1
|
Sfarad HK, Allweis TM. Postoperative Complications Following Lumpectomy With Intraoperative X-Ray Radiation Therapy: A Retrospective Comparative Study. Clin Breast Cancer 2024; 24:237-242. [PMID: 38233254 DOI: 10.1016/j.clbc.2023.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 10/28/2023] [Accepted: 12/16/2023] [Indexed: 01/19/2024]
Abstract
BACKGROUND Lumpectomy with intraoperative radiation (IORT) is a relatively new modality for the treatment of early breast cancer. IORT delivers targeted radiation to the tumor bed and obviates the need for external beam radiation (EBRT) in 85% of the cases. IORT is being used increasingly around the world, however information regarding early and late postoperative complications associated with the procedure is limited. AIM To describe and compare complication rates after lumpectomy and IORT with those seen after lumpectomy and EBRT or lumpectomy alone. METHODS Clinical, demographic, and histopathological data were collected from electronic medical records and a retrospectively maintained database. Postoperative complications were compared for patients undergoing lumpectomy with IORT, lumpectomy with EBRT, and lumpectomy alone over the same period. RESULTS A total of 445 patients were included in the study: 113 underwent lumpectomy with IORT, 253 had lumpectomy followed by EBRT, and 79 had Lumpectomy alone. Postoperative seroma was documented in 74 patients (65%) after IORT,87 (34%) after EBRT, and 9 (11%) after lumpectomy alone (P = .000). Surgical site infection requiring antibiotic treatment was diagnosed in 26 patients (23%) after IORT, 38 (15%) after EBRT, and 5 (6%) after lumpectomy alone (P = .013). Postoperative erythema was documented in 39 patients (34%) after IORT, 40 (16%) after EBRT, and 5 (6%) after lumpectomy alone (P = .000). Postoperative minor complications such as scar and breast deformity, edema, Mondor's syndrome, and chronic tenderness, were documented in 62 patients (55%) after IORT, 119 (47%) after EBRT, and 13 (17%) after lumpectomy alone (P = .000). The average follow-up was 14 months. CONCLUSIONS IORT is associated with an increased rate of postoperative complications compared to EBRT or lumpectomy alone. Most complications are minor and transient. We hypothesize that the increased occurrence of complications may also be attributed to overreporting, which is associated with the introduction of a new technology. Educating physicians and patients about potential complications and their course may help establish expectations and improve the management of postoperative complications.
Collapse
Affiliation(s)
| | - Tanir M Allweis
- Department of Breast Surgery, Hadassah Medical Center, Jerusalem, Israel; Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| |
Collapse
|
2
|
Yang G, Kim JW, Lee IJ, Jeong J, Ahn SG, Bae SJ, Kim JH, Cho Y. Feasibility of Intraoperative Radiotherapy Tumor Bed Boost in Patients with Breast Cancer after Neoadjuvant Chemotherapy. Yonsei Med J 2024; 65:129-136. [PMID: 38373832 PMCID: PMC10896667 DOI: 10.3349/ymj.2023.0229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 10/27/2023] [Accepted: 11/02/2023] [Indexed: 02/21/2024] Open
Abstract
PURPOSE This study aimed to assess the feasibility and safety of administering intraoperative radiotherapy (IORT) as a boost during breast-conserving surgery (BCS) following neoadjuvant chemotherapy for patients at high risk of breast cancer recurrence. MATERIALS AND METHODS Patients who underwent neoadjuvant chemotherapy received a single 20-Gy dose of IORT during BCS, followed by external beam radiotherapy 4-6 weeks after surgery. RESULTS The median follow-up duration was 31.0 months (range, 18.0-59.0 months). Initial tumor sizes had a median of 2.6 cm (range: 0.8-5.3 cm), reducing to 0.3 cm (range: 0-4.0 cm) after neoadjuvant chemotherapy. The most common neoadjuvant chemotherapy regimen was doxorubicin and cyclophosphamide, followed by paclitaxel (n=42, 73.7%). Among 57 patients who received neoadjuvant chemotherapy before BCS and IORT, 2 patients (3.5%) required secondary surgery to achieve negative resection margins due to initially positive margins. Regional lymph node irradiation was performed in 37 (64.9%) patients. There was no grade 3 or higher adverse events, with 4 patients (7.0%) experiencing grade 2 acute radiation dermatitis and 3 (5.3%) having less than grade 2 breast edema. Binary correlation analysis did not reveal statistically significant associations between applicator size or radiation therapy modality and the risk of treatment-related toxicity. Furthermore, chi-square analysis showed that the grade of treatment-related toxicity was not associated with the fractionated regimen (p=0.375). CONCLUSION Most patients successfully received IORT as a tumor bed boost after neoadjuvant chemotherapy. Thus, IORT may be a safe and feasible option for patients with advanced-stage breast cancer receiving neoadjuvant chemotherapy.
Collapse
Affiliation(s)
- Gowoon Yang
- Department of Radiation Oncology, Yonsei Cancer Center, Heavy Ion Therapy Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Jun Won Kim
- Department of Radiation Oncology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Ik Jae Lee
- Department of Radiation Oncology, Yonsei Cancer Center, Heavy Ion Therapy Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Joon Jeong
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Sung Gwe Ahn
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Soong June Bae
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jee Hung Kim
- Division of Medical Oncology, Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Yeona Cho
- Department of Radiation Oncology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea.
| |
Collapse
|
3
|
Zangouri V, Roshanshad A, Ranjbar A, Izadi M, Rajaeifar S, Goodarzi A, Nasrollahi H. Outcomes and complications of intraoperative radiotherapy versus external beam radiotherapy for early breast cancer. Cancer Rep (Hoboken) 2024; 7:e1950. [PMID: 38205671 PMCID: PMC10849931 DOI: 10.1002/cnr2.1950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 09/19/2023] [Accepted: 11/12/2023] [Indexed: 01/12/2024] Open
Abstract
BACKGROUND Intraoperative radiotherapy (IORT) is an alternative for external beam radiotherapy (EBRT) for early stage breast cancer (BC). Herein, we compared outcomes, postoperative and post-radiation complications of IORT and EBRT. METHODS We conducted a cohort study to compare complications of IORT and EBRT in patients. A checklist of the complications of IORT and EBRT, was used to assess and post-radiation complications and outcomes. RESULTS Overall, 264 women (121 in IORT and 143 in EBRT group) with a mean (SD) age of 55 ± 8.6 years analyzed in this study. The IORT group (quadrantectomy + SLNB + IORT) had more severe post-operative pain compared to the EBRT group (quadrantectomy + SLNB) (OR = 1.929, 95% CI: 1.116-3.332). Other postoperative complications, including edema, erythema, seroma, hematoma, and wound complications were not significantly different between the IORT and EBRT groups. EBRT was associated with higher rates post-radiation complications, including erythema (95.8% vs. 21.5%), skin dryness (30.8% vs. 12.4%), pruritus (26.6% vs. 17.4%), hyperpigmentation (48.3% vs. 9.9%), and telangiectasia (1.4% vs. 0.8%). Multivariate analysis showed that erythema, skin dryness and pruritus, and hyperpigmentation were more severe in the EBRT group, while breast induration was higher in the IORT group (OR = 4.109, 95% CI: 2.242-7.531). Excellent, good, and fair cosmetic outcome was seen in 11.2%, 72%, and 16.8% of the patients in the EBRT group and 29.8%, 63.6%, and 6.6% in the IORT group, respectively, suggesting that the cosmetic outcome was significantly better in the IORT group (P < .001). There wasn't statistically significant difference in recurrence-free survival and overall survival rates between two groups of patients who received either IORT or EBRT (P = .953, P = .56). CONCLUSION IORT is considered to have lower post-radiation complications and better cosmetic outcomes in breast cancer patients. Therefore, IORT might be used as the treatment of choice in eligible patients.
Collapse
Affiliation(s)
- Vahid Zangouri
- Surgical Oncology Division, General Surgery DepartmentShiraz University of Medical SciencesShirazIran
- Breast Diseases Research CenterShiraz University of Medical SciencesShirazIran
| | - Amirhossein Roshanshad
- Student Research CommitteeShiraz University of Medical SciencesShirazIran
- Poostchi Ophthalmology Research CenterShiraz University of Medical SciencesShirazIran
| | - Aliyeh Ranjbar
- Breast Diseases Research CenterShiraz University of Medical SciencesShirazIran
- Student Research CommitteeShiraz University of Medical SciencesShirazIran
| | - Mahsa Izadi
- Student Research CommitteeShiraz University of Medical SciencesShirazIran
| | - Sara Rajaeifar
- Student Research CommitteeShiraz University of Medical SciencesShirazIran
| | - Ali Goodarzi
- Student Research CommitteeShiraz University of Medical SciencesShirazIran
| | - Hamid Nasrollahi
- Radiation Oncology, Radio‐Oncology Department, School of MedicineShiraz University of Medical SciencesShirazIran
| |
Collapse
|
4
|
Mirkazemi MS, Mahdavi SR, Nafissi N, Monfared AS, Ghoreishi SM, Gorji KE. Estimating the skin dose near to the applicator and acute toxicity in breast cancer patients: An intraoperative electron radiotherapy technique. J Cancer Res Ther 2023; 19:650-656. [PMID: 37470589 DOI: 10.4103/jcrt.jcrt_898_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Introduction Intraoperative electron radiation therapy (IOERT) is one of the most recently popular therapeutic methods for breast cancer. This study aimed to measure the skin dose near the applicator during IOERT of breast cancer patients, as well as, the incidence of acute toxicity after surgery. Materials and Methods Thirty-six female patients participated in the current study with the prescribed dose of 21 and 12 Gy for IOERT as full and boost, respectively. The skin dose was investigated based on different applicator sizes, tumor bed thicknesses, and monitor units (MUs). The energy was chosen 8 MeV, and EBT3 film was used for the dosimetric process. In addition, the acute toxicity included healing time for the surgical wound, scaling of the skin, itching, necrosis, redness as well as seroma formation for 1 week and 1 month were recorded. The results were compared to those of 22 patients who underwent the surgery without IOERT. Results The highest skin dose for the patients was obtained 2.09 Gy, which is lower than the threshold dose (6 Gy). Furthermore, the findings showed that the average skin dose was higher in bigger applicator sizes and MU and lower tumor bed thicknesses. The average of wound healing for the patient underwent IOERT and without the use of IOERT (as the control group) was 19.32 and 11.67 days, respectively. One month after surgery, the volume of aspirated seroma was higher in the patients who performed IOERT compared to the control group (250 ml vs. 200 ml). It is notable that there were not observed any redness, itching, scaling, and necrosis in both investigated groups. Conclusion Owing to the results, the skin dose during IOERT was lower than the recommended level. The dose of IOERT as a full was higher than boost which can be related to the lower number of the patients in full method; however, there was a well-tolerated without severe acute complication, especially seroma formation and wound healing time in both full and boost methods.
Collapse
Affiliation(s)
| | - Seyed Rabi Mahdavi
- Department of Medical Physics, Iran University of Medical Sciences, Tehran, Iran
| | - Nahid Nafissi
- Surgical Department, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Ali Shabestani Monfared
- Cancer Research Center, Health Research Institute, Babol University of Medical Sciences, Babol, Iran
| | - Seyedeh Masoumeh Ghoreishi
- Cellular and Molecular Biology Research Center, Health Research Institute, Babol University of Medical Sciences, Babol, Iran
| | | |
Collapse
|
5
|
Vaidya JS, Vaidya UJ, Baum M, Bulsara MK, Joseph D, Tobias JS. Global adoption of single-shot targeted intraoperative radiotherapy (TARGIT-IORT) for breast cancer—better for patients, better for healthcare systems. Front Oncol 2022; 12:786515. [PMID: 36033486 PMCID: PMC9406153 DOI: 10.3389/fonc.2022.786515] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 06/28/2022] [Indexed: 12/30/2022] Open
Abstract
Micro abstractTargeted intraoperative radiotherapy (TARGIT-IORT) is delivered immediately after lumpectomy for breast cancer. We estimated its impact. At least 44,752 patients with breast cancer were treated with TARGIT-IORT in 260 centres in 35 countries, saving >20 million miles of travel and preventing ~2,000 non–breast cancer deaths. The TARGIT-IORT website (https://targit.org.uk/travel) provides maps and tools to find the nearest centre offering TARGIT-IORT and travel savings.BackgroundTargeted intraoperative radiotherapy (TARGIT-IORT) delivers radiotherapy targeted to the fresh tumour bed exposed immediately after lumpectomy for breast cancer. TARGIT-A trial found TARGIT-IORT to be as effective as whole-breast radiotherapy, with significantly fewer deaths from non–breast cancer causes. This paper documents its worldwide impact and provides interactive tools for clinicians and patients.MethodCentres using TARGIT-IORT provided the date of the first case and the total number of patients. We plotted these data on a customised Google Map. An interactive web-based tool provided directions to the closest centre. Using the data from the TARGIT-A trial, we estimated the total savings in travel miles, carbon footprint, and the number of non–breast cancer deaths that might be prevented.ResultsData from 242 (93%) of the 260 centres treating patients from 35 countries were available. From the first patient treated in 1998 to early 2020, at least 44,752 women with breast cancer have been treated with TARGIT-IORT. The TARGIT-IORT website (https://targit.org.uk/travel) displays the Google Map of centres with number of cases and an interactive tool for patients to find the nearest centre offering TARGIT-IORT and their travel savings. Scaling up to the already treated patients, >20 million miles of travel would have been saved and about 2,000 deaths prevented.ConclusionOne can ascertain the number of patients treated with a novel treatment. These data show how widely TARGIT-IORT has now been adopted and gives an indication of its beneficial worldwide impact on a large number of women with breast cancer.
Collapse
Affiliation(s)
- Jayant Sharad Vaidya
- Division of Surgery and Interventional Science, University College London, London, United Kingdom
- *Correspondence: Jayant Sharad Vaidya, ;
| | - Uma Jayant Vaidya
- Medical Sciences Division Brasenose College, University of Oxford, Oxford, United Kingdom
| | - Michael Baum
- Division of Surgery and Interventional Science, University College London, London, United Kingdom
| | - Max Kishor Bulsara
- Division of Surgery and Interventional Science, University College London, London, United Kingdom
- Department of Biostatistics, University of Notre Dame, Fremantle, WA, Australia
| | - David Joseph
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Perth, WA, Australia
| | - Jeffrey S. Tobias
- Department of Clinical Oncology, University College London Hospitals, London, United Kingdom
| |
Collapse
|
6
|
Acree P, Kapadia A, Mahatme R, Zhang L, Patel D, Almoney C, Park G, Kofsky M, Matin S, Habibi M. Review of Current Accepted Practices in Identification of the Breast Lumpectomy Tumor Bed. Adv Radiat Oncol 2022; 7:100848. [PMID: 36148372 PMCID: PMC9486415 DOI: 10.1016/j.adro.2021.100848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 11/01/2021] [Indexed: 11/29/2022] Open
Abstract
Purpose Of the 260,000 women diagnosed with breast cancer annually in the United States, more than 60% are treated with breast-conserving surgery or lumpectomy, followed by radiation to decrease the chance of local recurrence. More than 70% of breast cancer recurrences are localized to the original tumor cavity. Hence, targeted radiation therapy after lumpectomy is critical for recurrence prevention. With 30,000 patients annually opting for oncoplastic reconstruction of the breast after lumpectomy to improve cosmesis, the resulting tissue rearrangement increases the difficulty for radiation oncologists to accurately delineate the cavity when planning radiation therapy. Owing to the absence of a standardized protocol, it is important to assess the efficacy of various methods used to mark the tumor cavity for improved delineation. Methods and Materials A keyword search and analysis was used to compile relevant articles on PubMed (National Center for Biotechnology Information). Results Currently, a common practice for tumor cavity localization is applying titanium surgical clips to the borders of lumpectomy cavity. Tissue movement and seroma formation both impact the positioning of surgical clips within the tumor cavity and lead to significant interobserver variability. Furthermore, the main application of surgical clips is to control the small vessels during surgery, and that can create confusion when the same clips are used for tumor bed localization. All alternative solutions present more precise tumor bed delineation but possess individual concerns with workflow integration, patient comfort, and accuracy. Though liquid-based fiducials were found to be the most effective for delineating tumor cavities, there are still drawbacks for clinical use. Conclusions These findings should encourage medical innovators to develop novel techniques for tumor cavity marking to increase delineation accuracy and effectively target at-risk tissue. Future solutions in this space should consider the properties of liquid-based fiducial markers to improve radiation oncologists' ability to precisely delineate the tumor cavity.
Collapse
|
7
|
Guillerm SO, Bourstyn E, Itti R, Cahen-Doidy L, Quéro L, Labidi M, Marchand E, Lorphelin H, Giacchetti S, Cuvier C, Espié M, Teixeira L, Hennequin C. Intraoperative Radiotherapy for Breast Cancer in Elderly Women. Clin Breast Cancer 2021; 22:e109-e113. [PMID: 34154928 DOI: 10.1016/j.clbc.2021.05.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 04/18/2021] [Accepted: 05/06/2021] [Indexed: 11/17/2022]
Abstract
PURPOSE To evaluate outcomes and postoperative toxicities after intraoperative radiotherapy (IORT) in elderly women. POPULATION Women older than 65 years, with infiltrating ductal breast cancer ≤3 cm, expressing estrogen receptor (ER+) without Her2 overexpression, and with negative axillary nodes. TREATMENT Treatment consisted of partial mastectomy with a sentinel lymph node biopsy (SLNB) procedure; in case of positive SLNB, IORT was cancelled. IORT consisted in a total dose of 20 Gy in 1 fraction delivered at the surface of the applicator with the Intrabeam® technique. RESULTS IORT was planned to be administered to a total of 225 patients but was cancelled for 34 patients during surgery. Thus 191 patients were analyzed; mean age was 76 years, with 57 patients (30%) >80 years. Despite inclusion criteria, 15 had lobular carcinoma and 7 were triple negative. With a median follow-up of 40 months, we observed only 1 local recurrence, located in the skin over the initial tumor. The 5-year local relapse rate was 1.7%. A wound healing delay (>15 days) was observed in 21 patients (11%). Sixty-six patients (35%) had postoperative complications, mainly grade 2, resolving within a few days. Two patients needed surgical drainage for local abscesses. Long-term (>1 year) cosmetic outcome was evaluated in 120 patients and was judged excellent or good in 102 (91%). CONCLUSION IORT can be safely given to elderly women, with a good local control rate and without major toxicities.
Collapse
Affiliation(s)
- S Ophie Guillerm
- Radiation Oncology Department, Saint-Louis Hospital, Paris, France; Breast Cancer Unit, Saint-Louis Hospital, Paris, France
| | - Edwige Bourstyn
- Radiation Oncology Department, Saint-Louis Hospital, Paris, France; Breast Cancer Unit, Saint-Louis Hospital, Paris, France
| | - Ramona Itti
- Radiation Oncology Department, Saint-Louis Hospital, Paris, France; Breast Cancer Unit, Saint-Louis Hospital, Paris, France
| | - Laurence Cahen-Doidy
- Radiation Oncology Department, Saint-Louis Hospital, Paris, France; Breast Cancer Unit, Saint-Louis Hospital, Paris, France
| | - Laurent Quéro
- Radiation Oncology Department, Saint-Louis Hospital, Paris, France; Breast Cancer Unit, Saint-Louis Hospital, Paris, France
| | - Mouna Labidi
- Radiation Oncology Department, Saint-Louis Hospital, Paris, France; Breast Cancer Unit, Saint-Louis Hospital, Paris, France
| | - Eva Marchand
- Radiation Oncology Department, Saint-Louis Hospital, Paris, France; Breast Cancer Unit, Saint-Louis Hospital, Paris, France
| | - Henri Lorphelin
- Radiation Oncology Department, Saint-Louis Hospital, Paris, France; Breast Cancer Unit, Saint-Louis Hospital, Paris, France
| | - Sylvie Giacchetti
- Radiation Oncology Department, Saint-Louis Hospital, Paris, France; Breast Cancer Unit, Saint-Louis Hospital, Paris, France
| | - Caroline Cuvier
- Radiation Oncology Department, Saint-Louis Hospital, Paris, France; Breast Cancer Unit, Saint-Louis Hospital, Paris, France
| | - Marc Espié
- Radiation Oncology Department, Saint-Louis Hospital, Paris, France; Breast Cancer Unit, Saint-Louis Hospital, Paris, France
| | - Luis Teixeira
- Radiation Oncology Department, Saint-Louis Hospital, Paris, France; Breast Cancer Unit, Saint-Louis Hospital, Paris, France
| | - Christophe Hennequin
- Radiation Oncology Department, Saint-Louis Hospital, Paris, France; Breast Cancer Unit, Saint-Louis Hospital, Paris, France.
| |
Collapse
|
8
|
Post IORT seroma complication in breast cancer surgery. JOURNAL OF RADIOTHERAPY IN PRACTICE 2020. [DOI: 10.1017/s1460396920000679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractBackground:Intraoperative radiotherapy (IORT) has gained popularity over recent years due to its impact on shortening the radiotherapy treatment time for early breast cancer. It has certainly proven effective as an exclusive treatment or when combined with whole breast irradiation (WBIR). Seroma is a common non-life-threatening complication that may delay treatment and impose challenges on radiological diagnostic follow-up.Aim:To review and compare the occurrence of seroma in patients who received exclusive IORT or when combined with WBIR and to outline the diagnostic challenges encountered during radiological follow-up.Materials and methods:Based on strict selection criteria, all eligible patients who received IORT ± WBIR treatment between 2012 and 2019 in a university hospital setting were included. Demographic data, histological diagnosis, tumour size, tumour grade, lymphovascular invasion, nodal status, receptor status, treatment with neoadjuvant hormonal chemotherapy, applicator size, dose used, duration of radiotherapy treatment, timing of seroma development and duration of seroma were documented. Both clinical and radiological follow-up were exercised in all patients.Results:The total number of patients treated with breast conserving surgery (BCS) and IORT was 86. Age ranged between 31 and 75 years with the median age of 51 years. Patients treated exclusively with IORT were 39 (45%) while those who received the IORT as a boost were 47 (55%). Seroma was observed in 39(45%) of both IORT and IORT\WBIR patients. Those included 15(38%) of the exclusive IORT treated patients and 24 (62%) of those treated as a boost. Duration of asymptomatic seroma ranged from 6 months to 6 years. Repeated aspiration was performed in 2 (5%) patients. Postoperative seroma occurred independent of age histological diagnosis, tumour size, tumour grade, lymphovascular invasion, nodal status, receptor status, treatment with neoadjuvant hormonal\chemotherapy, applicator size, dose used or duration of radiotherapy treatment. All reviewed patients have shown increased risk of developing seroma; however, an increased incidence of seroma in the IORT + WBIR treated patients was higher than those who received exclusive IORT treatment.Conclusion:Postoperative seroma is a common non-life-threatening entity that occasionally may lead to delay in the subsequent treatment plan. IORT is a safe modality with many benefits; however, it may increase the risk of seroma formation independent of the clinical parameters. Promoting the expertise in post IORT breast imaging aids in overcoming diagnostic challenges.
Collapse
|
9
|
Rana S, Naik A, Pillai S, Vetto J, Pommier R, Kubicky CD. Outcomes of intraoperative radiotherapy for early-stage breast cancer: Experience from a multidisciplinary breast oncology program. Am J Surg 2019; 219:655-659. [PMID: 31242962 DOI: 10.1016/j.amjsurg.2019.06.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2019] [Revised: 06/03/2019] [Accepted: 06/08/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Intraoperative radiotherapy (IORT) was implemented at our institution for early stage breast cancer patients including those with geographic or medical co-morbidity limitations to whole breast radiation therapy (WBRT). METHODS Retrospective review of patients (n = 127) who underwent IORT from 2009 to 2016 for breast cancer. Demographics, pathology, toxicity, and recurrences were ascertained. RESULTS The median age was 67 years (interquartile range: 62-73). At median follow-up (49.6 months), 5 patients (4%) had ipsilateral breast tumor recurrence with median time to recurrence of 36.8 months. Acute and late grade ≥3 skin toxicities were observed in 3.1% and 4.7% of patients, respectively. A subset (n = 7) who received prior ipsilateral WBRT was found to have no subsequent local recurrence, one case of acute grade 3 skin toxicity, and no late toxicity. CONCLUSIONS IORT is a safe and effective alternative to whole breast radiotherapy, and serves as a suitable alternative to completion mastectomy in locally recurrent breast cancer.
Collapse
Affiliation(s)
- Shushan Rana
- Oregon Health & Science University, 3181 SW Sam Jackson Rd, Portland, OR, 97239, USA.
| | - Arpana Naik
- Oregon Health & Science University, 3181 SW Sam Jackson Rd, Portland, OR, 97239, USA
| | - Susha Pillai
- Oregon Health & Science University, 3181 SW Sam Jackson Rd, Portland, OR, 97239, USA
| | - John Vetto
- Oregon Health & Science University, 3181 SW Sam Jackson Rd, Portland, OR, 97239, USA
| | - Rodney Pommier
- Oregon Health & Science University, 3181 SW Sam Jackson Rd, Portland, OR, 97239, USA
| | - Charlotte Dai Kubicky
- Oregon Health & Science University, 3181 SW Sam Jackson Rd, Portland, OR, 97239, USA
| |
Collapse
|
10
|
König L, Lang K, Heil J, Golatta M, Major G, Krug D, Hörner-Rieber J, Häfner MF, Koerber SA, Harrabi S, Bostel T, Debus J, Uhl M. Acute Toxicity and Early Oncological Outcomes After Intraoperative Electron Radiotherapy (IOERT) as Boost Followed by Whole Breast Irradiation in 157 Early Stage Breast Cancer Patients-First Clinical Results From a Single Center. Front Oncol 2019; 9:384. [PMID: 31165041 PMCID: PMC6536702 DOI: 10.3389/fonc.2019.00384] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Accepted: 04/24/2019] [Indexed: 11/13/2022] Open
Abstract
Introduction: Breast conserving surgery (BCS) followed by postoperative whole breast irradiation (WBI) is the current standard of care for early stage breast cancer patients. Boost to the tumor bed is recommended for patients with a higher risk of local recurrence and may be applied with different techniques. Intraoperative electron radiotherapy (IOERT) offers several advantages compared to other techniques, like direct visualization of the tumor bed, better skin sparing, less inter- and intrafractional motion, but also radiobiological effects may be beneficial. Objective of this retrospective analysis of IOERT as boost in breast cancer patients was to assess acute toxicity and early oncological outcomes. Material and Methods: All patients, who have been irradiated between 11/2014 and 01/2018 with IOERT during BCS were analyzed. IOERT was applied using the mobile linear accelerator Mobetron with a total dose of 10 Gy, prescribed to the 90% isodose. After ensured woundhealing, WBI followed with normofractionated or hypofractionated regimens. Patient reports, including diagnostic examinations and toxicity were analyzed after surgery and 6-8 weeks after WBI. Overall survival, distant progression-free survival, in-breast and contralateral breast local progression-free survival were calculated using the Kaplan-Meier method. Furthermore, recurrence patterns were assessed. Results: In total, 157 patients with a median age of 57 years were evaluated. Postoperative adverse events were mild with seroma and hematoma grade 1-2 in 26% and grade 3 in 0.6% of the patients. Wound infections grade 2-3 occurred in 2.2% and wound dehiscence grade 1-2 in 1.9% of the patients. Six to eight weeks after WBI radiotherapy-dependent acute dermatitis grade 1-2 was most common in 90.9% of the patients. Only 4.6% of the patients suffered from dermatitis grade 3. No grade 4 toxicities were documented after surgery or WBI. 2- and 3-year overall survival and distant progression-free survival, were 97.5 and 93.6, and 0.7 and 2.8%, respectively. In-breast recurrence and contralateral breast cancer rates after 3 years were 1.9 and 2.8%, respectively. Conclusion: IOERT boost during BCS is a safe treatment option with low acute toxicity. Short-term recurrence rates are comparable to previously published data and emphasize, that IOERT as boost is an effective treatment.
Collapse
Affiliation(s)
- Laila König
- Department of Radiation Oncology, University Hospital Heidelberg, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany
| | - Kristin Lang
- Department of Radiation Oncology, University Hospital Heidelberg, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany
| | - Jörg Heil
- Department of Gynecology and Obstetrics, University Hospital Heidelberg, Heidelberg, Germany
| | - Michael Golatta
- Department of Gynecology and Obstetrics, University Hospital Heidelberg, Heidelberg, Germany
| | - Gerald Major
- Department of Radiation Oncology, University Hospital Heidelberg, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany
| | - David Krug
- Department of Radiation Oncology, University Hospital Heidelberg, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany.,Department of Radiation Oncology, University Hospital Schleswig Holstein, Kiel, Germany
| | - Juliane Hörner-Rieber
- Department of Radiation Oncology, University Hospital Heidelberg, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany
| | - Matthias F Häfner
- Department of Radiation Oncology, University Hospital Heidelberg, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany
| | - Stefan A Koerber
- Department of Radiation Oncology, University Hospital Heidelberg, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany
| | - Semi Harrabi
- Department of Radiation Oncology, University Hospital Heidelberg, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany
| | - Tilman Bostel
- Department of Radiation Oncology, University Hospital Heidelberg, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany.,Department of Radiation Oncology, University Hospital Mainz, Mainz, Germany
| | - Jürgen Debus
- Department of Radiation Oncology, University Hospital Heidelberg, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany
| | - Matthias Uhl
- Department of Radiation Oncology, University Hospital Heidelberg, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany
| |
Collapse
|
11
|
Seroma in breast surgery: all the surgeons fault? Arch Gynecol Obstet 2018; 298:951-959. [PMID: 30196358 DOI: 10.1007/s00404-018-4880-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Accepted: 08/22/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Despite a trend for less radical surgical approaches in breast cancer due to better understanding of tumour biology and new treatment options such as neoadjuvant chemotherapy (NAC) and intra-operative radiotherapy (IORT), seroma production remains one of the main surgical side effects that can result in prolonged recovery, delay of radiotherapy and patient discomfort. The aim of this study is to provide an update on risk factors for seroma production after breast cancer surgery considering the latest treatment options. METHODS A retrospective analysis of seroma production in primary breast cancer patients treated between 01.01.2010 and 31.12.2014 at the Breast Cancer Centre, University Hospital Ulm, was performed. Patients with previous breast/axillary surgery or more than one intervention were excluded. Seroma formation was measured using wound drains placed in breast and axilla. RESULTS In total, 581 patients met the inclusion criteria. Median age at diagnosis was 60 years, and median BMI 25.6 kg/m2. 60 (10.3%) patients had a mastectomy, 175 (30.1%) patients received IORT, and 72 (12.4%) patients received NAC. Median amount of seroma production was 82.5 ml (range 0-3012.5 ml). Multivariate analysis revealed that most of the observed variation in seroma production was due to type of surgery (mastectomy vs. breast conserving), length of surgery and number of removed lymph nodes. Both NAC and IORT explained a significant but very small amount of the observed variation in seroma production. CONCLUSION The most important factors for seroma production are extent and duration of breast surgery.
Collapse
|
12
|
Barrou J, Tallet A, Cohen M, Bannier M, Buttarelli M, Gonzague L, Jauffret C, Lambaudie E, Rua S, Tyran M, Varela L, Houvenaeghel G. Contribution of intraoperative radiotherapy (IORT) for therapeutic de-escalation in early breast cancer: Report of a single institution's experience. Breast J 2018; 24:715-723. [DOI: 10.1111/tbj.12993] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Revised: 06/16/2017] [Accepted: 06/21/2017] [Indexed: 11/28/2022]
Affiliation(s)
- Julien Barrou
- Institut Paoli Calmette and CRCM; Aix Marseille University; Marseille France
| | - Agnes Tallet
- Institut Paoli Calmette and CRCM; Aix Marseille University; Marseille France
| | - Monique Cohen
- Institut Paoli Calmette and CRCM; Aix Marseille University; Marseille France
| | - Marie Bannier
- Institut Paoli Calmette and CRCM; Aix Marseille University; Marseille France
| | - Max Buttarelli
- Institut Paoli Calmette and CRCM; Aix Marseille University; Marseille France
| | - Laurence Gonzague
- Institut Paoli Calmette and CRCM; Aix Marseille University; Marseille France
| | - Camille Jauffret
- Institut Paoli Calmette and CRCM; Aix Marseille University; Marseille France
| | - Eric Lambaudie
- Institut Paoli Calmette and CRCM; Aix Marseille University; Marseille France
| | - Sandrine Rua
- Institut Paoli Calmette and CRCM; Aix Marseille University; Marseille France
| | - Margueritte Tyran
- Institut Paoli Calmette and CRCM; Aix Marseille University; Marseille France
| | - Leonel Varela
- Institut Paoli Calmette and CRCM; Aix Marseille University; Marseille France
| | - Gilles Houvenaeghel
- Institut Paoli Calmette and CRCM; Aix Marseille University; Marseille France
| |
Collapse
|
13
|
Chin C, Jadeja P, Taback B, Horowitz DP, Feldman SM, Ha R, Connolly EP. Evaluation of Partial Breast Reirradiation with Intraoperative Radiotherapy after Prior Thoracic Radiation: A Single-Institution Report of Outcomes and Toxicity. Front Oncol 2017; 7:175. [PMID: 28894694 PMCID: PMC5581322 DOI: 10.3389/fonc.2017.00175] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Accepted: 07/31/2017] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Mastectomy is the current standard of care for ipsilateral breast tumor recurrences after prior whole breast irradiation (WBI). We report our single-institution experience with breast-conserving surgery (BCS) followed by intraoperative radiotherapy (IORT) as an alternative to salvage mastectomy for new or recurrent breast cancers that develop in the setting of prior thoracic radiation. METHODS We performed an IRB-approved retrospective review of patients treated with breast IORT between September 2013 and November 2016. We identified 12 patients who declined salvage mastectomy for their breast cancer after prior thoracic radiation. IORT was delivered using the Intrabeam™ device (Carl Zeiss, Germany). A dose of 20 Gy was prescribed to the lumpectomy cavity surface using 50 kV X-rays. We graded both acute and late treatment-related breast toxicities using the National Cancer Institute Common Terminology Criteria for Adverse Events version 4.0. Local control, mastectomy-free survival, distant metastasis, and overall survival were determined. RESULTS Our study included nine patients who developed a new or recurrent ipsilateral breast cancer after prior WBI for early-stage breast cancer, two patients with primary breast cancer after mantle-field radiation for Hodgkin's lymphoma, and one patient with a synchronous stage III non-small cell lung cancer treated with definitive radiation to the ipsilateral lung and mediastinum. The median time from prior radiation to presentation was 18 years (range: 2 months to 46 years). All patients successfully underwent partial breast reirradiation with IORT and were able to preserve their breast. At a median follow-up of 14 months (4-25 months), there were no local or distant recurrences. There was a single non-cancer-related death. In the acute setting, we observed grade 1 toxicity in 58% (n = 7), grade 2 toxicity in 17% (n = 2), and no grade 3 or higher toxicity. In the late setting, at least 3 months after IORT, we observed grade 1 hyperpigmentation and/or fibrosis in 50% (n = 6), symptomatic seroma requiring drainage in 33% (n = 4). A single patient developed an abscess requiring hospitalization and intravenous antibiotic therapy. CONCLUSION BCS with IORT is a feasible salvage option for patients who present with localized breast cancer after prior thoracic radiation treatment. Continued follow-up of these patients is warranted given the incidence of delayed toxicity.
Collapse
Affiliation(s)
- Christine Chin
- Radiation Oncology, NYP-Columbia University Medical Center, New York, NY, United States
| | - Priya Jadeja
- Breast Surgery, NYP-Columbia University Medical Center, Herbert Irving Pavilion, New York, NY, United States
| | - Bret Taback
- Breast Surgery, NYP-Columbia University Medical Center, Herbert Irving Pavilion, New York, NY, United States
| | - David P. Horowitz
- Radiation Oncology, NYP-Columbia University Medical Center, New York, NY, United States
| | - Sheldon M. Feldman
- Breast Surgery and Breast Surgical Oncology, Montefiore M-E Center for Cancer Care, Bronx, NY, United States
| | - Richard Ha
- Radiology, NYP-Columbia University Medical Center, Herbert Irving Pavilion, New York, NY, United States
| | - Eileen P. Connolly
- Radiation Oncology, NYP-Columbia University Medical Center, New York, NY, United States
| |
Collapse
|
14
|
Lee JJB, Choi J, Ahn SG, Jeong J, Lee IJ, Park K, Kim K, Kim JW. In vivo dosimetry and acute toxicity in breast cancer patients undergoing intraoperative radiotherapy as boost. Radiat Oncol J 2017; 35:121-128. [PMID: 28712278 PMCID: PMC5518452 DOI: 10.3857/roj.2017.00150] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Revised: 04/27/2017] [Accepted: 05/22/2017] [Indexed: 01/24/2023] Open
Abstract
Purpose To report the results of a correlation analysis of skin dose assessed by in vivo dosimetry and the incidence of acute toxicity. This is a phase 2 trial evaluating the feasibility of intraoperative radiotherapy (IORT) as a boost for breast cancer patients. Materials and Methods Eligible patients were treated with IORT of 20 Gy followed by whole breast irradiation (WBI) of 46 Gy. A total of 55 patients with a minimum follow-up of 1 month after WBI were evaluated. Optically stimulated luminescence dosimeter (OSLD) detected radiation dose delivered to the skin during IORT. Acute toxicity was recorded according to the Common Terminology Criteria for Adverse Events v4.0. Clinical parameters were correlated with seroma formation and maximum skin dose. Results Median follow-up after IORT was 25.9 weeks (range, 12.7 to 50.3 weeks). Prior to WBI, only one patient developed acute toxicity. Following WBI, 30 patients experienced grade 1 skin toxicity and three patients had grade 2 skin toxicity. Skin dose during IORT exceeded 5 Gy in two patients: with grade 2 complications around the surgical scar in one patient who received 8.42 Gy. Breast volume on preoperative images (p = 0.001), ratio of applicator diameter and breast volume (p = 0.002), and distance between skin and tumor (p = 0.003) showed significant correlations with maximum skin dose. conclusions IORT as a boost was well-tolerated among Korean women without severe acute complication. In vivo dosimetry with OSLD can help ensure safe delivery of IORT as a boost.
Collapse
Affiliation(s)
- Jason Joon Bock Lee
- Department of Radiation Oncology, Yonsei University College of Medicine, Seoul, Korea
| | - Jinhyun Choi
- Department of Radiation Oncology, Yonsei University College of Medicine, Seoul, Korea
| | - Sung Gwe Ahn
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Joon Jeong
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Ik Jae Lee
- Department of Radiation Oncology, Yonsei University College of Medicine, Seoul, Korea
| | - Kwangwoo Park
- Department of Radiation Oncology, Yonsei University College of Medicine, Seoul, Korea
| | - Kangpyo Kim
- Department of Radiation Oncology, Yonsei University College of Medicine, Seoul, Korea
| | - Jun Won Kim
- Department of Radiation Oncology, Yonsei University College of Medicine, Seoul, Korea
| |
Collapse
|
15
|
TGF-β1 Is Present at High Levels in Wound Fluid from Breast Cancer Patients Immediately Post-Surgery, and Is Not Increased by Intraoperative Radiation Therapy (IORT). PLoS One 2016; 11:e0162221. [PMID: 27589056 PMCID: PMC5010202 DOI: 10.1371/journal.pone.0162221] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Accepted: 08/18/2016] [Indexed: 12/13/2022] Open
Abstract
In patients with low-risk breast cancer, intraoperative radiotherapy (IORT) during breast-conserving surgery is a novel and convenient treatment option for delivering a single high dose of irradiation directly to the tumour bed. However, edema and fibrosis can develop after surgery and radiotherapy, which can subsequently impair quality of life. TGF- β is a strong inducer of the extracellular matrix component hyaluronan (HA). TGF-β expression and HA metabolism can be modulated by irradiation experimentally, and are involved in edema and fibrosis. We therefore hypothesized that IORT may regulate these factors.Wound fluid (WF) draining from breast lumpectomy sites was collected and levels of TGF-β1 and HA were determined by ELISA. Proliferation and marker expression was analyzed in primary lymphatic endothelial cells (LECs) treated with recombinant TGF-β or WF. Our results show that IORT does not change TGF-β1 or HA levels in wound fluid draining from breast lumpectomy sites, and does not lead to accumulation of sHA oligosaccharides. Nevertheless, concentrations of TGF-β1 were high in WF from patients regardless of IORT, at concentrations well above those associated with fibrosis and the suppression of LEC identity. Consistently, we found that TGF-β in WF is active and inhibits LEC proliferation. Furthermore, all three TGF-β isoforms inhibited LEC proliferation and suppressed LEC marker expression at pathophysiologically relevant concentrations. Given that TGF-β contributes to edema and plays a role in the regulation of LEC identity, we suggest that inhibition of TGF-β directly after surgery might prevent the development of side effects such as edema and fibrosis.
Collapse
|
16
|
Epstein MS, Silverstein MJ, Lin K, Kim B, De Leon C, Khan S, Guerra LE, Snyder L, Coleman C, Lopez J, Mackintosh R, Chen P. Acute and Chronic Complications in Patients with Ductal Carcinoma in Situ Treated with Intraoperative Radiation Therapy. Breast J 2016; 22:630-636. [DOI: 10.1111/tbj.12650] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Melinda S. Epstein
- Hoag Institute for Research and Education; Hoag Memorial Hospital Presbyterian; Newport Beach California
| | - Melvin J. Silverstein
- Department of Surgery; Hoag Memorial Hospital Presbyterian; Newport Beach California
- Keck School of Medicine; University of Southern California; Los Angeles California
| | - Kevin Lin
- Department of Radiology; Hoag Memorial Hospital Presbyterian; Newport Beach California
| | - Brian Kim
- Department of Radiology; Hoag Memorial Hospital Presbyterian; Newport Beach California
| | - Cristina De Leon
- Hoag Institute for Research and Education; Hoag Memorial Hospital Presbyterian; Newport Beach California
| | - Sadia Khan
- Department of Surgery; Hoag Memorial Hospital Presbyterian; Newport Beach California
- Keck School of Medicine; University of Southern California; Los Angeles California
| | | | - Lincoln Snyder
- Department of Surgery; Hoag Memorial Hospital Presbyterian; Newport Beach California
| | - Colleen Coleman
- Department of Surgery; Hoag Memorial Hospital Presbyterian; Newport Beach California
| | - January Lopez
- Department of Radiology; Hoag Memorial Hospital Presbyterian; Newport Beach California
| | - Ralph Mackintosh
- Department of Radiology; Hoag Memorial Hospital Presbyterian; Newport Beach California
| | - Peter Chen
- Department of Radiology; Hoag Memorial Hospital Presbyterian; Newport Beach California
| |
Collapse
|
17
|
Epstein M, Silverstein M, Lin K, Kim B, Khan S, De Leon C, Guerra L, Snyder L, Coleman C, Lopez J, Mackintosh R, Chen P. Acute and Chronic Complications in Breast Cancer Patients Treated with Intraoperative Radiation Therapy. Ann Surg Oncol 2016; 23:3304-9. [PMID: 27334211 DOI: 10.1245/s10434-016-5316-y] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Intraoperative radiation therapy (IORT) permits the delivery of radiation therapy directly to the tumor bed at the time of surgery. Minimal data are available about the complications associated with this modality of treatment using the Xoft(®) Axxent Electronic Brachytherapy (Axxent) System. METHODS A total of 702 patients who received IORT using the Xoft(®) Axxent System at Hoag Memorial Hospital Presbyterian between June 2010-February 2016 were accrued in an IORT data registry study. The prospective and retrospective protocols were approved by the institutional review board and met the guidelines of their responsible governmental agency. Data were collected at 1 week, 1 month, 3 months, 6 months, 1 year, and thereafter yearly. Acute complications were defined as those occurring within the first month. Chronic complications were those that persisted beyond 6 months. RESULTS Acute complications were observed in 21 % of patients and included hematomas that required drainage, seromas requiring drainage more than 3 times, infections treated with antibiotics or surgery, necrosis requiring surgery, and erythema. Chronic complications were observed in 13 % of patients and included seromas, fibrosis, and hyperpigmentation. The majority of acute and chronic problems from IORT were mild. If grade I erythema, fibrosis, and hyperpigmentation were removed, only 32 of 702 (4.6 %) had significant complications. Our complication rates were comparable to those of the TARGIT trial. CONCLUSIONS IORT is a modality that safely delivers radiation therapy to patients diagnosed with breast cancer. This technique allows women who cannot (or decline to) undergo whole breast radiation to consider breast-conserving therapy rather than mastectomy.
Collapse
Affiliation(s)
- Melinda Epstein
- Hoag Institute for Research and Education, Hoag Memorial Hospital Presbyterian, Newport Beach, USA.
| | - Melvin Silverstein
- Department of Surgery, Hoag Memorial Hospital Presbyterian, Newport Beach, USA.,Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, USA
| | - Kevin Lin
- Department of Radiology, Hoag Memorial Hospital Presbyterian, Newport Beach, USA
| | - Brian Kim
- Department of Radiology, Hoag Memorial Hospital Presbyterian, Newport Beach, USA
| | - Sadia Khan
- Department of Surgery, Hoag Memorial Hospital Presbyterian, Newport Beach, USA.,Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, USA
| | - Cristina De Leon
- Hoag Institute for Research and Education, Hoag Memorial Hospital Presbyterian, Newport Beach, USA
| | | | - Lincoln Snyder
- Department of Surgery, Hoag Memorial Hospital Presbyterian, Newport Beach, USA
| | - Colleen Coleman
- Department of Surgery, Hoag Memorial Hospital Presbyterian, Newport Beach, USA
| | - January Lopez
- Department of Radiology, Hoag Memorial Hospital Presbyterian, Newport Beach, USA
| | - Ralph Mackintosh
- Department of Radiology, Hoag Memorial Hospital Presbyterian, Newport Beach, USA
| | - Peter Chen
- Department of Radiology, Hoag Memorial Hospital Presbyterian, Newport Beach, USA
| |
Collapse
|
18
|
Ebner F, Schramm A, Bottke D, Friedl TW, Wiegel T, Fink V, Lato K, Bekes I, Janni W, de Gregorio N. Comparison of seroma production in breast conserving surgery with or without intraoperative radiotherapy as tumour bed boost. Arch Gynecol Obstet 2016; 294:861-6. [PMID: 27256339 DOI: 10.1007/s00404-016-4124-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Accepted: 05/19/2016] [Indexed: 11/25/2022]
Abstract
INTRODUCTION One of the most common complications in breast conserving surgery is seroma formation. The origin of seroma formation remains unclear. While intraoperative radiotherapy (IORT) has been shown to be an alternative to whole breast irradiation, the influence on seroma production is unclear. Therefore, this analysis compares seroma production in patients with breast conserving surgery with or without IORT as tumour bed boost during breast conserving surgery. METHOD A retrospective analysis of seroma production in patients with nodal-negative (pN0sn) pT1/2 primary breast cancer treated between September 2010 and October 2013 at the Breast Cancer Centre, University Hospital Ulm was performed. Patients with neoadjuvant chemotherapy, previous breast/axillary surgery or more than one intervention were excluded. IORT was applied as a tumour bed boost with 50-kV X-rays (Intra beam(®)) delivering 9 Gy at the applicator surface. Seroma formation was measured using wound drains placed in breast and in axilla. RESULTS Data of 152 patients (99 -IORT; 53 +IORT) were available for analysis. No significant differences between patients with or without IORT with regard to seroma production and number of days until drain removal were found (all p > 0.05). CONCLUSION Patients with IORT encountered no increased seroma production and removal of the drains was not delayed compared to patients with breast conserving surgery only. Our results indicate that IORT does not increase the seroma production compared to surgery alone.
Collapse
Affiliation(s)
- Florian Ebner
- Klinik für Frauenheilkunde und Geburtshilfe, Universität Ulm, Prittwitzstr. 43, 89075, Ulm, Germany.
| | - Amelie Schramm
- Klinik für Frauenheilkunde und Geburtshilfe, Universität Ulm, Prittwitzstr. 43, 89075, Ulm, Germany
| | - Dirk Bottke
- Klinik für Strahlentherapie und Radioonkologie, Universität Ulm, Albert-Einstein-Allee 23, 89081, Ulm, Germany
| | - Thomas Wp Friedl
- Klinik für Frauenheilkunde und Geburtshilfe, Universität Ulm, Prittwitzstr. 43, 89075, Ulm, Germany
| | - Thomas Wiegel
- Klinik für Strahlentherapie und Radioonkologie, Universität Ulm, Albert-Einstein-Allee 23, 89081, Ulm, Germany
| | - Visnja Fink
- Klinik für Frauenheilkunde und Geburtshilfe, Universität Ulm, Prittwitzstr. 43, 89075, Ulm, Germany
| | - Kristian Lato
- Klinik für Frauenheilkunde und Geburtshilfe, Universität Ulm, Prittwitzstr. 43, 89075, Ulm, Germany
| | - Inga Bekes
- Klinik für Frauenheilkunde und Geburtshilfe, Universität Ulm, Prittwitzstr. 43, 89075, Ulm, Germany
| | - Wolfgang Janni
- Klinik für Frauenheilkunde und Geburtshilfe, Universität Ulm, Prittwitzstr. 43, 89075, Ulm, Germany
| | - Nikolaus de Gregorio
- Klinik für Frauenheilkunde und Geburtshilfe, Universität Ulm, Prittwitzstr. 43, 89075, Ulm, Germany
| |
Collapse
|
19
|
Zur M, Shai A, Leviov M, Bitterman A, Shiloni E, Ben Yosef R, Steiner M. Short-term complications of intra-operative radiotherapy for early breast cancer. J Surg Oncol 2016; 113:370-3. [DOI: 10.1002/jso.24157] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2015] [Accepted: 12/22/2015] [Indexed: 11/10/2022]
Affiliation(s)
- Maoz Zur
- Department of Oncology; Lin and Carmel Lady Davis Medical Centers; Haifa Israel
| | - Ayelet Shai
- Department of Oncology; Galilee Medical Center; Nahariyya Israel
- Faculty of Medicine; Bar-Ilan University; Zefat Israel
| | - Michelle Leviov
- Department of Oncology; Lin and Carmel Lady Davis Medical Centers; Haifa Israel
| | - Arie Bitterman
- Department of Surgery A; Carmel Lady Davis Medical Center; Haifa Israel
| | - Eitan Shiloni
- Department of Surgery B; Carmel Lady Davis Medical Center; Haifa Israel
- Bruce Rappaport Faculty of Medicine; Technion Israel Institute of Technology; Haifa Israel
| | - Rahamim Ben Yosef
- Bruce Rappaport Faculty of Medicine; Technion Israel Institute of Technology; Haifa Israel
- Radiotherapy Unit; Oncology Institute; Rambam Health Care Campus; Haifa Israel
| | - Mariana Steiner
- Department of Oncology; Lin and Carmel Lady Davis Medical Centers; Haifa Israel
| |
Collapse
|
20
|
Tuschy B, Berlit S, Romero S, Sperk E, Wenz F, Kehl S, Sütterlin M. Clinical aspects of intraoperative radiotherapy in early breast cancer: short-term complications after IORT in women treated with low energy x-rays. Radiat Oncol 2013; 8:95. [PMID: 23607703 PMCID: PMC3643839 DOI: 10.1186/1748-717x-8-95] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2012] [Accepted: 04/18/2013] [Indexed: 11/18/2022] Open
Abstract
Background To assess postoperative complications, clinical outcome and histological findings in patients undergoing intraoperative radiotherapy with low energy x-rays for early breast cancer. Methods We retrospectively analysed data of 208 women who underwent intraoperative irradiation during breast conserving surgery (BCS) between 2002 and 2007. Demographic, clinical and surgical parameters as well as short-term complications within the first postoperative week and histological findings were evaluated. Toxicities were assessed using the CTC/EORTC Score. Results Postoperative complications were rare and the immediate toxicity low, without any grade 3/4 acute toxicity. The most frequent postoperative side effects were suggillation (24%) and palpable seroma (17.3%). In 78.6% of the axillary seroma and in 25% of the breast seroma a needle aspiration was inevitable. Erythema grade I-II of the breast was found in 27 women (13%); whereas in 7 patients (3.4%), mastitis was confirmed. In 57.7% of the cases, the pathological assessment revealed ductal invasive breast cancer and tumour size ranged between 0.1 and 4.5 cm (mean = 1.6 cm). Conclusion IORT using Intrabeam® during BCS is safe, although it is associated with postoperative adverse events such as seroma. These should be mentioned and explained to women in detail during the preoperative discussion. This explicitly clinical description is useful for daily clinical practice; especially for giving a detailed analysis of the postoperative side effects during preoperative counselling.
Collapse
Affiliation(s)
- Benjamin Tuschy
- Department of Gynaecology and Obstetrics, University Medical Centre Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.
| | | | | | | | | | | | | |
Collapse
|
21
|
Research opportunities in intraoperative radiation therapy: the next decade 2013-2023. Clin Transl Oncol 2013; 15:683-90. [PMID: 23463592 DOI: 10.1007/s12094-013-1019-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2013] [Accepted: 01/30/2013] [Indexed: 10/27/2022]
Abstract
The reality of intraoperative radiation therapy (IORT) practice is consistent with an efficient and highly precise radiation therapy technique to safely boost areas at risk for local recurrence. Long-term clinical experience has shown that IORT-containing multi-modality regimens appear to improve local disease control, if not survival in many diseases. Research with IORT is a multidisciplinary scenario that covers knowledge from radiation beam adapted development to advance molecular biology for bio-predictability of outcome. The technical parameters employed in IORT procedures are important information to be recorded for quality assurance and clinical results analysis. In addition, specific treatment planning systems for IORT procedures are available, to help in the treatment decision-making process. A systematic revision of opportunities for research and innovation in IORT is reported including radiation beam modulation, delivery, dosimetry and planning; infrastructure and treatment factors; experimental and clinical radiobiology; clinical trials, innovation and translational research development.
Collapse
|
22
|
Senthi S, Link E, Chua BH. Cosmetic Outcome and Seroma Formation After Breast-Conserving Surgery With Intraoperative Radiation Therapy Boost for Early Breast Cancer. Int J Radiat Oncol Biol Phys 2012; 84:e139-44. [DOI: 10.1016/j.ijrobp.2012.03.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2011] [Revised: 02/26/2012] [Accepted: 03/06/2012] [Indexed: 10/27/2022]
|
23
|
Wasser K, Schnitzer A, Engel D, Krammer J, Wenz F, Kraus-Tiefenbacher U, Suetterlin M, Schoenberg SO, Weisser G. First description of MR mammographic findings in the tumor bed after intraoperative radiotherapy (IORT) of breast cancer. Clin Imaging 2012; 36:176-84. [PMID: 22542375 DOI: 10.1016/j.clinimag.2011.08.024] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2011] [Revised: 08/27/2011] [Accepted: 08/30/2011] [Indexed: 11/28/2022]
Abstract
The aim was to investigate changes in the tumor bed on magnetic resonance mammography (MRM) after intraoperative radiotherapy (IORT) and whether they would limit the diagnostic value of posttherapeutic MRM. We retrospectively investigated 36 patients undergoing MRM after IORT (median interval 2.8 years, range 0.4-7.1). Wound cavities with fat necrosis were common after IORT (81%). They were associated with persisting contrast enhancement, i.e., enhancement was mostly seen irrespective of the posttherapeutic interval. It normally presented as rim enhancement and did not cause any diagnostic uncertainty if viewed together with other tissue characteristics. We do not expect a limited diagnostic value of MRM after IORT.
Collapse
Affiliation(s)
- Klaus Wasser
- Institute of Clinical Radiology and Nuclear Medicine, University Medical Center, Mannheim, Medical Faculty Mannheim, Heidelberg University, Germany.
| | | | | | | | | | | | | | | | | |
Collapse
|
24
|
Mukesh MB, Barnett G, Cumming J, Wilkinson JS, Moody AM, Wilson C, Wishart GC, Coles CE. Association of breast tumour bed seroma with post-operative complications and late normal tissue toxicity: results from the Cambridge Breast IMRT trial. Eur J Surg Oncol 2012; 38:918-24. [PMID: 22704052 DOI: 10.1016/j.ejso.2012.05.008] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2012] [Revised: 05/15/2012] [Accepted: 05/21/2012] [Indexed: 01/12/2023] Open
Abstract
AIMS There are two main surgical techniques for managing the tumour bed after breast cancer excision. Firstly, closing the defect by suturing the cavity walls together and secondly leaving the tumour bed open thus allowing seroma fluid to collect. There is debate regarding which technique is preferable, as it has been reported that a post-operative seroma increase post-operative infection rates and late normal tissue side effects. METHODS Data from 648 patients who participated in the Cambridge Breast IMRT trial were used. Seromas were identified on axial CT images at the time of radiotherapy planning and graded as not visible/subtle or easily visible. An association was sought between the presence of seroma and the development of post-operative infection, post-operative haematoma and 2 and 5 years normal tissue toxicity (assessed using serial photographs, clinical assessment and self assessment questionnaire). RESULTS The presence of easily visible seroma was associated with increased risk of post-operative infection (OR = 1.80; p = 0.004) and post-operative haematoma (OR = 2.1; p = 0.02). Breast seroma was an independent risk factor for whole breast induration and tumour bed induration at 2 and 5 years. The presence of breast seroma was also associated with inferior overall cosmesis at 5 years. There was no significant association between the presence of seroma and the development of either breast shrinkage or breast pain. CONCLUSION The presence of seroma at the time of radiotherapy planning is associated with increased rates of post-operative infection and haematoma. It is also an independent risk factor for late normal tissue toxicity. This study suggests that full thickness surgical closure may be desirable for patients undergoing breast conservation and radiotherapy.
Collapse
Affiliation(s)
- M B Mukesh
- Oncology Centre, Cambridge University Hospitals NHS Foundation Trust, Box 193, Hills Road, Cambridge CB2 0QQ, UK
| | | | | | | | | | | | | | | |
Collapse
|
25
|
Wenz F, Blank E, Welzel G, Hofmann F, Astor D, Neumaier C, Herskind C, Gerhardt A, Suetterlin M, Kraus-Tiefenbacher U. Intraoperative radiotherapy during breast-conserving surgery using a miniature x-ray generator (Intrabeam®): theoretical and experimental background and clinical experience. ACTA ACUST UNITED AC 2012; 8:39-47. [PMID: 22171773 DOI: 10.2217/whe.11.82] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Breast cancer is currently the most frequent indication for intraoperative radiotherapy with increasing numbers worldwide. Intraoperative radiotherapy can be used as a tumor bed boost followed by whole breast radiotherapy, or as a distinct form of accelerated partial breast irradiation in selected patients. This article summarizes the theoretical background including pattern of recurrence and distribution of tumor cell foci in the breast and discusses the rationale for intraoperative radiotherapy, especially using a miniature x-ray generator (Intrabeam(®)). The concepts of how to avoid geographic and temporal miss by giving radiotherapy during surgery to the open wound cavity are described. Experimental and clinical experience is presented based on in vitro experiments and more than 300 treated patients in a single department with mature follow-up.
Collapse
Affiliation(s)
- Frederik Wenz
- Department of Radiation Oncology, University Medical Centre Mannheim, University of Heidelberg, 68167 Mannheim, Germany.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
26
|
Blank E, Kraus-Tiefenbacher U, Welzel G, Keller A, Bohrer M, Sütterlin M, Wenz F. Single-center long-term follow-up after intraoperative radiotherapy as a boost during breast-conserving surgery using low-kilovoltage x-rays. Ann Surg Oncol 2010; 17 Suppl 3:352-8. [PMID: 20853058 DOI: 10.1245/s10434-010-1265-z] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2010] [Indexed: 11/18/2022]
Abstract
BACKGROUND Intraoperative radiotherapy (IORT) during breast-conserving surgery as a boost followed by whole-breast radiotherapy is increasingly used. METHODS Between February 2002 and December 2008, a total of 197 patients were treated with IORT as a boost (20 Gy, 50 kV x-rays; Intrabeam System, Carl Zeiss Surgical, Oberkochen, Germany) during breast-conserving surgery, followed by whole-breast radiotherapy (46-50 Gy). Systemic therapy was provided according to the St. Gallen consensus. Patients were recalled every 6-12 months for follow-up. Findings were scored according to the LENT-SOMA scale. RESULTS Median age was 61.8 (range 30-84) years, and median follow-up was 37 (range 5-91) months. There were T1, T2, and Tx tumors in 129, 67, and 1 patients, respectively, and N0, N1, N2, and N3 disease in 144, 36, 15, and 2 patients, respectively. Until December 2009, 5 local invasive relapses, 1 local ductal carcinoma-in-situ, 1 axillary relapse, 6 secondary cancers, and 11 distant metastases were seen, resulting in a 5-year disease-free survival of 81.0% and an overall survival of 91.3%. Local relapse-free survival (invasive cancers) at 3 and 5 years was 97.0%. After a follow-up of 5 years (n =58), only 8 patients (13.8%) had chronic skin toxicities, and 2 patients (3.4%) had a marked increase in density (fibrosis III), while 62.0% had no/barely palpable fibrosis 0-I. Other toxicities observed included severe pain (n = 4, 6.9%), retraction (n =17, 29.3%), edema of the breast (n =1, 1.7%), and lymphedema in general (n =2, 3.4%). CONCLUSIONS After IORT as a tumor bed boost with low-kilovoltage x-rays followed by whole-breast radiotherapy, low local recurrence and chronic toxicity rates were seen after 5-year follow-up.
Collapse
Affiliation(s)
- Elena Blank
- Department of Radiation Oncology, University Medical Centre Mannheim, University of Heidelberg, Mannheim, Germany.
| | | | | | | | | | | | | |
Collapse
|