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Martinez C, Meterissian S, Saidi A, Tremblay F, Meguerditchian AN, Fleiszer D, Lambert C, David M, Panet-Raymond V, Abdulkarim B, Hijal T. Targeted Intraoperative Radiation Therapy during Breast-Conserving Surgery for Patients with Early Stage Breast Cancer: A Phase II Single Center Prospective Trial. Adv Radiat Oncol 2023; 8:101236. [PMID: 37408681 PMCID: PMC10318266 DOI: 10.1016/j.adro.2023.101236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 03/26/2023] [Indexed: 07/07/2023] Open
Abstract
Purpose Patients with early stage breast cancer (ESBC) are conventionally treated with breast-conserving surgery (BCS) followed by whole-breast external beam radiation therapy (EBRT). The emergence of targeted intraoperative radiation therapy (TARGIT) with Intrabeam has been used as a therapeutic alternative for patients with risk-adapted ESBC. Here we present our radiation therapy toxicities (RTT), postoperative complications (PC), and short-term outcomes of the prospective phase II trial at the McGill University Health Center. Methods and Materials Patients aged ≥50 years with biopsy-proven hormone receptor-positive, grade 1 or 2, invasive ductal carcinoma of the breast, cT1N0, were eligible for the study. Enrolled patients underwent BCS followed by immediate TARGIT of 20 Gy in 1 fraction. Upon final pathology, patients with low-risk breast cancer (LRBC) received no further EBRT, and those with high-risk breast cancer (HRBC) received further 15 to 16 fractions of whole breast EBRT. HRBC criteria included pathologic tumor size >2 cm, grade 3, positive lympho-vascular invasion, multifocal disease, close margins (<2 mm), or positive nodal disease. Results A total of 61 patients with ESBC were enrolled in the study; upon final pathology, 40 (65.6%) had LRBC, and 21 (34.4%) had HRBC. The median follow-up was 3.9 years. The most common HRBC criteria were close margins in 66.6% (n = 14) and lymphovascular invasion in 28.6% (n = 6). No grade 4 RTT were observed in either group. The most common PC were seroma and cellulitis for both groups. The rate of locoregional recurrence was 0% in both groups. The overall survival in LRBC was 97.5% and in HRBC 95.2% with no significant differences. Deaths were nonbreast cancer related. Conclusions In patients with ESBC undergoing BCS, the use of TARGIT shows low rates of RTT and PC complications. Moreover, our short-term outcomes show no significant difference at 3.9 years median follow-up for locoregional recurrence or overall survival between groups of patients receiving TARGIT alone or TARGIT followed by EBRT. Of all patients, 34.4% required further EBRT, most commonly due to close margins.
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Affiliation(s)
- Constanza Martinez
- Division of Radiation Oncology, McGill University Health Centre, Quebec, Canada
| | - Sarkis Meterissian
- Department of Surgery, McGill University Health Centre, Montreal, Quebec, Canada
| | - Asma Saidi
- Division of Radiation Oncology, McGill University Health Centre, Quebec, Canada
| | - Francine Tremblay
- Department of Surgery, McGill University Health Centre, Montreal, Quebec, Canada
| | | | - David Fleiszer
- Department of Surgery, McGill University Health Centre, Montreal, Quebec, Canada
| | - Christine Lambert
- Division of Radiation Oncology, McGill University Health Centre, Quebec, Canada
| | - Marc David
- Division of Radiation Oncology, McGill University Health Centre, Quebec, Canada
| | | | - Bassam Abdulkarim
- Division of Radiation Oncology, McGill University Health Centre, Quebec, Canada
| | - Tarek Hijal
- Division of Radiation Oncology, McGill University Health Centre, Quebec, Canada
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Polgár C, Major T, Takácsi-Nagy Z, Fodor J. Breast-Conserving Surgery Followed by Partial or Whole Breast Irradiation: Twenty-Year Results of a Phase 3 Clinical Study. Int J Radiat Oncol Biol Phys 2020; 109:998-1006. [PMID: 33186620 DOI: 10.1016/j.ijrobp.2020.11.006] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 10/22/2020] [Accepted: 11/02/2020] [Indexed: 01/08/2023]
Abstract
PURPOSE To report the 20-year results of a phase 3 clinical trial comparing the survival and cosmetic results of breast-conserving surgery followed by partial breast irradiation (PBI) or whole breast irradiation (WBI). METHODS AND MATERIALS Between 1998 and 2004, 258 selected patients with low-risk invasive breast carcinoma (pT1 pN0-1mi, grade 1-2, nonlobular breast cancer) resected with negative margins were randomized after breast-conserving surgery to receive PBI (n = 128) or 50 Gy WBI (n = 130). Partial breast irradiation was given either by multicatheter high-dose-rate (HDR) brachytherapy (BT; n = 88) with 7 × 5.2 Gy twice daily or 50 Gy external beam irradiation with electron beams (n = 40). RESULTS Median follow-up time was 17 years. The 20-year actuarial rates of ipsilateral breast tumor recurrences were 9.6% versus 7.9% (P = .59) in the PBI and WBI arms, respectively. There was no significant difference in the 20-year probability of disease-free (79.7% vs 78.3%), cancer-specific (92.6% vs 88.1%), and overall survival (59.5% vs 59.7%). Significantly more patients had excellent or good cosmetic result in the PBI and WBI groups (79.2% vs 59.5%; P = .0007). CONCLUSIONS The 20-year updated results of our phase 3 clinical trial add further scientific evidence that PBI either with multicatheter HDR BT or electron beams for low-risk invasive breast carcinomas yield long-term local tumor control and survival comparable to those achieved with standard WBI. Interstitial HDR BT improved cosmetic results compared with WBI.
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Affiliation(s)
- Csaba Polgár
- Center of Radiotherapy, National Institute of Oncology, Budapest, Hungary; Department of Oncology, Semmelweis University, Budapest, Hungary.
| | - Tibor Major
- Center of Radiotherapy, National Institute of Oncology, Budapest, Hungary; Department of Oncology, Semmelweis University, Budapest, Hungary
| | - Zoltán Takácsi-Nagy
- Center of Radiotherapy, National Institute of Oncology, Budapest, Hungary; Department of Oncology, Semmelweis University, Budapest, Hungary
| | - János Fodor
- Department of Oncology, Semmelweis University, Budapest, Hungary
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Recht A. Whole-Breast Irradiation Is the Preferred Standard of Care for the Majority of Patients With Early-Stage Breast Cancer. J Clin Oncol 2020; 38:2263-2267. [PMID: 32442072 DOI: 10.1200/jco.19.02388] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Affiliation(s)
- Abram Recht
- Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA
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Isbell A, Dunmore-Griffith J, Abayomi O. Strut-adjusted volume implant (SAVI) brachytherapy-based accelerated partial breast irradiation (APBI) in African American women. Breast Cancer Res Treat 2017; 162:69-76. [DOI: 10.1007/s10549-016-4091-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2016] [Accepted: 12/19/2016] [Indexed: 11/30/2022]
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Dosimetric considerations and early clinical experience of accelerated partial breast irradiation using multi-lumen applicators in the setting of breast augmentation. J Contemp Brachytherapy 2015; 7:423-9. [PMID: 26816499 PMCID: PMC4716129 DOI: 10.5114/jcb.2015.56515] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Accepted: 11/08/2015] [Indexed: 11/25/2022] Open
Abstract
Purpose Accelerated partial breast irradiation (APBI) is an accepted treatment option in breast-conserving therapy for early stage breast cancer. However, data regarding outcomes of patients treated with multi-lumen catheter systems who have existing breast implants is limited. The purpose of this study was to report treatment parameters, outcomes, and possible dosimetric correlation with cosmetic outcome for this population of patients at our institution. Material and methods We report the treatment and outcome of seven consecutive patients with existing breast implants and early stage breast cancer who were treated between 2009 and 2013 using APBI following lumpectomy. All patients were treated twice per day for five days to a total dose of 34 Gy using a high-dose-rate 192Ir source. Cosmetic outcomes were evaluated using the Harvard breast cosmesis scale, and late toxicities were reported using the Radiation Therapy Oncology Group (RTOG) late radiation morbidity schema. Results After a mean follow-up of 32 months, all patients have remained cancer free. Six out of seven patients had an excellent or good cosmetic outcome. There were no grade 3 or 4 late toxicities. The average total breast implant volume was 279.3 cc, received an average mean dose of 12.1 Gy, and a maximum dose of 234.1 Gy. The average percentage of breast implant volume receiving 50%, 75%, 100%, 150%, and 200% of the prescribed dose was 15.6%, 7.03%, 4.6%, 1.58%, and 0.46%, respectively. Absolute volume of breast implants receiving more than 50% of prescribed dose correlated with worse cosmetic outcomes. Conclusions Accelerated partial breast irradiation using a multi-lumen applicator in patients with existing breast implants can safely be performed with promising early clinical results. The presence of the implant did not compromise the ability to achieve dosimetric criteria; however, dose to the implant and the irradiated implant volume may be related with worse cosmetic outcomes.
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Recommendations from GEC ESTRO Breast Cancer Working Group (I): Target definition and target delineation for accelerated or boost Partial Breast Irradiation using multicatheter interstitial brachytherapy after breast conserving closed cavity surgery. Radiother Oncol 2015; 115:342-8. [DOI: 10.1016/j.radonc.2015.06.010] [Citation(s) in RCA: 86] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Revised: 06/08/2015] [Accepted: 06/08/2015] [Indexed: 11/18/2022]
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Budrukkar A, Gurram L, Upreti RR, Munshi A, Jalali R, Badwe R, Parmar V, Shet T, Gupta S, Wadasadawala T, Sarin R. Clinical outcomes of prospectively treated 140 women with early stage breast cancer using accelerated partial breast irradiation with 3 dimensional computerized tomography based brachytherapy. Radiother Oncol 2015; 115:349-54. [DOI: 10.1016/j.radonc.2015.03.002] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2014] [Revised: 03/02/2015] [Accepted: 03/02/2015] [Indexed: 11/16/2022]
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Trifiletti DM, Jones R, Showalter SL, Libby BB, Brenin DR, Schroen A, Morris MM, Reardon KA, Showalter TN. Techniques for intraoperative radiation therapy for early-stage breast carcinoma. Future Oncol 2015; 11:1047-58. [DOI: 10.2217/fon.15.26] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
ABSTRACT Intraoperative radiation therapy (IORT) is a method of accelerated partial breast irradiation developed to replace other longer courses of radiotherapy with a single radiation session administered at the time of breast-conserving surgery. The purpose of this review is to summarize the advantages and disadvantages of breast IORT techniques that are currently available, as well to consider potential alternative techniques for breast IORT or ultra-short course breast radiotherapy. Furthermore, we highlight the published outcomes for the IORT treatment approaches including: electron therapy, superficial photon therapy and other techniques. Potential future directions of IORT are explored including novel IORT techniques utilizing intraoperative brachytherapy with in-room imaging and rapid treatment planning.
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Affiliation(s)
- Daniel M Trifiletti
- Department of Radiation Oncology, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Ryan Jones
- Department of Radiation Oncology, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Shayna L Showalter
- Division of Surgical Oncology, Department of Surgery, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Bruce B Libby
- Department of Radiation Oncology, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - David R Brenin
- Division of Surgical Oncology, Department of Surgery, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Anneke Schroen
- Division of Surgical Oncology, Department of Surgery, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Monica M Morris
- Department of Radiation Oncology, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Kelli A Reardon
- Department of Radiation Oncology, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Timothy N Showalter
- Department of Radiation Oncology, University of Virginia School of Medicine, Charlottesville, VA, USA
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Panet-Raymond V, Truong PT, Watson PH. Ipsilateral breast tumor recurrence after breast-conserving therapy. Expert Rev Anticancer Ther 2014; 10:1229-38. [DOI: 10.1586/era.10.87] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Moran MS. Should Low-Risk Patients Be Treated With Three-Dimensional Conformal Radiation Therapy–Accelerated Partial-Breast Irradiation in an Off-Protocol Setting? J Clin Oncol 2013; 31:4032-7. [DOI: 10.1200/jco.2013.51.1642] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Lei RY, Leonard CE, Howell KT, Henkenberns PL, Johnson TK, Hobart TL, Fryman SP, Kercher JM, Widner JL, Kaske T, Carter DL. Four-year clinical update from a prospective trial of accelerated partial breast intensity-modulated radiotherapy (APBIMRT). Breast Cancer Res Treat 2013; 140:119-33. [PMID: 23824363 PMCID: PMC3706719 DOI: 10.1007/s10549-013-2623-x] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2013] [Accepted: 06/22/2013] [Indexed: 01/03/2023]
Abstract
This prospective Phase II single-arm study gathered data on the use of intensity-modulated radiotherapy (IMRT) to deliver accelerated partial breast irradiation (APBI). Four-year efficacy, cosmesis, and toxicity results are presented. Between February 2004 and September 2007, 136 consecutive patients with Stage 0/I breast cancer and negative margins ≥0.2 cm were treated on protocol. Patients received 38.5 Gy in 10 equal fractions delivered twice daily. Breast pain and cosmesis were rated by patient, and cosmesis was additionally evaluated by physician per Radiation Therapy Oncology Group (RTOG) criteria. The National Cancer Institute Common Terminology Criteria for Adverse Events (NCI CTCAE v3.0) was used to grade toxicities. 136 patients (140 breasts) with median follow-up of 53.1 months (range, 8.9-83.2) were evaluated. Population characteristics included median age of 61.9 years and Tis (13.6 %), T1a (18.6 %), T1b (36.4 %), and T1c (31.4 %). Kaplan-Meier estimates at 4 years: ipsilateral breast tumor recurrence 0.7 %; contralateral breast failure 0 %; distant failure 0.9 %; overall survival 96.8 %; and cancer-specific survival 100 %. At last follow-up, patients and physicians rated cosmesis as excellent/good in 88.2 and 90.5 %, respectively; patients rated breast pain as none/mild in 97.0 %. Other observations included edema (1.4 %), telangiectasia (3.6 %), five cases of grade 1 radiation recall (3.6 %), and two cases of rib fractures (1.4 %). This analysis represents the largest cohort and longest follow-up of APBI utilizing IMRT reported to date. Four-year results continue to demonstrate excellent local control, survival, cosmetic results, and toxicity profile.
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Affiliation(s)
- Rachel Y. Lei
- Rocky Mountain Cancer Centers, 22 W. Dry Creek Circle, Littleton, CO 80120 USA
- Rocky Mountain Cancer Center, 1700 S. Potomac Street, Aurora, CO 80012 USA
| | - Charles E. Leonard
- Rocky Mountain Cancer Centers, 22 W. Dry Creek Circle, Littleton, CO 80120 USA
| | - Kathryn T. Howell
- Rocky Mountain Cancer Centers, 22 W. Dry Creek Circle, Littleton, CO 80120 USA
| | | | - Timothy K. Johnson
- Rocky Mountain Cancer Centers, 22 W. Dry Creek Circle, Littleton, CO 80120 USA
| | - Tracy L. Hobart
- Rocky Mountain Cancer Centers, 22 W. Dry Creek Circle, Littleton, CO 80120 USA
| | - Shannon P. Fryman
- Rocky Mountain Cancer Centers, 22 W. Dry Creek Circle, Littleton, CO 80120 USA
- Rocky Mountain Cancer Center, 1700 S. Potomac Street, Aurora, CO 80012 USA
| | | | | | - Terese Kaske
- Sally Jobe Diagnostic Breast Center, Greenwood Village, CO USA
| | - Dennis L. Carter
- Rocky Mountain Cancer Center, 1700 S. Potomac Street, Aurora, CO 80012 USA
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Polgár C, Fodor J, Major T, Sulyok Z, Kásler M. Breast-conserving therapy with partial or whole breast irradiation: ten-year results of the Budapest randomized trial. Radiother Oncol 2013; 108:197-202. [PMID: 23742961 DOI: 10.1016/j.radonc.2013.05.008] [Citation(s) in RCA: 264] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2013] [Revised: 05/03/2013] [Accepted: 05/11/2013] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND PURPOSE To report the long-term results of a single-institution randomized study comparing the results of breast-conserving treatment with partial breast irradiation (PBI) or conventional whole breast irradiation (WBI). PATIENTS AND METHODS Between 1998 and 2004, 258 selected women with pT1 pN0-1mi M0, grade 1-2, non-lobular breast cancer without the presence of extensive intraductal component and resected with negative margins were randomized after BCS to receive 50 Gy WBI (n=130) or PBI (n=128). The latter consisted of either 7 × 5.2 Gy high-dose-rate (HDR) multi-catheter brachytherapy (BT; n=88) or 50 Gy electron beam (EB) irradiation (n=40). Primary endpoint was local recurrence (LR) as a first event. Secondary endpoints were overall survival (OS), cancer-specific survival (CSS), disease-free survival (DFS), and cosmetic results. RESULTS After a median follow up of 10.2 years, the ten-year actuarial rate of LR was 5.9% and 5.1% in PBI and WBI arms, respectively (p=0.77). There was no significant difference in the ten-year probability of OS (80% vs 82%), CSS (94% vs 92%), and DFS (85% vs 84%), either. The rate of excellent-good cosmetic result was 81% in the PBI, and 63% in the control group (p<0.01). CONCLUSIONS Partial breast irradiation delivered by interstitial HDR BT or EB for a selected group of early-stage breast cancer patients produces similar ten-year results to those achieved with conventional WBI. Significantly better cosmetic outcome can be achieved with HDR BT implants compared with the outcome after WBI.
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Affiliation(s)
- Csaba Polgár
- Center of Radiotherapy, National Institute of Oncology, Budapest, Hungary.
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15
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Moser EC, Vrieling C. Accelerated partial breast irradiation: the need for well-defined patient selection criteria, improved volume definitions, close follow-up and discussion of salvage treatment. Breast 2012; 21:707-15. [PMID: 23127279 DOI: 10.1016/j.breast.2012.09.014] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2012] [Revised: 08/17/2012] [Accepted: 09/23/2012] [Indexed: 12/24/2022] Open
Abstract
Breast-conserving therapy, including whole breast irradiation, has become a well-established alternative to mastectomy in early-stage breast cancer patients, with similar survival rates and better cosmetic outcome. However, many women are still treated with mastectomy, due to logistical issues related to the long course of radiotherapy (RT). To reduce mastectomy rates and/or omission of RT after breast-conserving surgery, shorter, hypofractionated RT treatments have been introduced. More recently, the necessity of routinely treating the entire breast in all patients has been questioned, leading to the development of partial breast radiotherapy. With accelerated partial breast irradiation (APBI) these two approaches have been combined: the tumor bed with a 1-2 cm margin is irradiated either intra-operatively (single fraction) or postoperatively over 5-15 days. Different techniques have been developed, including interstitial brachytherapy, intra-cavity brachytherapy, intra-operative radiotherapy and external beam radiotherapy. These techniques are being evaluated in several ongoing phase III studies. Since its introduction, APBI has been the subject of continuous debate. ASTRO and GEC-ESTRO have published guidelines for patient selection for APBI, and strongly recommend that APBI be carried out within ongoing clinical trials. Recently, the patient selection criteria for APBI have also been up for debate, following the publication of results from different groups that do/do not confirm a difference in recurrence risk among the ASTRO defined risk groups. This paper reviews the different APBI techniques, current recommendations for patient selection, available clinical data and ongoing clinical trials. A case report is included to illustrate the need for careful follow-up of patients treated with APBI.
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Affiliation(s)
- Elizabeth C Moser
- Breast Unit/Department of Radiotherapy, Champalimaud Cancer Centre, Lisbon, Portugal.
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Israel PZ, Robbins A, Shroff P, Brown S, McLaughlin M, Pope K. Three-year clinical outcome using the Contura multilumen balloon breast brachytherapy catheter to deliver accelerated partial breast irradiation (APBI): Improving radiation standards for the optimal application of APBI. Brachytherapy 2012; 11:316-21. [DOI: 10.1016/j.brachy.2011.07.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2011] [Revised: 07/24/2011] [Accepted: 07/25/2011] [Indexed: 11/24/2022]
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Acute toxicity and early cosmetic outcome in patients treated with multilumen balloon brachytherapy with skin spacing ≤ 7.0 millimeters. J Contemp Brachytherapy 2012; 4:8-13. [PMID: 23346134 PMCID: PMC3551367 DOI: 10.5114/jcb.2012.27946] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2012] [Revised: 03/06/2012] [Accepted: 03/18/2012] [Indexed: 11/24/2022] Open
Abstract
Purpose To review institutional experience treating patients who underwent breast conserving surgery and adjuvant accelerated partial breast irradiation with multilumen balloon brachytherapy (MLB) with close skin spacing (≤7 mm). Material and methods Since July 2009, 26 patients with skin spacing ≤ 7.0 mm were treated with breast-conserving therapy and adjuvant MLB brachytherapy. Patients were treated with either the Contura or MammoSite ML catheter to a total dose of 34 Gy in 10 fractions. Patients were assessed for acute toxicity at the completion of treatment and 1-month post treatment. Cosmesis and late toxicity were assessed at three-month intervals thereafter. Results The median age of the patients was 56 years and median follow-up was 9 months. Sixteen patients had skin spacing of 5.0–7.0 mm, 10 with < 5.0 mm (median 5.8). The median percentage of the target (PTV_EVAL) receiving ≥ 95% of the prescription dose was 95.6%. The median volume of PTV_EVAL receiving ≥ 200% of the prescription dose was 6.1 cc. The maximum skin dose was 118.2% (median). The most commonly observed acute toxicity was grade 1-2 dermatitis (65.4%). The rate of post-treatment seroma and infection was 38.5% and 3.8%, respectively. Excellent/good cosmetic outcomes seen at the time of last follow-up was 92.3%. Conclusions MLB brachytherapy is safe and feasible in patients with close skin spacing, with acute toxicity and early cosmesis similar to other published series. These devices may broaden the application of balloon brachytherapy in patients previously excluded from this treatment based on anatomy.
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Shaikh AY, LaCombe MA, Du H, Raghavan VT, Nanda RK, Bloomer WD. Accelerated partial breast irradiation using once-daily fractionation: analysis of 312 cases with four years median follow-up. Radiat Oncol 2012; 7:17. [PMID: 22309790 PMCID: PMC3292468 DOI: 10.1186/1748-717x-7-17] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2011] [Accepted: 02/06/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There are limited data on accelerated partial breast irradiation (APBI) using external beam techniques. Moreover, there are recent reports of increased fibrosis and unacceptable cosmesis with APBI using external beam with BID fractionation. We adopted a once daily regimen of APBI with fractionation similar to that shown to be effective in a Canadian randomized trial of whole breast irradiation. It is unclear whether patients with DCIS or invasive lobular carcinoma (ILC) are suitable for APBI. METHODS The retrospective cohort included 310 patients with 312 tumors of T1-T2N0-N1micM0 invasive ductal carcinoma (IDC), ILC, or Tis (DCIS) treated with APBI via external beam. Most patients were treated using IMRT with 16 daily fractions of 270 cGy to a dose of 4320 cGy. The target volume included the lumpectomy cavity plus 1.0 cm to account for microscopic disease and an additional 0.5 to 1.0 cm for setup uncertainty and breathing motion. Ipsilateral breast failure (IBF) was pathologically confirmed as a local failure (LF) or an elsewhere failure (EF). RESULTS Median follow-up was 49 months. Among the 312 cases, 213 were IDC, 31 ILC, and 68 DCIS. Median tumor size was 1.0 cm. There were 9 IBFs (2.9%) including 5 LFs and 4 EFs. The IBF rates among patients with IDC, ILC, and DCIS were 2.4%, 3.2%, and 4.4%, respectively, with no significant difference between histologies. When patients were analyzed by the ASTRO APBI consensus statement risk groups, 32% of treated cases were considered suitable, 50% cautionary, and 18% unsuitable. The IBF rates among suitable, cautionary, and unsuitable patients were 4.0%, 2.6%, and 1.8%, respectively, with no significant difference between risk groups. Acute skin reactions were rare and long-term cosmetic outcome was very good to excellent. CONCLUSIONS External beam APBI with once daily fractionation has a low rate of IBF consistent with other published APBI studies. The ASTRO risk stratification did not differentiate a subset of patients with a higher rate of IBF. APBI may be an appropriate treatment for women with DCIS and ILC.
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Affiliation(s)
- Arif Y Shaikh
- Department of Radiation Medicine, NorthShore University HealthSystem, 2650 Ridge Ave, Evanston, IL 60201, USA.
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Khan AJ, Arthur D, Vicini F, Beitsch P, Kuerer H, Goyal S, Lyden M, Haffty BG. Six-year analysis of treatment-related toxicities in patients treated with accelerated partial breast irradiation on the American Society of Breast Surgeons MammoSite Breast Brachytherapy registry trial. Ann Surg Oncol 2011; 19:1477-83. [PMID: 22109731 DOI: 10.1245/s10434-011-2133-1] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2011] [Indexed: 12/24/2022]
Abstract
BACKGROUND The American Society of Breast Surgeons (ASBrS) enrolled women in a registry trial to prospectively study patients treated with the MammoSite RTS device. This report presents 6-year data on treatment-related toxicities from the trial. METHODS A total of 1449 primary early-stage breast cancers were treated with accelerated partial breast irradiation (APBI) using the MammoSite device (34 Gy in 10 fractions) in 1440 women. Of these, 1255 case (87%) had invasive breast cancer (IBC) (median size = 10 mm) and 194 cases (13%) had ductal carcinoma in situ (DCIS) (median size = 8 mm). Median follow-up was 59 months. Fisher exact test was performed to correlate categorical covariates with toxicity. RESULTS Breast seromas were reported in 28% of cases (35.5% with open cavity and 21.7% with closed cavity placement). Also, 13% of all treated breasts developed symptomatic seromas, and 77% of these seromas developed during the 1st year after treatment. There were 172 cases (11.9%) that required drainage to correct. Use of chemotherapy and balloon fill >50 cc were associated with the development of symptomatic seromas. Also, 2.3% of patients developed fat necrosis (FN). The incidence of FN during years 1 and 2 were 0.9% and 0.8%, respectively. Seroma formation, use of hormonal therapy, breast infection, and A/B cup size were associated with fat necrosis. There were 138 infections (9.5%) recorded; 98% occurred during the 1st year after treatment. Chemotherapy and seroma formation were associated with the development of infections. CONCLUSIONS Treatment-related toxicities 6 years after treatment with APBI using the MammoSite device are similar to those reported with other forms of APBI with similar follow-up.
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Affiliation(s)
- A J Khan
- Department of Radiation Oncology, Cancer Institute of New Jersey, New Brunswick, NJ, USA.
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Abstract
Breast-conserving therapy (BCT) and mastectomy have equal survival outcomes. Rates of local recurrence after BCT have declined steadily, largely as a result of the widespread use of systemic therapy. Sentinel node biopsy has replaced axillary dissection for staging the axilla, and in women undergoing BCT with whole-breast irradiation (WBI), axillary dissection is not needed for local control or survival in those with fewer than three involved sentinel nodes. Alternatives to 6 weeks of WBI have been shown to be safe and effective for subsets of breast cancer patients, and the use of preoperative chemotherapy allows BCT in some women who require mastectomy if surgery is the initial step in treatment. The combination of the smaller cancers detected with screening and the routine use of multimodality therapy has resulted in a decrease in the morbidity of local therapy and improved cancer treatment outcomes.
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Affiliation(s)
- Alice Ho
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York 10065, USA
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Hoover S, Bloom E, Patel S. Review of breast conservation therapy: then and now. ISRN ONCOLOGY 2011; 2011:617593. [PMID: 22229101 PMCID: PMC3200284 DOI: 10.5402/2011/617593] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/01/2011] [Accepted: 05/11/2011] [Indexed: 01/03/2023]
Abstract
Breast conservation therapy (BCT), which is the marriage of breast conserving surgery and radiation therapy to the breast, has revolutionized the treatment of breast cancer over the last few decades. Surgical direction had seen a heightened interest in the performance of cosmetically superior partial and segmental resections in breast conservation as well as increased demand by patients for breast preservation. The broadening of approaches to delivery of breast irradiation from whole breast to accelerated partial breast has allowed more patients to opt for breast conservation and allowed for what appears to be comparable measurable outcomes in emerging data. As well, the addition of state-of-the-art chemotherapeutic and hormonal therapies has allowed improved outcomes of patients from both local regional recurrence and overall survival standpoints. This paper will provide an overview of BCT and review some of the newest developments in optimizing this therapy for patients with breast cancer from a surgical-, medical-, and radiation-oncology standpoint.
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Affiliation(s)
- Susan Hoover
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
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22
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McHaffie DR, Patel RR, Adkison JB, Das RK, Geye HM, Cannon GM. Outcomes After Accelerated Partial Breast Irradiation in Patients With ASTRO Consensus Statement Cautionary Features. Int J Radiat Oncol Biol Phys 2011; 81:46-51. [PMID: 20732760 DOI: 10.1016/j.ijrobp.2010.05.011] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2009] [Revised: 04/16/2010] [Accepted: 05/07/2010] [Indexed: 11/18/2022]
MESH Headings
- Age Factors
- Brachytherapy/methods
- Brachytherapy/standards
- Breast Neoplasms/mortality
- Breast Neoplasms/pathology
- Breast Neoplasms/radiotherapy
- Breast Neoplasms/surgery
- Carcinoma in Situ/mortality
- Carcinoma in Situ/pathology
- Carcinoma in Situ/radiotherapy
- Carcinoma in Situ/surgery
- Carcinoma, Ductal, Breast/mortality
- Carcinoma, Ductal, Breast/pathology
- Carcinoma, Ductal, Breast/radiotherapy
- Carcinoma, Ductal, Breast/surgery
- Consensus
- Disease-Free Survival
- Dose Fractionation, Radiation
- Female
- Follow-Up Studies
- Humans
- Middle Aged
- Neoplasm Recurrence, Local/pathology
- Neoplasm Staging
- Patient Selection
- Radiation Oncology/standards
- Risk
- Societies, Medical/standards
- Tumor Burden
- Wisconsin
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Affiliation(s)
- Derek R McHaffie
- Department of Human Oncology, University of Wisconsin School of Medicine and Public Health, Madison, WI 53792, USA
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23
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Abstract
Generally, the limits of local tumor control are in part connected with the term "field cancerization" and are known from oral, lung, prostate, or mammary cancer. With the example of breast cancer (BC), the problem of ipsilateral breast tumor recurrences (IBTR) after breast-conserving surgery will be reviewed. Three types of local recurrences are distinguished: true recurrences, new primaries, or residual tumors. Good data for BC allow the description of the time-dependent risk of these three types, relative to the diagnosis of the primary tumor, because the time of initiation and the growth duration of the IBTR can be estimated. Two hypotheses explain the data: first, local recurrences may be initiated years before the diagnosis of a primary tumor (PT) and can then appear as multifocal PT at diagnosis, and second, true local recurrences probably do not metastasize. The generalizability of these hypotheses for other tumors will be discussed.
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Affiliation(s)
- Dieter Hölzel
- Munich Cancer Registry (MCR), Munich Cancer Center (MCC), Institute of medical Informatics, Biometry and Epidemiology (IBE), Ludwig-Maximilians-University (LMU) Munich, Munich, Germany.
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Lettmaier S, Kreppner S, Lotter M, Walser M, Ott OJ, Fietkau R, Strnad V. Radiation exposure of the heart, lung and skin by radiation therapy for breast cancer: A dosimetric comparison between partial breast irradiation using multicatheter brachytherapy and whole breast teletherapy. Radiother Oncol 2011; 100:189-94. [DOI: 10.1016/j.radonc.2010.07.011] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2010] [Revised: 07/09/2010] [Accepted: 07/09/2010] [Indexed: 11/26/2022]
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Brown S, McLaughlin M, Pope DK, Haile K, Hughes L, Israel PZ, Lyden M. A dosimetric comparison of the Contura multilumen balloon breast brachytherapy catheter vs. the single-lumen MammoSite balloon device in patients treated with accelerated partial breast irradiation at a single institution. Brachytherapy 2011; 10:68-73. [DOI: 10.1016/j.brachy.2010.01.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2009] [Revised: 12/22/2009] [Accepted: 01/05/2010] [Indexed: 10/19/2022]
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26
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Improvements in Critical Dosimetric Endpoints Using the Contura Multilumen Balloon Breast Brachytherapy Catheter to Deliver Accelerated Partial Breast Irradiation: Preliminary Dosimetric Findings of a Phase IV Trial. Int J Radiat Oncol Biol Phys 2011; 79:26-33. [DOI: 10.1016/j.ijrobp.2009.10.025] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2009] [Revised: 10/13/2009] [Accepted: 10/14/2009] [Indexed: 11/23/2022]
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Beitsch PD, Patel RR, Lorenzetti JD, Wurzer JC, Tucker JC, Laduzinsky SJ, Kugler MA. Post-surgical treatment of early-stage breast cancer with electronic brachytherapy: an intersociety, multicenter brachytherapy trial. Onco Targets Ther 2010; 3:211-8. [PMID: 21124748 PMCID: PMC2994203 DOI: 10.2147/ott.s14514] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Electronic brachytherapy (EBT) was developed to allow accelerated partial breast irradiation to be performed in a patient procedure room with minimal shielding. This observational, nonrandomized, multicenter study evaluated EBT as a post-surgical adjuvant radiation therapy for early stage breast cancer. METHODS This study included women aged 50 years or more with invasive carcinoma or ductal carcinoma in situ, tumor size ≤3 cm, negative lymph node status, and negative surgical margins. The endpoints were skin and subcutaneous toxicities, efficacy outcomes, cosmetic outcomes, and device performance. In this interim report, 1-month, 6-month, and 1-year follow-up data are available on 68, 59, and 37 patients, respectively. RESULTS The EBT device performed consistently, delivering the prescribed 34 Gy to all 69 patients (10 fractions/patient). Most adverse events were Grade 1 and included firmness, erythema, breast tenderness, hyperpigmentation, pruritis, field contracture, seroma, rash/desquamation, palpable mass, breast edema, hypopigmentation, telangiectasia, and blistering, which were anticipated. Breast infection occurred in two (2.9%) patients. No tumor recurrences were reported. Cosmetic outcomes were excellent or good in 83.9%-100% of evaluable patients at 1 month, 6 months, and 1 year. CONCLUSION This observational, nonrandomized, multicenter study demonstrates that this EBT device was reliable and well tolerated as an adjuvant radiation therapy for early stage breast cancer.
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Vicini F, Winter K, Wong J, Pass H, Rabinovitch R, Chafe S, Arthur D, Petersen I, White J, McCormick B. Initial efficacy results of RTOG 0319: three-dimensional conformal radiation therapy (3D-CRT) confined to the region of the lumpectomy cavity for stage I/ II breast carcinoma. Int J Radiat Oncol Biol Phys 2010; 77:1120-7. [PMID: 19910132 PMCID: PMC3365530 DOI: 10.1016/j.ijrobp.2009.06.067] [Citation(s) in RCA: 124] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2009] [Revised: 06/11/2009] [Accepted: 06/12/2009] [Indexed: 12/24/2022]
Abstract
PURPOSE This prospective study (Radiation Therapy Oncology Group 0319) examines the use of three-dimensional conformal external beam radiotherapy (3D-CRT) to deliver accelerated partial breast irradiation (APBI). Initial data on efficacy and toxicity are presented. METHODS AND MATERIALS Patients with Stage I or II breast cancer with lesions < or =3 cm, negative margins and with < or =3 positive nodes were eligible. The 3D-CRT was 38.5 Gy in 3.85 Gy/fraction delivered 2x/day. Ipsilateral breast, ipsilateral nodal, contralateral breast, and distant failure (IBF, INF, CBF, DF) were estimated using the cumulative incidence method. Mastectomy-free, disease-free, and overall survival (MFS, DFS, OS) were recorded. The National Cancer Institute Common Terminology Criteria for Adverse Events, version 3, was used to grade acute and late toxicity. RESULTS Fifty-eight patients were entered and 52 patients are eligible and evaluable for efficacy. The median age of patients was 61 years with the following characteristics: 46% tumor size <1 cm; 87% invasive ductal histology; 94% American Joint Committee on Cancer Stage I; 65% postmenopausal; 83% no chemotherapy; and 71% with no hormone therapy. Median follow-up is 4.5 years (1.7-4.8). Four-year estimates (95% CI) of efficacy are: IBF 6% (0-12%) [4% within field (0-9%)]; INF 2% (0-6%); CBF 0%; DF 8% (0-15%); MFS 90% (78-96%); DFS 84% (71-92%); and OS 96% (85-99%). Only two (4%) Grade 3 toxicities were observed. CONCLUSIONS Initial efficacy and toxicity using 3D-CRT to deliver APBI appears comparable to other experiences with similar follow-up. However, additional patients, further follow-up, and mature Phase III data are needed to evaluate the extent of application, limitations, and value of this particular form of APBI.
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MESH Headings
- Adult
- Aged
- Aged, 80 and over
- Breast Neoplasms/mortality
- Breast Neoplasms/pathology
- Breast Neoplasms/radiotherapy
- Breast Neoplasms/surgery
- Carcinoma, Ductal, Breast/mortality
- Carcinoma, Ductal, Breast/pathology
- Carcinoma, Ductal, Breast/radiotherapy
- Carcinoma, Ductal, Breast/surgery
- Female
- Follow-Up Studies
- Humans
- Mastectomy, Segmental
- Middle Aged
- Prospective Studies
- Radiotherapy, Conformal/adverse effects
- Radiotherapy, Conformal/methods
- Reproducibility of Results
- Survival Analysis
- Treatment Outcome
- Tumor Burden
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Affiliation(s)
- Frank Vicini
- Department of Radiation Oncology, William Beaumont Hospital, Royal Oak, MI 48073, USA.
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Ko EC, Koprowski CD, Dickson-Witmer D, Penman E, Sorensen M, Hanlon AL, Sammons S, Farach A, Strasser J. Partial vs. whole breast irradiation in a community hospital: A retrospective cohort analysis of 200 patients. Brachytherapy 2010; 9:248-53. [DOI: 10.1016/j.brachy.2009.12.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2009] [Revised: 12/02/2009] [Accepted: 12/03/2009] [Indexed: 11/26/2022]
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Whipp E, Beresford M, Sawyer E, Halliwell M. True Local Recurrence Rate in the Conserved Breast After Magnetic Resonance Imaging–Targeted Radiotherapy. Int J Radiat Oncol Biol Phys 2010; 76:984-90. [DOI: 10.1016/j.ijrobp.2009.03.026] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2008] [Revised: 02/24/2009] [Accepted: 03/03/2009] [Indexed: 11/27/2022]
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Dosimetric Improvements in Balloon Based Brachytherapy Using the Contura ® Multi-Lumen Balloon (MLB) Catheter to Deliver Accelerated Partial Breast Irradiation. J Contemp Brachytherapy 2010; 2:1-8. [PMID: 28031736 PMCID: PMC5183641 DOI: 10.5114/jcb.2010.13716] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2010] [Accepted: 03/15/2010] [Indexed: 11/17/2022] Open
Abstract
Purpose Preliminary dosimetric findings in patients managed with the Contura® Multi-Lumen Balloon (MLB) breast brachytherapy catheter to deliver accelerated partial breast irradiation (APBI) on a multi-institutional phase IV registry trial were reviewed. Material and methods CT-based 3D planning with dose optimization was performed for all patients. For the study, new ideal dosimetric goals were developed: 1) ≥ 95% of the prescribed dose (PD) covering ≥ 90% of the target volume (TV), 2) a maximum skin dose ≤ 125% of the PD, 3) maximum rib dose ≤ 145% of the PD, and 4) the V150 ≤ 50 cc and V200 ≤ 10 cc. The frequency of concurrently achieving these dosimetric goals using the Contura® MLB was investigated. Results 194 cases were evaluable. Employing the MLB, all ideal dosimetric criteria were achieved in 76% of cases. Evaluating dosimetric criteria separately, 90% and 89% of cases met the new ideal skin and rib dose criteria, respectively. In 96%, ideal TV coverage goals were achieved and in 96%, dose homogeneity criteria (V150 and V200) were met. For skin spacing ≥ 5-7 mm, the median skin dose was 121% of the PD and when < 5 mm, the median skin dose was 124.4%. For rib distancees < 5 mm, the median rib dose was reduced to 136.4% of the PD. For skin spacing < 7 mm and distance to rib < 5 mm, the median skin and rib doses were concurrently limited to 121% and 142.8% of the PD, respectively. Conclusions The Contura® MLB catheter provides potential improvements in dosimetric capabilities (i.e., reduced skin and rib doses and improved TV coverage) in many clinical scenarios.
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Polgár C, Van Limbergen E, Pötter R, Kovács G, Polo A, Lyczek J, Hildebrandt G, Niehoff P, Guinot JL, Guedea F, Johansson B, Ott OJ, Major T, Strnad V. Patient selection for accelerated partial-breast irradiation (APBI) after breast-conserving surgery: recommendations of the Groupe Européen de Curiethérapie-European Society for Therapeutic Radiology and Oncology (GEC-ESTRO) breast cancer working group based on clinical evidence (2009). Radiother Oncol 2010; 94:264-73. [PMID: 20181402 DOI: 10.1016/j.radonc.2010.01.014] [Citation(s) in RCA: 449] [Impact Index Per Article: 32.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2009] [Revised: 01/04/2010] [Accepted: 01/23/2010] [Indexed: 01/08/2023]
Abstract
PURPOSE To give recommendations on patient selection criteria for the use of accelerated partial-breast irradiation (APBI) based on available clinical evidence complemented by expert opinion. METHODS AND MATERIALS Overall, 340 articles were identified by a systematic search of the PubMed database using the keywords "partial-breast irradiation" and "APBI". This search was complemented by searches of reference lists of articles and handsearching of relevant conference abstracts and book chapters. Of these, 3 randomized and 19 prospective non-randomized studies with a minimum median follow-up time of 4 years were identified. The authors reviewed the published clinical evidence on APBI, complemented by relevant clinical and pathological studies of standard breast-conserving therapy and, through a series of personal communications, formulated the recommendations presented in this article. RESULTS The GEC-ESTRO Breast Cancer Working Group recommends three categories guiding patient selection for APBI: (1) a low-risk group for whom APBI outside the context of a clinical trial is an acceptable treatment option; including patients ageing at least 50 years with unicentric, unifocal, pT1-2 (<or=30 mm) pN0, non-lobular invasive breast cancer without the presence of an extensive intraductal component (EIC) and lympho-vascular invasion (LVI) and with negative surgical margins of at least 2mm, (2) a high-risk group, for whom APBI is considered contraindicated; including patients ageing <or=40 years; having positive margins, and/or multicentric or large (>30 mm) tumours, and/or EIC positive or LVI positive tumours, and/or 4 or more positive lymph nodes or unknown axillary status (pNx), and (3) an intermediate-risk group, for whom APBI is considered acceptable only in the context of prospective clinical trials. CONCLUSIONS These recommendations will provide a clinical guidance regarding the use of APBI outside the context of a clinical trial before large-scale randomized clinical trial outcome data become available. Furthermore they should promote further clinical research focusing on controversial issues in the treatment of early-stage breast carcinoma.
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Affiliation(s)
- Csaba Polgár
- Department of Radiotherapy, National Institute of Oncology, Budapest, Hungary.
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Polgár C, Major T, Fodor J, Sulyok Z, Somogyi A, Lövey K, Németh G, Kásler M. Accelerated partial-breast irradiation using high-dose-rate interstitial brachytherapy: 12-year update of a prospective clinical study. Radiother Oncol 2010; 94:274-9. [PMID: 20181401 DOI: 10.1016/j.radonc.2010.01.019] [Citation(s) in RCA: 163] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2009] [Revised: 01/26/2010] [Accepted: 01/29/2010] [Indexed: 01/19/2023]
Abstract
BACKGROUND AND PURPOSE To report the 12-year updated results of accelerated partial-breast irradiation (APBI) using multicatheter interstitial high-dose-rate (HDR) brachytherapy (BT). PATIENTS AND METHODS Forty-five prospectively selected patients with T1N0-N1mi, nonlobular breast cancer without the presence of an extensive intraductal component and with negative surgical margins were treated with APBI after breast-conserving surgery (BCS) using interstitial HDR BT. A total dose of 30.3 Gy (n=8) and 36.4 Gy (n=37) in seven fractions within 4 days was delivered to the tumour bed plus a 1-2 cm margin. The median follow-up time was 133 months for surviving patients. Local and regional control, disease-free (DFS), cancer-specific (CSS), and overall survival (OS), as well as late side effects, and cosmetic results were assessed. RESULTS Four (8.9%) ipsilateral breast tumour recurrences were observed, for a 5-, 10-, and 12-year actuarial rate of 4.4%, 9.3%, and 9.3%, respectively. A total of two regional nodal failures were observed for a 12-year actuarial rate of 4.4%. The 12-year DFS, CSS, and OS was 75.3%, 91.1%, and 88.9%, respectively. Grade 3 fibrosis was observed in one patient (2.2%). No patient developed grade 3 teleangiectasia. Fat necrosis requiring surgical intervention occurred in one woman (2.2%). Cosmetic results were rated excellent or good in 35 patients (77.8%). CONCLUSIONS Twelve-year results with APBI using HDR multicatheter interstitial implants continue to demonstrate excellent long-term local tumour control, survival, and cosmetic results with a low-rate of late side effects.
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Affiliation(s)
- Csaba Polgár
- Department of Radiotherapy, National Institute of Oncology, Budapest, Hungary.
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Accelerated partial breast irradiation consensus statement from the American Society for Radiation Oncology (ASTRO). Int J Radiat Oncol Biol Phys 2009; 74:987-1001. [PMID: 19545784 DOI: 10.1016/j.ijrobp.2009.02.031] [Citation(s) in RCA: 598] [Impact Index Per Article: 39.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2009] [Accepted: 02/25/2009] [Indexed: 01/05/2023]
Abstract
PURPOSE To present guidance for patients and physicians regarding the use of accelerated partial-breast irradiation (APBI), based on current published evidence complemented by expert opinion. METHODS AND MATERIALS A systematic search of the National Library of Medicine's PubMed database yielded 645 candidate original research articles potentially applicable to APBI. Of these, 4 randomized trials and 38 prospective single-arm studies were identified. A Task Force composed of all authors synthesized the published evidence and, through a series of meetings, reached consensus regarding the recommendations contained herein. RESULTS The Task Force proposed three patient groups: (1) a "suitable" group, for whom APBI outside of a clinical trial is acceptable, (2) a "cautionary" group, for whom caution and concern should be applied when considering APBI outside of a clinical trial, and (3) an "unsuitable" group, for whom APBI outside of a clinical trial is not generally considered warranted. Patients who choose treatment with APBI should be informed that whole-breast irradiation (WBI) is an established treatment with a much longer track record that has documented long-term effectiveness and safety. CONCLUSION Accelerated partial-breast irradiation is a new technology that may ultimately demonstrate long-term effectiveness and safety comparable to that of WBI for selected patients with early breast cancer. This consensus statement is intended to provide guidance regarding the use of APBI outside of a clinical trial and to serve as a framework to promote additional clinical investigations into the optimal role of APBI in the treatment of breast cancer.
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Mutyala S, Yaparpalvi R, Choi W, Mehta K, Spierer M, Kalnicki S. Placement of MammoSite brachytherapy catheter under computed-tomography scan guidance. Technol Cancer Res Treat 2009; 8:177-80. [PMID: 19445534 DOI: 10.1177/153303460900800301] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Placement of the MammoSite breast brachytherapy catheter is most commonly performed either intraoperatively or under ultrasound-guided technique. Below, we present a case report of an alternate approach utilizing CT-scan guidance. This is the first reported case of a balloon brachytherapy catheter placement with this technique.
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Affiliation(s)
- S Mutyala
- Department of Radiation Oncology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA.
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Limbergen EV. Accelerated partial breast irradiation with intracavitary balloon brachytherapy may be not as simple as it was supposed to be. Radiother Oncol 2009; 91:147-9. [DOI: 10.1016/j.radonc.2009.04.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Abstract
Balloon-based brachytherapy was developed to render accelerated partial-breast irradiation more accessible to breast cancer patients. Xoft Axxent electronic brachytherapy (eBX) is a novel method of accelerated partial-breast irradiation that utilizes an electronic source to produce x-rays. eBX does not require a high dose rate afterloader unit or a shielded vault and, thus, may appeal to a larger number of patients undergoing the accelerated partial-breast irradiation procedure. eBX is associated with a lower radiation dose to normal tissues and larger 'hot spots' than treatment with the MammoSite device. Additional applications are also being developed for eBX, including endometrial cancer treatment.
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Affiliation(s)
- Adam Dickler
- Department of Radiation Oncology, Little Company of Mary Hospital, 2800 West 95th Street, Evergreen Park, IL 60805, USA.
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Cuttino LW, Todor D, Rosu M, Arthur DW. Skin and chest wall dose with multi-catheter and MammoSite breast brachytherapy: Implications for late toxicity. Brachytherapy 2009; 8:223-226. [DOI: 10.1016/j.brachy.2008.11.007] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2008] [Revised: 10/31/2008] [Accepted: 11/04/2008] [Indexed: 11/17/2022]
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Current status and perspectives of brachytherapy for breast cancer. Int J Clin Oncol 2009; 14:7-24. [DOI: 10.1007/s10147-008-0867-y] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2008] [Indexed: 10/21/2022]
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Brown S, McLaughlin M, Pope K, Haile K, Hughes L, Israel PZ. Initial radiation experience evaluating early tolerance and toxicities in patients undergoing accelerated partial breast irradiation using the Contura Multi-Lumen Balloon breast brachytherapy catheter. Brachytherapy 2009; 8:227-233. [PMID: 19217353 DOI: 10.1016/j.brachy.2008.11.013] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2008] [Revised: 11/13/2008] [Accepted: 11/14/2008] [Indexed: 10/21/2022]
Abstract
PURPOSE We reviewed our institution's experience treating patients with the Contura Multi-Lumen Balloon (SenoRx, Inc., Irvine, CA) breast brachytherapy catheter to deliver accelerated partial breast irradiation. METHODS AND MATERIALS Forty-one patients treated with breast-conserving therapy received adjuvant radiation using the Contura catheter (34Gy in 3.4Gy fractions). Thirteen patients had Stage 0, 21 had Stage I, and 7 had Stage II breast cancer. Median followup was 8 months (range, 1-17). RESULTS Median, minimum skin spacing was 10mm (range, 2-17). Median, maximum skin doses (% of prescribed dose [PD]) were 99.7 (range, 57.1-124.1). Eight patients were treated with a skin spacing <or=5mm and 2 had a spacing of 2mm. Median, maximum rib doses were 102.6% of PD (10.0-187.7), and the median percentage of the planning target volume for evaluation (PTV_EVAL) receiving 95% of the PD was 98.8 (range, 79.4-107.4). The median volume receiving 200% of the PD was 5.7cc (range, 1.3-9.9). The percentage of patients with excellent/good cosmetic results at 6 months (n=15) and 12 months (n=12) was 100%. Patient tolerance was assessed on a scale 0-10 (0=no pain, 10=requiring narcotic analgesics). In 37 out of 38 patients, pain was graded <or=3 at the time of catheter insertion. Four breast infections (11%) and one transient symptomatic seroma (3%) developed. CONCLUSION Adjuvant accelerated partial breast irradiation using the Contura Multi-Lumen Balloon catheter exhibited similar toxicities to standard single lumen balloon brachytherapy with improvements in dosimetric capabilities (i.e., reduced skin and rib doses and improved PTV_EVAL coverage).
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Affiliation(s)
- Sheree Brown
- Department of Radiation Oncology, WellStar Kennestone Hospital, Marietta, GA
| | - Mark McLaughlin
- Department of Radiation Oncology, WellStar Kennestone Hospital, Marietta, GA.
| | - Keith Pope
- Department of Radiation Oncology, WellStar Kennestone Hospital, Marietta, GA
| | - Kenneth Haile
- Department of Radiation Oncology, WellStar Kennestone Hospital, Marietta, GA
| | - Laurie Hughes
- Department of Radiation Oncology, WellStar Kennestone Hospital, Marietta, GA
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Tubiana M. Can we reduce the incidence of second primary malignancies occurring after radiotherapy? A critical review. Radiother Oncol 2009; 91:4-15; discussion 1-3. [PMID: 19201045 DOI: 10.1016/j.radonc.2008.12.016] [Citation(s) in RCA: 208] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2008] [Revised: 11/27/2008] [Accepted: 12/31/2008] [Indexed: 12/19/2022]
Abstract
Second primary malignancies (SPMs) occurring after oncological treatment have become a major concern during the past decade. Their incidence has long been underestimated because most patients had a short life expectancy after treatment or their follow-up was shorter than 15 years. With major improvement of long-term survival, longer follow-up, cancer registries and end-result programs, it was found that the cumulative incidence of SPM could be as high as 20% of patients treated by radiotherapy. This cumulative proportion varies with several factors, which ought to be studied more accurately. The delay between irradiation and solid tumor emergence is seldom shorter than 10 years and can be as long as half a century. Thus, inclusion in a cohort of patients with a short follow-up leads to an underestimation of the proportion of SPM caused by treatment, unless actuarial cumulative incidence is computed. The incidence varies with the tissue and organs, the age of the patient at treatment, hereditary factors, but also, and probably mainly, with dose distribution, size of the irradiated volume, dose, and dose-rate. An effort toward a reduction in their incidence is mandatory. Preliminary data suggest that SPMs are mainly observed in tissues having absorbed doses above 2 Gy (fractionated irradiation) and that their incidence increases with the dose. However, in children thyroid and breast cancers are observed following doses as low as 100 mGy, and in adults lung cancers have been reported for doses of 500 mGy, possibly due to interaction with tobacco. The dose distribution and the dose per fraction have a major impact. However, the preliminary data regarding these factors need confirmation. Dose-rates appear to be another important factor. Some data suggest that certain patients, who could be identified, have a high susceptibility to radiocancer induction. Efforts should be made to base SPM reduction on solid data and not on speculation or models built on debatable hypotheses regarding the dose-carcinogenic effect relationship. In parallel, radiation therapy philosophy must evolve, and the aim of treatment should be to deliver the minimal effective radiation therapy rather than the maximal tolerable dose.
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Dickler A. Xoft Axxent electronic brachytherapy: a new device for delivering brachytherapy to the breast. Nat Rev Clin Oncol 2009; 6:138-42. [PMID: 19174776 DOI: 10.1038/ncponc1319] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2007] [Accepted: 08/08/2008] [Indexed: 12/19/2022]
Abstract
Balloon-based brachytherapy was developed to simplify the brachytherapy technique and make accelerated partial breast irradiation more accessible to patients with breast cancer who are suitable candidates for this technique. Xoft Axxent (Xoft, Inc., Sunnyvale, CA) electronic brachytherapy is a novel method of accelerated partial breast irradiation that uses an electronic source to produce X-rays. Xoft Axxent treatment does not require a high-dose-rate afterloader unit or a shielded vault, unlike other brachytherapy techniques that use iridium-192, such as MammoSite brachytherapy. Xoft Axxent is associated with the delivery of less radiation to normal tissues, and increased high radiation dose regions or 'hot spots' to the target volume compared with treatment with the MammoSite device. Further research will be needed to determine subgroups of patients who might benefit from treatment with Xoft Axxent electronic brachytherapy.
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Affiliation(s)
- Adam Dickler
- Department of Radiation Oncology, Little Company of Mary Hospital, Evergreen Park, IL 60805, USA.
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Dickler A, Seif N, Kirk MC, Patel MB, Bernard D, Coon A, Dowlatshahi K, Das RK, Patel RR. A dosimetric comparison of MammoSite® and ClearPath high-dose-rate breast brachytherapy devices. Brachytherapy 2009; 8:14-8. [DOI: 10.1016/j.brachy.2008.07.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2008] [Revised: 07/30/2008] [Accepted: 07/31/2008] [Indexed: 11/30/2022]
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Beitsch PD, Hodge CW, Dowlat K, Francescatti D, Gittleman MA, Israel P, Nelson JC, Potruch T, Snider, Jr HC, Whitworth P, Zannis VJ, Patel RR. The Surgeon’s Role in Breast Brachytherapy. Breast J 2009; 15:93-100. [DOI: 10.1111/j.1524-4741.2008.00676.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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In Response to Dr. Yaeger. Int J Radiat Oncol Biol Phys 2008. [DOI: 10.1016/j.ijrobp.2008.01.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Vicini F, Beitsch PD, Quiet CA, Keleher AJ, Garcia D, Snider HC, Gittleman MA, Zannis VJ, Kuerer HM, Lyden M. Three-year analysis of treatment efficacy, cosmesis, and toxicity by the American Society of Breast Surgeons MammoSite Breast Brachytherapy Registry Trial in patients treated with accelerated partial breast irradiation (APBI). Cancer 2008; 112:758-66. [PMID: 18181095 DOI: 10.1002/cncr.23227] [Citation(s) in RCA: 118] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND This report presents 3 years of data on treatment efficacy, cosmetic results, and toxicities for patients enrolled on the American Society of Breast Surgeons MammoSite (Cytyc, Bedford, Mass) Breast Brachytherapy Registry Trial. METHODS A total of 1440 patients (1449 cases) with early stage breast cancer who were undergoing breast-conserving therapy were treated with the MammoSite device to deliver accelerated partial breast irradiation (APBI) (34 Gy in 3.4 Gy fractions). Of these, 1255 (87%) cases had invasive breast cancer (IBC; median size = 10 mm), and 194 (13%) cases had ductal carcinoma in situ (DCIS; median size = 8 mm). Median follow-up was 30.1 months. RESULTS Twenty-three (1.6%) cases developed an ipsilateral breast tumor recurrence (IBTR) for a 2-year actuarial rate of 1.04% (1.11% for IBC and 0.59% for DCIS). No variables were associated with IBTR. Six (0.4%) patients developed an axillary failure. The percentages of breasts with good to excellent cosmetic results at 12 (n = 980), 24 (n = 752), 36 (n = 403), and 48 months (n = 67 cases) were 95%, 94%, 93%, and 93%, respectively. Breast seromas were reported in 23.9% of cases (30% in open-cavity implants and 19% in closed-cavity implants). Symptomatic seromas occurred in 10.6% of cases, and 1.5% of cases developed fat necrosis. A subset analysis of the first 400 consecutive cases enrolled was performed (352 with IBC, 48 DCIS). With a median follow-up of 37.5 months, the 3-year actuarial rate of IBTR was 1.79%. CONCLUSIONS Treatment efficacy, cosmesis, and toxicity 3 years after treatment with APBI using the MammoSite device are good and similar to those reported with other forms of APBI with similar follow-up.
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Affiliation(s)
- Frank Vicini
- Department of Radiation Oncology, William Beaumont Hospital, Royal Oak, Michigan 48072, USA.
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Arthur DW, Winter K, Kuske RR, Bolton J, Rabinovitch R, White J, Hanson WF, Wilenzick RM, McCormick B. A Phase II trial of brachytherapy alone after lumpectomy for select breast cancer: tumor control and survival outcomes of RTOG 95-17. Int J Radiat Oncol Biol Phys 2008; 72:467-73. [PMID: 18294778 DOI: 10.1016/j.ijrobp.2007.12.056] [Citation(s) in RCA: 142] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2007] [Accepted: 12/19/2007] [Indexed: 12/21/2022]
Abstract
PURPOSE Radiation Therapy Oncology Group 95-17 is a prospective Phase II cooperative group trial of accelerated partial breast irradiation (APBI) alone using multicatheter brachytherapy after lumpectomy in select early-stage breast cancers. Tumor control and survival outcomes are reported. METHODS AND MATERIALS Eligibility criteria included Stage I/II breast carcinoma confirmed to be <3 cm, unifocal, invasive nonlobular histology with zero to three positive axillary nodes without extracapsular extension. APBI treatment was delivered with either low-dose-rate (LDR) (45 Gy in 3.5-5 days) or high-dose-rate (HDR) brachytherapy (34 Gy in 10 twice-daily fractions over 5 days). End points evaluated included in-breast control, regional control, mastectomy-free rate, mastectomy-free survival, disease-free survival, and overall survival. The study was designed to analyze the HDR and LDR groups separately and without comparison. RESULTS Between 1997 and 2000, 100 patients were accrued and 99 were eligible; 66 treated with HDR brachytherapy and 33 treated with LDR brachytherapy. Eighty-seven patients had T1 lesions and 12 had T2 lesions. Seventy-nine were pathologically N0 and 20 were N1. Median follow-up in the HDR group is 6.14 years with the 5-year estimates of in-breast, regional, and contralateral failure rates of 3%, 5%, and 2%, respectively. The LDR group experienced similar results with a median follow-up of 6.22 years. The 5-year estimates of in-breast, regional, and contralateral failure rates of 6%, 0%, and 6%, respectively. CONCLUSION Patients treated with multicatheter partial breast brachytherapy in this trial experienced excellent in-breast control rates and overall outcome that compare with reports from APBI studies with similar extended follow-up.
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Affiliation(s)
- Douglas W Arthur
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, VA 23298-0058, USA.
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Chino JP, Marks LB. Prone Positioning Causes the Heart To Be Displaced Anteriorly Within the Thorax: Implications for Breast Cancer Treatment. Int J Radiat Oncol Biol Phys 2008; 70:916-20. [DOI: 10.1016/j.ijrobp.2007.11.001] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2007] [Revised: 11/01/2007] [Accepted: 11/01/2007] [Indexed: 01/10/2023]
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Belkacémi Y, Marsiglia H, Hannoun-Levi JM, Orecchia R, Kuten A, Dubois JB, Lartigau E. Irradiation partielle et accélérée du sein: une réelle perspective thérapeutique pour le cancer du sein de bon pronostic. ONCOLOGIE 2008. [DOI: 10.1007/s10269-007-0793-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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