Sciences "M. Serio," University of Florence
- Radiation Oncology Unit, Oncology Department, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Kyubo Kim
- Radiation Oncology Unit, Oncology Department, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
- Department of Radiation Oncology, Ewha Womans University Mokdong Hospital, Ewha Womans University College of Medicine, Seoul, Republic of Korea
| | - Lorenzo Livi
- Department of Experimental and Clinical Biomedical Sciences "M. Serio," University of Florence
- Radiation Oncology Unit, Oncology Department, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| |
Collapse
|
6
|
McDuff SGR, Blitzblau RC. Optimizing Adjuvant Treatment Recommendations for Older Women with Biologically Favorable Breast Cancer: Short-Course Radiation or Long-Course Endocrine Therapy? Curr Oncol 2022; 30:392-400. [PMID: 36661681 PMCID: PMC9857309 DOI: 10.3390/curroncol30010032] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 12/16/2022] [Accepted: 12/20/2022] [Indexed: 12/28/2022] Open
Abstract
Omission of radiotherapy among older women taking 5 years of adjuvant endocrine therapy following breast conserving surgery for early-stage, hormone sensitive breast cancers is well-studied. However, endocrine therapy toxicities are significant, and many women have difficulty tolerating endocrine therapy, particularly elderly patients with comorbidities. Omission of endocrine therapy among women receiving adjuvant radiation is less well-studied, but available randomized and non-randomized data suggest that this approach may confer equivalent local control and survival for select patients. Herein we review available randomized and non-randomized outcome data for women treated with radiation monotherapy and emphasize the need for future prospective, randomized studies of endocrine therapy omission.
Collapse
Affiliation(s)
- Susan G. R. McDuff
- Department of Radiation Oncology, Duke Cancer Center, Durham, NC 27710, USA
| | | |
Collapse
|
7
|
Sigaudi V, Zannetti M, Ferrara E, Manfredda I, Mones E, Loi G, Krengli M, Franco P. Ultra-Hypofractionation for Whole-Breast Irradiation in Early Breast Cancer: Interim Analysis of a Prospective Study. Biomedicines 2022; 10:biomedicines10102568. [PMID: 36289830 PMCID: PMC9599048 DOI: 10.3390/biomedicines10102568] [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: 09/14/2022] [Revised: 10/03/2022] [Accepted: 10/11/2022] [Indexed: 11/16/2022] Open
Abstract
We report on the early clinical outcomes of a prospective series of early breast cancer (EBC) patients treated with ultra-hypofractionated post-operative whole-breast irradiation (WBI) after breast-conserving surgery (BCS) and axillary management. Primary endpoints were patient's compliance and acute toxicity. Secondary endpoints included physician-rated cosmesis and ipsilateral breast tumour recurrence (IBTR). Acute toxicity was evaluated at the end of WBI, 3 weeks and 6 months thereafter, according to the Common Terminology Criteria for Adverse Events (v. 5.0). Patients were treated between September 2021 and May 2022. The treatment schedule for WBI consisted of either 26 Gy in 5 fractions over one week (standard approach) or 28.5 Gy in 5 fractions over 5 weeks (reserved to elders). Inverse planned intensity-modulated radiation therapy (IMRT) was used employing a static technique. A total of 70 patients were treated. Fifty-nine were treated with the 26 Gy/5 fr/1 w and 11 with the 28.5 Gy/5 fr/5 ws schedule. Median age was 67 and 70 in the two groups. Most of the patients had left-sided tumours (53.2%) in the 26 Gy/5 fr/1 w or right-sided lesions (63.6%) in the 28.5 Gy/5 fr/5 ws group. Most of the patients had a clinical T1N0 disease and a pathological pT1pN0(sn) after surgery. Ductal invasive carcinoma was the most frequent histology. Luminal A intrinsic subtyping was most frequent. Most of the patients underwent BCS and sentinel lymph node biopsy and adjuvant endocrine therapy. All patients completed the treatment program as planned. Maximum detected acute skin toxicities were grade 2 erythema (6.7%), grade 2 induration (4.4%), and grade 2 skin colour changes. No early IBTR was observed. Ultra-hypofractionated WBI provides favourable compliance and early clinical outcomes in EBC after BCS in a real-world setting.
Collapse
Affiliation(s)
- Valeria Sigaudi
- Department of Translational Medicine (DIMET), University of Eastern Piedmont, 28100 Novara, Italy
| | - Micol Zannetti
- Department of Translational Medicine (DIMET), University of Eastern Piedmont, 28100 Novara, Italy
| | - Eleonora Ferrara
- Department of Radiation Oncology, Maggiore della Carità University Hospital, 28100 Novara, Italy
| | - Irene Manfredda
- Department of Radiation Oncology, Maggiore della Carità University Hospital, 28100 Novara, Italy
| | - Eleonora Mones
- Department of Medical Physics, Maggiore della Carità University Hospital, 28100 Novara, Italy
| | - Gianfranco Loi
- Department of Medical Physics, Maggiore della Carità University Hospital, 28100 Novara, Italy
| | - Marco Krengli
- Department of Translational Medicine (DIMET), University of Eastern Piedmont, 28100 Novara, Italy
- Department of Radiation Oncology, Maggiore della Carità University Hospital, 28100 Novara, Italy
| | - Pierfrancesco Franco
- Department of Translational Medicine (DIMET), University of Eastern Piedmont, 28100 Novara, Italy
- Department of Radiation Oncology, Maggiore della Carità University Hospital, 28100 Novara, Italy
- Correspondence: ; Tel.: +39-0321-3733424
| |
Collapse
|
8
|
Aristei C, Bölükbaşı Y, Kaidar-Person O, Pfeffer R, Arenas M, Boersma LJ, Ciabattoni A, Coles CE, Franco P, Krengli M, Leonardi MC, Marazzi F, Masiello V, Meattini I, Montero A, Offersen B, Trigo ML, Bourgier C, Genovesi D, Kouloulias V, Morganti AG, Meduri B, Pasinetti N, Pedretti S, Perrucci E, Rivera S, Tombolini V, Vidali C, Valentini V, Poortmans P. Ways to improve breast cancer patients' management and clinical outcome: The 2020 Assisi Think Tank Meeting. Crit Rev Oncol Hematol 2022; 177:103774. [PMID: 35917884 DOI: 10.1016/j.critrevonc.2022.103774] [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: 06/08/2021] [Revised: 07/19/2022] [Accepted: 07/29/2022] [Indexed: 10/16/2022] Open
Abstract
We report on the third Assisi Think Tank Meeting (ATTM) on breast cancer, a brainstorming project which involved European radiation and clinical oncologists who were dedicated to breast cancer research and treatment. Held on February 2020, the ATTM aimed at identifying key clinical questions in current clinical practice and "grey" areas requiring research to improve management and outcomes. Before the meeting, three key topics were selected: 1) managing patients with frailty due to either age and/or multi-morbidity; 2) stereotactic radiation therapy and systemic therapy in the management of oligometastatic disease; 3) contralateral breast tumour prevention in BCRA-mutated patients. Clinical practice in these areas was investigated by means of an online questionnaire. In the lapse period between the survey and the meeting, the working groups reviewed data, on-going studies and the clinical challenges which were then discussed in-depth and subjected to intense brainstorming during the meeting; research protocols were also proposed. Methodology, outcome of discussions, conclusions and study proposals are summarized in the present paper. In conclusion, this report presents an in-depth analysis of the state of the art, grey areas and controversies in breast cancer radiation therapy and discusses how to confront them in the absence of evidence-based data to guide clinical decision-making.
Collapse
Affiliation(s)
- Cynthia Aristei
- Radiation Oncology Section, Department of Medicine and Surgery, University of Perugia and Perugia General Hospital, Perugia, Italy.
| | - Yasemin Bölükbaşı
- Radiation Oncology Acıbadem Mehmet Ali Aydınlar University School of Medicine, Istanbul, Turkey
| | - Orit Kaidar-Person
- Breast Radiation Unit, Radiation Oncology, Sheba Medical Center, Ramat Gan, Israel
| | - Raphael Pfeffer
- Oncology Institute, Assuta Medical Center, Tel Aviv and Ben Gurion University Medical School, Israel
| | - Meritxell Arenas
- Universitat Rovira I Virgili, Radiation Oncology Department, Hospital Universitari Sant Hoan de Reus, IISPV, Spain
| | - Liesbeth J Boersma
- Radiation Oncology (Maastro), GROW School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Antonella Ciabattoni
- Department of Radiation Oncology, San Filippo Neri Hospital, ASL Rome 1, Rome, Italy
| | | | - Pierfrancesco Franco
- Depatment of Translational Medicine, University of Eastern Piedmont and Department of Radiation Oncology, 'Maggiore della Carità' University Hospital, Novara, Italy
| | - Marco Krengli
- Depatment of Translational Medicine, University of Eastern Piedmont and Department of Radiation Oncology, 'Maggiore della Carità' University Hospital, Novara, Italy
| | | | - Fabio Marazzi
- Unità Operativa di Radioterapia Oncologica, Dipartimento di Diagnostica per Immagine, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Gemelli IRCSS Roma, Italy
| | - Valeria Masiello
- Unità Operativa di Radioterapia Oncologica, Dipartimento di Diagnostica per Immagine, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Gemelli IRCSS Roma, Italy
| | - Icro Meattini
- Department of Experimental and Clinical Biomedical Sciences "M. Serio", University of Florence & Radiation Oncology Unit - Oncology Department, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Angel Montero
- Department of Radiation Oncology, University Hospital HM Sanchinarro, HM Hospitales, Madrid, Spain
| | - Birgitte Offersen
- Department of Experimental Clinical Oncology, Department of Oncology, Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
| | - Maria Lurdes Trigo
- Service of Brachytherapy, Department of Image and Radioncology, Instituto Português Oncologia Porto Francisco Gentil E.P.E., Portugal
| | - Céline Bourgier
- Radiation Oncology, ICM-Val d'Aurelle, Univ Montpellier, Montpellier, France
| | - Domenico Genovesi
- Radiation Oncology, Ospedale Clinicizzato Chieti and University "G. d'Annunzio", Chieti, Italy
| | - Vassilis Kouloulias
- 2(nd) Department of Radiology, Radiotherapy Unit, Medical School, National and Kapodistrian University of Athens, Greece
| | - Alessio G Morganti
- Radiation Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna; DIMES, Alma Mater Studiorum Bologna University; Bologna, Italy
| | - Bruno Meduri
- Radiation Oncology Unit, University Hospital of Modena, Modena, Italy
| | - Nadia Pasinetti
- Radiation Oncology Service, ASST Valcamonica Esine and Brescia University, Brescia, Italy
| | - Sara Pedretti
- Istituto del Radio "O.Alberti" - Spedali Civili Hospital and Brescia University, Brescia
| | | | - Sofia Rivera
- Radiation Oncology, Institut Gustave Roussy, Villejuif, France
| | - Vincenzo Tombolini
- Radiation Oncology, Department of Radiological, Oncological and Pathological Science, University "La Sapienza", Roma, Italy
| | - Cristiana Vidali
- former Senior Assistant Department of Radiation Oncology, Azienda Sanitaria Universitaria Integrata di Trieste, Trieste, Italy
| | - Vincenzo Valentini
- Division of Radiation Oncology, IEO European Institute of Oncology, IRCCS, Milan, Italy
| | - Philip Poortmans
- Department of Radiation Oncology, Iridium Kankernetwerk, Antwerp, Belgium; University of Antwerp, Faculty of Medicine and Health Sciences, Antwerp, Belgium
| |
Collapse
|
9
|
Management Strategies for Older Patients with Low-Risk Early-Stage Breast Cancer: A Physician Survey. Curr Oncol 2021; 29:1-13. [PMID: 35049675 PMCID: PMC8774930 DOI: 10.3390/curroncol29010001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Revised: 12/06/2021] [Accepted: 12/08/2021] [Indexed: 01/06/2023] Open
Abstract
When managing older patients with lower-risk hormone-receptor-positive (HR+), HER2 negative (HER2-) early-stage breast cancer (EBC), the harms and benefits of adjuvant therapies should be taken into consideration. A survey was conducted among Canadian oncologists on the definitions of "low risk" and "older", practice patterns, and future trial designs. We contacted 254 physicians and 21% completed the survey (50/242). Most respondents (68%, 34/50) agreed with the definition of "low risk" HR+/HER2- EBC being node-negative and either: ≤3 cm and low histological grade, ≤2 cm and intermediate grade, or ≤1 cm and high grade. The most popular chronological and biological age definition for older patients was ≥70 (45%, 22/49; 45% 21/47). In patients ≥ 70 with low risk EBC, most radiation and medical oncologists would recommend post-lumpectomy radiotherapy (RT) and endocrine therapy (ET). Seventy-eight percent (38/49) felt that trials are needed to evaluate RT and ET's role in patients ≥ 70. The favored design was ET alone, vs. RT plus ET (39%, 15/38). The preferred primary and secondary endpoints were disease-free survival and quality of life, respectively. Although oncologists recommended both RT and ET, there is interest in performing de-escalation trials in patients ≥ 70.
Collapse
|
10
|
Wang L, Sun M, Yang S, Chen Y, Li T. Intraoperative Radiotherapy Is Not a Better Alternative to Whole Breast Radiotherapy as a Therapeutic Option for Early-Stage Breast Cancer. Front Oncol 2021; 11:737982. [PMID: 34976796 PMCID: PMC8716392 DOI: 10.3389/fonc.2021.737982] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 11/23/2021] [Indexed: 12/11/2022] Open
Abstract
Objective Intraoperative radiotherapy (IORT) in early-stage breast cancer has been studied over the years. However, it has not been demonstrated whether IORT is more suitable as a therapeutic option for early-stage breast cancer than whole breast radiotherapy (WBRT). Therefore, we performed a meta-analysis to compare the efficacy and safety of IORT to those of WBRT as therapeutic options for early-stage breast cancer patients receiving breast-conserving surgery (INPLASY2020120008). Methods PubMed, Embase, and Cochrane Library databases were searched from inception to October 2021. Computerized and manual searches were adopted to identify eligible randomized control trials from online databases. Risk ratio (RR) and 95% confidence intervals (CI) were calculated by random-effect models to assess the relative risk. Potential publication bias was quantified by Begg’s and Egger’s tests. Results Based on our inclusion criteria, 10 randomized control trials involving 5,698 patients were included in this meta-analysis. This meta-analysis showed that the IORT group was associated with a higher local recurrence risk (RR = 2.111, 95% CI, 1.130–3.943, p = 0.0191), especially in the long-term follow-up subgroup or published after 2020 subgroup or Caucasian subgroup (RR = 2.404, 95% CI, 1.183–4.885, p = 0.0154). Subgroup analysis showed that the IORT group had a higher recurrence risk than the WBRT group in the polycentric randomized controlled trial subgroup (RR = 1.213, 95% CI, 1.030–1.428, p = 0.0204). Pooled analysis showed that there was no statistically significant difference in overall survival, recurrence-free survival, distant metastasis-free survival, and cancer-specific survival between IORT and WBRT groups. Additionally, the risk of skin toxicity was reduced, but the incidences of fat toxicity, edema, and scar calcification were significantly increased in the patients who underwent IORT in comparison to those who underwent WBRT. Conclusion This meta-analysis revealed that IORT was not a better alternative to WBRT. More large-scale and well-designed clinical trials with longer follow-up periods are encouraged to further investigate the value of IORT. Systematic Review Registration https://inplasy.com/inplasy-2020-12-0008/.
Collapse
Affiliation(s)
- Linwei Wang
- Department of Radiation and Medical Oncology, Hubei Key Laboratory of Tumor Biological Behaviors/Hubei Cancer Clinical Study Center, Zhongnan Hospital, Wuhan University, Wuhan, China
| | - Min Sun
- Department of General Surgery, Taihe Hospital, Hubei University of Medicine, Shiyan, China
| | - Shuailong Yang
- Department of Radiation and Medical Oncology, The Central Hospital of Wuhan, Wuhan, China
| | - Yuanyuan Chen
- Department of Radiation and Medical Oncology, Hubei Key Laboratory of Tumor Biological Behaviors/Hubei Cancer Clinical Study Center, Zhongnan Hospital, Wuhan University, Wuhan, China
- *Correspondence: Tian Li, ; Yuanyuan Chen,
| | - Tian Li
- School of Basic Medicine, Fourth Military Medical University, Xi’an, China
- *Correspondence: Tian Li, ; Yuanyuan Chen,
| |
Collapse
|
11
|
Experiences and Perceptions of Older Adults with Lower-Risk Hormone Receptor-Positive Breast Cancer about Adjuvant Radiotherapy and Endocrine Therapy: A Patient Survey. Curr Oncol 2021; 28:5215-5226. [PMID: 34940075 PMCID: PMC8700141 DOI: 10.3390/curroncol28060436] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Revised: 12/02/2021] [Accepted: 12/05/2021] [Indexed: 12/24/2022] Open
Abstract
Older patients with lower-risk hormone receptor-positive (HR+) breast cancer are frequently offered both radiotherapy (RT) and endocrine therapy (ET) after breast-conserving surgery (BCS). A survey was performed to assess older patients’ experiences and perceptions regarding RT and ET, and participation interest in de-escalation trials. Of the 130 patients approached, 102 eligible patients completed the survey (response rate 78%). The median age of respondents was 74 (interquartile range 71–76). Most participants (71%, 72/102) received both RT and ET. Patients felt the role of RT and ET, respectively, was to: reduce ipsilateral tumor recurrence (91%, 90/99 and 62%, 61/99) and improve survival (56%, 55/99 and 49%, 49/99). More patients had significant concerns regarding ET (66%, 65/99) than RT (39%, 37/95). When asked which treatment had the most negative effect on their quality of life, the results showed: ET (35%, 25/72), RT (14%, 10/72) or both (8%, 6/72). Participants would rather receive RT (57%, 41/72) than ET (43%, 31/72). Forty-four percent (44/100) of respondents were either, “not comfortable” or “not interested” in participating in potential de-escalation trials. Although most of the adjuvant therapy de-escalation trials evaluate the omission of RT, de-escalation studies of ET are warranted and patient centered.
Collapse
|
12
|
Palumbo I, Borghesi S, Gregucci F, Falivene S, Fontana A, Aristei C, Ciabattoni A. Omission of adjuvant radiotherapy for older adults with early-stage breast cancer particularly in the COVID era: A literature review (on the behalf of Italian Association of Radiotherapy and Clinical Oncology). J Geriatr Oncol 2021; 12:1130-1135. [PMID: 34020908 PMCID: PMC8131185 DOI: 10.1016/j.jgo.2021.05.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 04/21/2021] [Accepted: 05/07/2021] [Indexed: 12/25/2022]
Abstract
This review is aimed at evaluating whether radiation therapy (RT) can be omitted in older adult early-stage low-risk breast cancer (BC) patients. The published data are particularly relevant at present, during the COVID-19 pandemic emergency, to define a treatment strategy and to prioritize essential therapy. Cochrane Database of Systematic Reviews and PubMED were systematically researched from outset through April 2020 using Mesh terms. Only randomized controlled trials (RCT), with one arm without adjuvant whole-breast irradiation (WBI), were included in the analysis. Recent literature regarding the COVID pandemic and BC RT was assessed. The reported RCTs identified a group of BC patients (pT1-2N0M0 R0, grade 1-2, estrogen receptor (ER) positive, human epidermal growth factor receptor 2 (HER2) negative tumours) in which the absolute risk of local recurrence (LR) was considered low enough to omit RT. The most common risk factors were tumor diameter, nodal and receptor status. Adjuvant RT had a significant impact on LR but not on distant metastasis (DM) or death. During the COVID 19 pandemic, results from RTCs were re-considered to define treatment recommendations for BC patients. International scientific societies and radiation oncology experts suggested RT omission, whenever possible, in older adult early-stage BC patients. Adjuvant RT might be omitted in a highly selected group of older adult early-stage BC patients with favourable prognostic factors. Hypofractionated regimens should be the standard. RT omission, partial breast irradiation (PBI), and ultra- hypofractionated regimens could be considered in selected cases due to the pandemic.
Collapse
Affiliation(s)
- Isabella Palumbo
- Radiation Oncology Section, University of Perugia and Perugia General Hospital, Perugia, Italy
| | - Simona Borghesi
- Radiation Oncology Department, Arezzo-Valdarno, Azienda USL Toscana Sud Est, Arezzo, Italy
| | - Fabiana Gregucci
- Radiation Oncology Division, Miulli-Felli Hospital, Acquaviva delle Fonti, Bari, Italy
| | - Sara Falivene
- Radiation Oncology Division, Ospedale del Mare, Asl Napoli 1 centro, Napoli, Italy
| | - Antonella Fontana
- Radiation Oncology Division, Santa Maria Goretti Hospital, Latina, Italy
| | - Cynthia Aristei
- Radiation Oncology Section, University of Perugia and Perugia General Hospital, Perugia, Italy,Corresponding author at: Radiation Oncology Section, Department of Medicine and Surgery, University of Perugia, Perugia General Hospital, Sant'Andrea delle Fratte, 06156 Perugia, Italy
| | - Antonella Ciabattoni
- Radiation Oncology Division, San Filippo Neri, Hospital, ASL Roma 1, Roma, Italy
| |
Collapse
|
13
|
Pignol JP, Hoekstra N, Wilke D, Dahn H, Nolan M, Vicini F. Estimation of Annual Secondary Lung Cancer Deaths Using Various Adjuvant Breast Radiotherapy Techniques for Early-Stage Cancers. Front Oncol 2021; 11:713328. [PMID: 34434899 PMCID: PMC8381359 DOI: 10.3389/fonc.2021.713328] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Accepted: 07/09/2021] [Indexed: 11/13/2022] Open
Abstract
Purpose Secondary lung cancer (SLC) can offset the benefit of adjuvant breast radiotherapy (RT), and risks compound sharply after 25 to 30 years. We hypothesized that SLC risk is mainly an issue for early-stage breast cancer, and that lives could be saved using different RT techniques. Patients and Methods The SEER database was used to extract breast patient age, stage survival, and radiotherapy utilization over time and per stage and to assess the factors associated with increased SLC risk with a multivariable competing risk Cox model. The number of SLC was calculated using the BEIR model modified with patient survival, age, and use of RT from the SEER database. Stage distribution and number of new breast cancer cases were obtained from the NAACCR. Mean lung dose for various irradiation techniques was obtained from measurement or literature. Results Out of the 765,697 non-metastatic breast cancers in the SEER database from 1988 to 2012, 49.8% received RT. RT significantly increased the SLC risk for longer follow-up (HR=1.58), early stage including DCIS, stage I and IIA (HR = 1.11), and younger age (HR=1.061) (all p<0.001). More advanced stages did not have significantly increased risk. In 2019, 104,743 early-stage breast patients received radiotherapy, and an estimated 3,413 will develop SLC (3.25%) leading to an excess of 2,900 deaths (2.77%). VMAT would reduce this mortality by 9.9%, hypofractionation 26 Gy in five fractions by 38.8%, a prone technique by 70.3%, 3D-CRT APBI by 43.3%, HDR brachytherapy by 71.1%, LDR by 80.7%, and robotic 4π APBI by 85.2%. Conclusions SLC after breast RT remains a clinically significant issue for early-stage breast cancers. This mortality could be significantly reduced using a prone technique or APBI.
Collapse
Affiliation(s)
- Jean-Philippe Pignol
- Radiation Oncology Department, Dalhousie University, Halifax, NS, Canada.,Radiation Oncology Department, Erasmus MC, Rotterdam, Netherlands
| | - Nienke Hoekstra
- Radiation Oncology Department, Erasmus MC, Rotterdam, Netherlands
| | - Derek Wilke
- Radiation Oncology Department, Dalhousie University, Halifax, NS, Canada
| | - Hannah Dahn
- Radiation Oncology Department, Dalhousie University, Halifax, NS, Canada
| | - Maureen Nolan
- Radiation Oncology Department, Dalhousie University, Halifax, NS, Canada
| | - Frank Vicini
- Radiation Oncology, 21st Century Oncology, Farmington Hills, MI, United States
| |
Collapse
|
14
|
Bellardita L, Colciago RR, Frasca S, De Santis MC, Gay S, Palorini F, La Rocca E, Valdagni R, Rancati T, Lozza L. Breast cancer patient perspective on opportunities and challenges of a genetic test aimed to predict radio-induced side effects before treatment: Analysis of the Italian branch of the REQUITE project. Radiol Med 2021; 126:1366-1373. [PMID: 34268681 DOI: 10.1007/s11547-021-01395-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 06/29/2021] [Indexed: 02/06/2023]
Abstract
AIM To explore breast cancer patient's perspective on future genetic testing for prediction of toxicity after breast radiotherapy (RT). MATERIALS AND METHODS The study involved patient enrolled in the Italian branch of the REQUITE project conducted at the National Cancer Institute in Milan. Semi-structured interviews were conducted within one month from the end of radiotherapy treatment by two radiation oncologists and a radiotherapy technician previously trained by a clinical psychologist with experience in the oncology field. Semi-structured interviews are characterized by a set of pre-defined questions and developed ad hoc by researchers in Leicester within the REQUITE project. The interview questions investigated interest in undergoing the genetic test and expectations on its usefulness and disadvantages. RESULTS Eighteen interviews were conducted and analysed. Forty-five initial codes were combined into nine themes which were then clustered in two main macro-areas (i) Opportunities and (ii) Challenges. Overall, all patients understand the aim of the genetic test and considered its intrinsic opportunity to make the physician more confident with the treatment. Regarding side effects, most of patients felt prepared to RT but not without fear. Many women considered important to have the largest and reliable information, also about negative experiences. Prevailing emotions were anxiety and fear but not connected to genetic test's result. CONCLUSIONS A genetic test could be an opportunity because generate knowledge and give patients a dynamic role in the decision-making approach. Prediction of single patient radiosensitivity before RT could prompt suggestion to entail a more and more tailored radiation treatment in the era of personalized approach.
Collapse
Affiliation(s)
- Lara Bellardita
- Prostate Cancer Program, Fondazione IRCCS Istituto Nazionale Dei Tumori, Milan, Italy
| | | | - Sarah Frasca
- Radiation Oncology 1 Fondazione IRCCS Istituto Nazionale Dei Tumori, Milan, Italy
| | | | - Simona Gay
- Prostate Cancer Program, Fondazione IRCCS Istituto Nazionale Dei Tumori, Milan, Italy
| | - Federica Palorini
- Prostate Cancer Program, Fondazione IRCCS Istituto Nazionale Dei Tumori, Milan, Italy
| | - Eliana La Rocca
- Radiation Oncology 1 Fondazione IRCCS Istituto Nazionale Dei Tumori, Milan, Italy.,Department of Oncology and Hemato-Oncology, Università Degli Studi Di Milano, Milan, Italy
| | - Riccardo Valdagni
- Prostate Cancer Program, Fondazione IRCCS Istituto Nazionale Dei Tumori, Milan, Italy.,Department of Radiotherapy, Università Degli Studi Di Milano Bicocca, Milan, Italy.,Radiation Oncology 1 Fondazione IRCCS Istituto Nazionale Dei Tumori, Milan, Italy.,Department of Oncology and Hemato-Oncology, Università Degli Studi Di Milano, Milan, Italy
| | - Tiziana Rancati
- Prostate Cancer Program, Fondazione IRCCS Istituto Nazionale Dei Tumori, Milan, Italy
| | - Laura Lozza
- Radiation Oncology 1 Fondazione IRCCS Istituto Nazionale Dei Tumori, Milan, Italy
| |
Collapse
|
15
|
Savard MF, Clemons M, Hutton B, Jemaan Alzahrani M, Caudrelier JM, Vandermeer L, Liu M, Saunders D, Sienkiewicz M, Stober C, Cole K, Shorr R, Arnaout A, Chang L. De-escalating adjuvant therapies in older patients with lower risk estrogen receptor-positive breast cancer treated with breast-conserving surgery: A systematic review and meta-analysis. Cancer Treat Rev 2021; 99:102254. [PMID: 34242928 DOI: 10.1016/j.ctrv.2021.102254] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 06/15/2021] [Accepted: 06/16/2021] [Indexed: 12/24/2022]
Abstract
PURPOSE Radiation therapy (RT) and endocrine therapy (ET) are standard treatments for hormone receptor-positive (HR+) breast cancer after breast-conserving surgery (BCS). However, many older patients are at greater risk of treatment-related toxicities and non-cancer related death, and less likely to benefit from these standard treatments. A systematic review was performed evaluating outcomes of omitting RT or ET in older patients aged ≥50 treated with BCS for lower-risk breast cancer. METHODS Medline, Embase, and the Cochrane Register of Controlled Trials were queried from 1980 to April 30th, 2020 for randomized controlled studies (RCTs) and prospective cohort studies (PCSs) evaluating omission of RT and/or ET compared to RT plus ET in patients. Meta-analysis was performed using random-effects models with findings reported as risk ratios (RR) with 95% confidence intervals (CI). RESULTS From 3860 citations, 10 prospective studies met eligibility criteria. Omission of RT alone was evaluated in 7 RCTs (n = 4604) and one PCS (n = 667); omission of ET alone was assessed in 1 PCS (n = 271); and omission of either ET or RT was compared to ET plus RT in 1 RCT (n = 495). Adjuvant RT compared to no RT reduced 5- and 10-year in-breast tumor recurrence [5-year: RR 0.16, 95 %CI 0.09-0.27 l 10-year: 0.28, 95 %CI 0.16-0.5], but had no effect on survival [5-year: RR 0.94, 95 %CI 0.77-1.15; 10-year: 1.01, 95 %CI 0.9-1.12]. CONCLUSION The current body of evidence suggests that RT can be omitted in older patients with lower-risk disease. However, more trials on the omission of ET are required to better inform treatment decisions.
Collapse
Affiliation(s)
- Marie-France Savard
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital and the University of Ottawa, Ottawa, Canada; Cancer Therapeutics Program, Ottawa Hospital Research Institute, Ottawa, Canada.
| | - Mark Clemons
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital and the University of Ottawa, Ottawa, Canada; Cancer Therapeutics Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Brian Hutton
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute and University of Ottawa, Ottawa, Canada
| | - Meshari Jemaan Alzahrani
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital and the University of Ottawa, Ottawa, Canada
| | - Jean-Michel Caudrelier
- Department of Radiology, Division of Radiation Oncology, The Ottawa Hospital Cancer Centre and the University of Ottawa, Ottawa, Canada
| | - Lisa Vandermeer
- Cancer Therapeutics Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Michelle Liu
- Cancer Therapeutics Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Deanna Saunders
- Cancer Therapeutics Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Marta Sienkiewicz
- Cancer Therapeutics Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Carol Stober
- Cancer Therapeutics Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Katherine Cole
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital and the University of Ottawa, Ottawa, Canada
| | | | - Angel Arnaout
- Cancer Therapeutics Program, Ottawa Hospital Research Institute, Ottawa, Canada; Department of Surgery, Division of General Surgery, The Ottawa Hospital and the University of Ottawa, Ottawa, Canada
| | - Lynn Chang
- Department of Radiology, Division of Radiation Oncology, The Ottawa Hospital Cancer Centre and the University of Ottawa, Ottawa, Canada
| |
Collapse
|
16
|
Davey MG, Davey CM, Ryan ÉJ, Lowery AJ, Kerin MJ. Combined breast conservation therapy versus mastectomy for BRCA mutation carriers - A systematic review and meta-analysis. Breast 2021; 56:26-34. [PMID: 33582622 PMCID: PMC7887648 DOI: 10.1016/j.breast.2021.02.001] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 01/05/2021] [Accepted: 02/01/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The non-inferiority of combined breast conservation surgery (BCS) and radiotherapy (breast conservation therapy or BCT) compared to mastectomy in sporadic breast cancer cases is well recognised. Uncertainty remains regarding optimal surgical practice in BRCA mutation carriers. AIMS To evaluate the oncological safety of combined BCT versus mastectomy in BRCA mutation carriers following breast cancer diagnosis. METHODS A systematic review was performed as per PRISMA and MOOSE guidelines. Observational studies comparing BCS and mastectomy in BRCA carriers were identified. Dichotomous variables were pooled as odds ratios (OR) using the Mantel-Haenszel method. Log hazard ratios (lnHR) for locoregional recurrence (LRR), contralateral breast cancer, disease-free and overall survival and their standard errors were calculated from Kaplan-Meier or cox-regression analyses and pooled using the inverse variance method. RESULTS Twenty three studies of 3807 patients met inclusion criteria; 2200 (57.7%) were BRCA1 and 1212 (31.8%) were BRCA2 carriers. Median age at diagnosis was 41 years with 96 months follow up. BCS was performed on 2157 (56.7%) while 1408 (41.5%) underwent mastectomy. An increased risk of LRR was observed in patients treated with BCS (HR:4.54, 95% Confidence Interval: 2.77-7.42, P < 0.001, heterogeneity (I2) = 0%). However, the risks of contralateral breast cancer (HR:1.51, 95%CI: 0.44-5.11, P = 0.510, I2 = 80%), disease recurrence (HR:1.16, 95%CI: 0.78-1.72, P = 0.470, I2 = 44%), disease-specific recurrence (HR:1.58, 95%CI: 0.79-3.15, P = 0.200, I2 = 38%) and death (HR:1.10, 95%CI: 0.72-1.69, P = 0.660, I2 = 38%) were equivalent for combined BCT and mastectomy. CONCLUSIONS Survival outcomes following combined BCT is comparable to mastectomy in BRCA carriers. However, the risk of LRR is increased. Patient counselling should be tailored to incorporate these findings.
Collapse
Affiliation(s)
- M G Davey
- The Lambe Institute for Translational Research, National University of Ireland, Galway, Ireland; Department of Surgery, Galway University Hospitals, Galway, Ireland.
| | - C M Davey
- School of Medicine, National University of Ireland, Galway, Ireland
| | - É J Ryan
- Department of Surgery, Galway University Hospitals, Galway, Ireland; Royal College of Surgeons in Ireland, Dublin, Ireland
| | - A J Lowery
- The Lambe Institute for Translational Research, National University of Ireland, Galway, Ireland; Department of Surgery, Galway University Hospitals, Galway, Ireland
| | - M J Kerin
- The Lambe Institute for Translational Research, National University of Ireland, Galway, Ireland; Department of Surgery, Galway University Hospitals, Galway, Ireland
| |
Collapse
|
17
|
New classifications of axillary lymph nodes and their anatomical-clinical correlations in breast surgery. World J Surg Oncol 2021; 19:93. [PMID: 33781279 PMCID: PMC8008673 DOI: 10.1186/s12957-021-02209-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Accepted: 03/19/2021] [Indexed: 02/07/2023] Open
Abstract
Background In the last decade, two research groups, the French group by Clough et al. (Br J Surg. 97:1659–65, 2010) and the Chinese one by Li et al. (ISRN Oncol 2013:279013, 2013), proposed two types of classification of axillary lymph nodes in breast cancer, identifying novel anatomic landmarks for dividing the axillary space in lymph node dissection. Main body Knowledge of the exact location of the sentinel node helps to focus the surgical dissection and to reduce the morbidity of sentinel lymph node biopsy procedures, in particular the risk of arm lymphedema, without compromising sensitivity. Conclusion In this article, we aimed at focusing on the clinical impact that the most recent classifications of axillary lymph nodes have obtained in literature, highlighting the importance of defining new demarcations to preserve the axillary lymph nodes as much as possible in breast surgery.
Collapse
|
18
|
Marino L, Lancellotta V, Franco P, Meattini I, Meduri B, Bernini M, Fabi A, Corvò R, Magrini SM, Pappagallo GL, Arcangeli S, D'Angelillo RM. Loco-regional adjuvant radiation therapy in breast cancer patients with positive axillary lymph-nodes at diagnosis (CN2) undergoing preoperative chemotherapy and with complete pathological lymph-nodes response. Development of GRADE (Grades of recommendation, assessment, Development and Evaluation) recommendation by the Italian Association of radiation therapy and Clinical Oncology (AIRO). Breast 2021; 55:119-127. [PMID: 33445150 PMCID: PMC7808946 DOI: 10.1016/j.breast.2020.12.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 12/22/2020] [Accepted: 12/29/2020] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE To perform a meta-analysis to determine the effect of loco-regional radiation therapy (RT) compared to no loco-regional RT for operated patients in clinical stage cN2 breast cancer at diagnosis and ypN0 after preoperative chemotherapy (PST). MATERIAL AND METHODS Eligible studies were identified through a systematic search of the medical literature performed independently by two researchers using a validated search strategy. An electronic search of Medline via PubMed and Embase (Breast cancer AND preoperative chemotherapy AND radiation therapy) was conducted with no language or publication status restrictions. The effect of loco-regional RT on overall (OS), disease free (DFS), loco-regional recurrence-free (LRRFS) survival and local recurrence was evaluated. An electronic search of Medline via PubMed and Embase (Toxicity AND radiation therapy breast cancer AND preoperative therapy; toxicity AND breast surgery AND preoperative chemotherapy) was conducted for outcomes of harm: major acute and late skin toxicity, lymphedema and cardiac events. RESULTS Of 333 studies identified, 4 retrospective studies reporting on a total of 1107 patients were included in the meta-analysis. Six and 3 reported data of acute and late skin toxicity, while 2 studies provided information on cardiac events. Pooled results showed no difference in terms of hazard ratio for loco-regional RT versus no loco-regional RT [hazard ratio (HR) = 0.82, 95% confidence interval (CI) 0.63-1.68]. Loco-regional RT was associated with an OS benefit in the subgroup analysis: IIIB-C (loco-regional RT 79.3% vs no loco-regional RT 71.2%, p = 0.027) and T3-T4 (loco-regional RT 82.6% vs no loco-regional RT 76.6%, p = 0.025). No difference was shown in terms of 5-year DFS (loco-regional RT 91.2% vs no loco-regional RT 83%, p = 0.441) and LRRFS (loco-regional RT 98.1% vs no loco-regional RT 92.3%, p = 0.148). There was no significant difference between the groups in terms of acute and late skin toxicities, lymphedema and cardiac events. CONCLUSIONS Because of the limitations due to the small number of studies and heterogeneity in the analysis, the present study does not allow to draw any definitive conclusion, highlighting the need for well-controlled trials to determine the effect of loco-regional RT in patients with cN2 having a pathological complete response in the axillary nodes after preoperative chemotherapy.
Collapse
Affiliation(s)
- Lorenza Marino
- Radiotherapy Oncology Department, Humanitas-Istituto Clinico Catanese, Misterbianco (CT), Italy
| | - Valentina Lancellotta
- Fondazione Policlinico Universitario A. Gemelli IRCCS, UOC di Radioterapia, Dipartimento di Scienze Radiologiche, Radioterapiche Ed Ematologiche, Roma, Italy.
| | - Pierfrancesco Franco
- Department of Oncology, Radiation Oncology, School of Medicine, University of Turin, Turin, Italy
| | - Icro Meattini
- Department of Experimental and Clinical Biomedical Sciences "M. Serio", University of Florence, Florence, Italy; Radiation Oncology Unit - Oncology Department, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Bruno Meduri
- Radiation Oncology Unit, University Hospital of Modena, Modena, Italy
| | - Marco Bernini
- Breast Surgery Unit, Oncology Department, Azienda Ospedaliero-Universitaria Careggi, University of Florence, Florence, Italy
| | - Alessandra Fabi
- Oncology Unit 1, Regina Elena National Cancer Institute, Rome, Italy; La Sapienza University, Rome, Italy
| | - Renzo Corvò
- Department of Radiation Oncology, IRCCS Ospedale Policlinico San Martino and Department of Health Science, University of Genoa, Genoa, Italy
| | - Stefano M Magrini
- Department of Radiation Oncology, ASST Ospedali Civili and Brescia University, Brescia, Italy
| | | | - Stefano Arcangeli
- Department of Radiation Oncology, Policlinico S. Gerardo and University of Milan "Bicocca", Milan, Italy
| | - Rolando M D'Angelillo
- Radiotherapy, Dipartimento di Biomedicina e Prevenzione, Università Degli Studi di Roma Tor Vergata, Rome, Italy
| |
Collapse
|
19
|
Li YL, Tian H, Jiang J, Zhang Y, Qi XW. Multifaceted regulation and functions of fatty acid desaturase 2 in human cancers. Am J Cancer Res 2020; 10:4098-4111. [PMID: 33414988 PMCID: PMC7783767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 11/02/2020] [Indexed: 06/12/2023] Open
Abstract
As an important hallmark of metabolic reprogramming in cancer, a disruption in fatty acid metabolism contributes to tumor proliferation, cell migration and invasion, and other tumor cell behaviors. In recent years, more and more studies have been conducted on fatty acid desaturase 2 (FADS2), the first rate-limiting enzyme for the biosynthesis of polyunsaturated fatty acids. These studies have found that FADS2 is abnormally expressed in cancers of the breast, lung, liver, and esophagus; melanoma; leukemia; and other malignant tumors. Furthermore, its expression is significantly correlated with tumor proliferation, cell migration and invasion, clonal formation, angiogenesis, ferroptosis, resistance to radiotherapy, histological grade, metastasis to lymph nodes, clinical stage, and prognosis. The abnormal expression of FADS2 results in an imbalance of cell membrane phospholipids, which disrupts the fluidity of the membrane structure and the transmission of signals and promotes the production of proinflammatory factors and arachidonic acid (AA) metabolites, ultimately harming human health. This article aims to systematically review the structural characteristics of FADS2; its function, expression, and mechanism of action; and the factors affecting its activity. This review also provides new ideas and strategies for the development of treatments aimed at the metabolic reprogramming of tumors.
Collapse
Affiliation(s)
- Yan-Ling Li
- Department of Breast and Thyroid Surgery, Southwest Hospital, Third Military Medical University Chongqing 400038, China
| | - Hao Tian
- Department of Breast and Thyroid Surgery, Southwest Hospital, Third Military Medical University Chongqing 400038, China
| | - Jun Jiang
- Department of Breast and Thyroid Surgery, Southwest Hospital, Third Military Medical University Chongqing 400038, China
| | - Yi Zhang
- Department of Breast and Thyroid Surgery, Southwest Hospital, Third Military Medical University Chongqing 400038, China
| | - Xiao-Wei Qi
- Department of Breast and Thyroid Surgery, Southwest Hospital, Third Military Medical University Chongqing 400038, China
| |
Collapse
|
20
|
Accelerated Partial Breast Radiation: Information on Dose, Volume, Fractionation, and Efficacy from Randomized Trials. Int J Radiat Oncol Biol Phys 2020; 108:1123-1128. [PMID: 33220220 DOI: 10.1016/j.ijrobp.2020.06.064] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 06/24/2020] [Indexed: 01/10/2023]
|
21
|
Analysis of Spatial Distribution and Prognostic Value of Different Pan Cytokeratin Immunostaining Intensities in Breast Tumor Tissue Sections. Int J Mol Sci 2020; 21:ijms21124434. [PMID: 32580421 PMCID: PMC7352516 DOI: 10.3390/ijms21124434] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Revised: 06/14/2020] [Accepted: 06/18/2020] [Indexed: 01/19/2023] Open
Abstract
Cancer risk prognosis could improve patient survival through early personalized treatment decisions. This is the first systematic analysis of the spatial and prognostic distribution of different pan cytokeratin immunostaining intensities in breast tumors. The prognostic model included 102 breast carcinoma patients, with distant metastasis occurrence as the endpoint. We segmented the full intensity range (0–255) of pan cytokeratin digitized immunostaining into seven discrete narrow grey level ranges: 0–130, 130–160, 160–180, 180–200, 200–220, 220–240, and 240–255. These images were subsequently examined by 33 major (GLCM), fractal and first-order statistics computational analysis features. Interestingly, while moderate intensities were strongly associated with metastasis outcome, high intensities of pan cytokeratin immunostaining provided no prognostic value even after an exhaustive computational analysis. The intense pan cytokeratin immunostaining was also relatively rare, suggesting the low differentiation state of epithelial cells. The observed variability in immunostaining intensities highlighted the intratumoral heterogeneity of the malignant cells and its association with a poor disease outcome. The prognostic importance of the moderate intensity range established by complex computational morphology analyses was supported by simple measurements of its immunostaining area which was associated with favorable disease outcome. This study reveals intratumoral heterogeneity of the pan cytokeratin immunostaining together with the prognostic evaluation and spatial distribution of its discrete intensities.
Collapse
|
22
|
Franco P, Kochbati L, Siano M, De Bari B. Suggestions for Radiation Oncologists during the COVID-19 Pandemic. BIOMED RESEARCH INTERNATIONAL 2020; 2020:4892382. [PMID: 32509860 PMCID: PMC7254074 DOI: 10.1155/2020/4892382] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 05/19/2020] [Indexed: 01/25/2023]
Abstract
SARS-CoV-2 pandemic and COVID-19 diffusion have recently become an international public health emergency. Cancer patients, as a frail population, are particularly exposed to the risk related to infections. The clinical decision-making process and the organizational workflow of radiotherapy department should be revised in the light of the critical situation. We herein provide practical suggestions derived from the available literature and discussed during an online session held within the e-learning educational program of the European School of Oncology on March 31st 2020.
Collapse
Affiliation(s)
| | - Lofti Kochbati
- Department of Radiation Oncology, Ariana, Tunis El Manar University, Tunisia
| | - Marco Siano
- Interdisciplinary Cancer Service-SIC, Riviera-Chablais Hospital, Rennaz, Switzerland
| | - Berardino De Bari
- Department of Radiation Oncology, Réseal Hospitalier Neuchâtelois, La-Chaux-de Fonds, Switzerland
| |
Collapse
|
23
|
Older age and comorbidity in breast cancer: is RT alone the new therapeutic frontier? J Cancer Res Clin Oncol 2020; 146:1791-1800. [PMID: 32405744 DOI: 10.1007/s00432-020-03243-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Accepted: 05/01/2020] [Indexed: 10/24/2022]
Abstract
AIM To assess the impact of age, comorbidities and endocrine therapy (ET) in older breast cancer (BC) patients treated with hypofractionated radiotherapy (Hypo-RT). METHODS From June 2009 to December 2017, we enrolled in this study 735 ER-positive BC patients (stage pT1-T2, pNx-1, M0 and age ≥ 65 years) receiving hypo-RT and followed them until September 2019. Baseline comorbidities included in the hypertension-augmented Charlson Comorbidity Index were retrospectively retrieved. Logistic regression model estimated adjusted-odds ratios (ORs) of ET prescription in relation to baseline patient and tumor characteristics. Competing risk analysis estimated 5-year cumulative incidence function (CIF) of ET discontinuation due to side effects (with BC progression or death as competing events), and its effect on locoregional recurrence (LRR) and distant metastasis (DM) (with death as competing event). RESULTS ET has been prescribed in 89% patients. In multivariable analysis, the odds of ET prescription was significantly reduced in older patients (≥ 80 years, OR 0.08, 95% CI 0.03-0.20) and significantly increased in patients with moderate comorbidity. Patients ≥ 80 years discontinued the prescribed therapy earlier and more frequently than younger (65-69 years) patients (p = 0.060). Five-year CIF of LLR, DM and death from causes other that BC were 1.7%, 2.2% and 7.5%, respectively. Patients who discontinued ET had higher chance of LRR (p = 0.004). ET use did not impact on OS in any of the analyzed groups. CONCLUSIONS In older patients, ET did not show a benefit in terms of overall survival. Further studies focusing on tailored treatment approaches are warranted to offer the best care in terms of adjuvant treatment to these patients.
Collapse
|
24
|
Romeo A, Castelli L, Franco P. The Effect of COVID-19 on Radiation Oncology Professionals and Patients With Cancer: From Trauma to Psychological Growth. Adv Radiat Oncol 2020; 5:705-706. [PMID: 32395671 PMCID: PMC7211720 DOI: 10.1016/j.adro.2020.04.024] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Affiliation(s)
- Annunziata Romeo
- Department of Psychology, "ReMind the Body" Research Group, University of Turin, Italy
| | - Lorys Castelli
- Department of Psychology, "ReMind the Body" Research Group, University of Turin, Italy
| | | |
Collapse
|
25
|
Meehan J, Gray M, Martínez-Pérez C, Kay C, Pang LY, Fraser JA, Poole AV, Kunkler IH, Langdon SP, Argyle D, Turnbull AK. Precision Medicine and the Role of Biomarkers of Radiotherapy Response in Breast Cancer. Front Oncol 2020; 10:628. [PMID: 32391281 PMCID: PMC7193869 DOI: 10.3389/fonc.2020.00628] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 04/06/2020] [Indexed: 12/24/2022] Open
Abstract
Radiotherapy remains an important treatment modality in nearly two thirds of all cancers, including the primary curative or palliative treatment of breast cancer. Unfortunately, largely due to tumor heterogeneity, tumor radiotherapy response rates can vary significantly, even between patients diagnosed with the same tumor type. Although in recent years significant technological advances have been made in the way radiation can be precisely delivered to tumors, it is proving more difficult to personalize radiotherapy regimens based on cancer biology. Biomarkers that provide prognostic or predictive information regarding a tumor's intrinsic radiosensitivity or its response to treatment could prove valuable in helping to personalize radiation dosing, enabling clinicians to make decisions between different treatment options whilst avoiding radiation-induced toxicity in patients unlikely to gain therapeutic benefit. Studies have investigated numerous ways in which both patient and tumor radiosensitivities can be assessed. Tumor molecular profiling has been used to develop radiosensitivity gene signatures, while the assessment of specific intracellular or secreted proteins, including circulating tumor cells, exosomes and DNA, has been performed to identify prognostic or predictive biomarkers of radiation response. Finally, the investigation of biomarkers related to radiation-induced toxicity could provide another means by which radiotherapy could become personalized. In this review, we discuss studies that have used these methods to identify or develop prognostic/predictive signatures of radiosensitivity, and how such assays could be used in the future as a means of providing personalized radiotherapy.
Collapse
Affiliation(s)
- James Meehan
- Translational Oncology Research Group, Institute of Genetics and Molecular Medicine, Western General Hospital, University of Edinburgh, Edinburgh, United Kingdom
| | - Mark Gray
- Translational Oncology Research Group, Institute of Genetics and Molecular Medicine, Western General Hospital, University of Edinburgh, Edinburgh, United Kingdom.,The Royal (Dick) School of Veterinary Studies and Roslin Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Carlos Martínez-Pérez
- Translational Oncology Research Group, Institute of Genetics and Molecular Medicine, Western General Hospital, University of Edinburgh, Edinburgh, United Kingdom.,Breast Cancer Now Edinburgh Research Team, Institute of Genetics and Molecular Medicine, Western General Hospital, University of Edinburgh, Edinburgh, United Kingdom
| | - Charlene Kay
- Translational Oncology Research Group, Institute of Genetics and Molecular Medicine, Western General Hospital, University of Edinburgh, Edinburgh, United Kingdom
| | - Lisa Y Pang
- The Royal (Dick) School of Veterinary Studies and Roslin Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Jennifer A Fraser
- School of Applied Science, Sighthill Campus, Edinburgh Napier University, Edinburgh, United Kingdom
| | - Amy V Poole
- School of Applied Science, Sighthill Campus, Edinburgh Napier University, Edinburgh, United Kingdom
| | - Ian H Kunkler
- Cancer Research UK Edinburgh Centre and Division of Pathology Laboratories, Institute of Genetics and Molecular Medicine, University of Edinburgh, Edinburgh, United Kingdom
| | - Simon P Langdon
- Cancer Research UK Edinburgh Centre and Division of Pathology Laboratories, Institute of Genetics and Molecular Medicine, University of Edinburgh, Edinburgh, United Kingdom
| | - David Argyle
- The Royal (Dick) School of Veterinary Studies and Roslin Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Arran K Turnbull
- Translational Oncology Research Group, Institute of Genetics and Molecular Medicine, Western General Hospital, University of Edinburgh, Edinburgh, United Kingdom.,Breast Cancer Now Edinburgh Research Team, Institute of Genetics and Molecular Medicine, Western General Hospital, University of Edinburgh, Edinburgh, United Kingdom
| |
Collapse
|