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Leonardi MC, Zerella MA, Lazzeroni M, Fusco N, Veronesi P, Galimberti VE, Corso G, Dicuonzo S, Rojas DP, Morra A, Gerardi MA, Lorubbio C, Zaffaroni M, Vincini MG, Orecchia R, Jereczek-Fossa BA, Magnoni F. Tools to Guide Radiation Oncologists in the Management of DCIS. Healthcare (Basel) 2024; 12:795. [PMID: 38610216 PMCID: PMC11011767 DOI: 10.3390/healthcare12070795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 03/27/2024] [Accepted: 04/03/2024] [Indexed: 04/14/2024] Open
Abstract
Similar to invasive breast cancer, ductal carcinoma in situ is also going through a phase of changes not only from a technical but also a conceptual standpoint. From prescribing radiotherapy to everyone to personalized approaches, including radiotherapy omission, there is still a lack of a comprehensive framework to guide radiation oncologists in decision making. Many pieces of the puzzle are finding their place as high-quality data mature and are disseminated, but very often, the interpretation of risk factors and the perception of risk remain very highly subjective. Sharing the therapeutic choice with patients requires effective communication for an understanding of risks and benefits, facilitating an informed decision that does not increase anxiety and concerns about prognosis. The purpose of this narrative review is to summarize the current state of knowledge to highlight the tools available to radiation oncologists for managing DCIS, with an outlook on future developments.
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Affiliation(s)
- Maria Cristina Leonardi
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, 20141 Milan, Italy; (M.C.L.); (S.D.); (D.P.R.); (A.M.); (M.A.G.); (C.L.); (M.Z.); (M.G.V.); (B.A.J.-F.)
| | - Maria Alessia Zerella
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, 20141 Milan, Italy; (M.C.L.); (S.D.); (D.P.R.); (A.M.); (M.A.G.); (C.L.); (M.Z.); (M.G.V.); (B.A.J.-F.)
| | - Matteo Lazzeroni
- Division of Cancer Prevention and Genetics, IEO, European Institute of Oncology IRCCS, 20141 Milan, Italy;
| | - Nicola Fusco
- Department of Oncology and Hemato-Oncology, University of Milan, 20141 Milan, Italy; (N.F.); (P.V.); (G.C.)
- Division of Pathology, IEO, European Institute of Oncology IRCCS, 20141 Milan, Italy
| | - Paolo Veronesi
- Department of Oncology and Hemato-Oncology, University of Milan, 20141 Milan, Italy; (N.F.); (P.V.); (G.C.)
- Division of Breast Surgery, IEO, European Institute of Oncology IRCCS, 20141 Milan, Italy; (V.E.G.); (F.M.)
| | - Viviana Enrica Galimberti
- Division of Breast Surgery, IEO, European Institute of Oncology IRCCS, 20141 Milan, Italy; (V.E.G.); (F.M.)
| | - Giovanni Corso
- Department of Oncology and Hemato-Oncology, University of Milan, 20141 Milan, Italy; (N.F.); (P.V.); (G.C.)
- Division of Breast Surgery, IEO, European Institute of Oncology IRCCS, 20141 Milan, Italy; (V.E.G.); (F.M.)
| | - Samantha Dicuonzo
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, 20141 Milan, Italy; (M.C.L.); (S.D.); (D.P.R.); (A.M.); (M.A.G.); (C.L.); (M.Z.); (M.G.V.); (B.A.J.-F.)
| | - Damaris Patricia Rojas
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, 20141 Milan, Italy; (M.C.L.); (S.D.); (D.P.R.); (A.M.); (M.A.G.); (C.L.); (M.Z.); (M.G.V.); (B.A.J.-F.)
| | - Anna Morra
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, 20141 Milan, Italy; (M.C.L.); (S.D.); (D.P.R.); (A.M.); (M.A.G.); (C.L.); (M.Z.); (M.G.V.); (B.A.J.-F.)
| | - Marianna Alessandra Gerardi
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, 20141 Milan, Italy; (M.C.L.); (S.D.); (D.P.R.); (A.M.); (M.A.G.); (C.L.); (M.Z.); (M.G.V.); (B.A.J.-F.)
| | - Chiara Lorubbio
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, 20141 Milan, Italy; (M.C.L.); (S.D.); (D.P.R.); (A.M.); (M.A.G.); (C.L.); (M.Z.); (M.G.V.); (B.A.J.-F.)
- Department of Oncology and Hemato-Oncology, University of Milan, 20141 Milan, Italy; (N.F.); (P.V.); (G.C.)
| | - Mattia Zaffaroni
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, 20141 Milan, Italy; (M.C.L.); (S.D.); (D.P.R.); (A.M.); (M.A.G.); (C.L.); (M.Z.); (M.G.V.); (B.A.J.-F.)
| | - Maria Giulia Vincini
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, 20141 Milan, Italy; (M.C.L.); (S.D.); (D.P.R.); (A.M.); (M.A.G.); (C.L.); (M.Z.); (M.G.V.); (B.A.J.-F.)
| | - Roberto Orecchia
- Scientific Directorate, IEO, European Institute of Oncology IRCCS, 20141 Milan, Italy;
| | - Barbara Alicja Jereczek-Fossa
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, 20141 Milan, Italy; (M.C.L.); (S.D.); (D.P.R.); (A.M.); (M.A.G.); (C.L.); (M.Z.); (M.G.V.); (B.A.J.-F.)
- Department of Oncology and Hemato-Oncology, University of Milan, 20141 Milan, Italy; (N.F.); (P.V.); (G.C.)
| | - Francesca Magnoni
- Division of Breast Surgery, IEO, European Institute of Oncology IRCCS, 20141 Milan, Italy; (V.E.G.); (F.M.)
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Minimally invasive tumor bed implant (MITBI) and peri-operative high-dose-rate brachytherapy (PHDRBT) for accelerated minimal breast irradiation (AMBI) or anticipated boost (A-PHDRBT-boost) in breast-conserving surgery for ductal carcinoma in situ. J Contemp Brachytherapy 2020; 12:521-532. [PMID: 33437299 PMCID: PMC7787199 DOI: 10.5114/jcb.2020.101684] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 09/24/2020] [Indexed: 11/17/2022] Open
Abstract
Purpose To evaluate our institutional experience of minimally invasive tumor bed implantation (MITBI) during breast-conserving surgery (BCS) for ductal carcinoma in situ (DCIS) to deliver peri-operative high-dose-rate brachytherapy (PHDRBT) as accelerated minimal breast irradiation (AMBI) or anticipated boost (A-PHDRBT-boost). Material and methods Patients older than 40, with clinical and radiological unifocal DCIS < 3 cm were considered potential candidates for accelerated partial breast irradiation (APBI) and were implanted during BCS using MITBI-technique. Patients who in final pathology reports showed free margins and no other microscopic tumor foci, received AMBI with PHDRBT (3.4 Gy BID in 5 days). Patients with adverse features received A-PHDRBT-boost with post-operative external beam radiotherapy (EBRT). Results Forty-one patients were implanted, and 36 were treated and analyzed. According to final pathology, 24 (67%) patients were suitable for AMBI and 12 (33%) were qualified for A-PHDRBT-boost. Reoperation rate for those with clear margins was 16.6% (6/36); this rate increased to 33% (4/12) for G3 histology, and 66% (4/6) were rescued using AMBI. Early complications were documented in 5 patients (14%). With a median follow-up of 97 (range, 42-138) months, 5-year rates of local, elsewhere, locoregional, and distant control were all 97.2%. 5-year ipsilateral breast tumor recurrence rates (IBTR) were 5.6% (2/36), 8.3% (2/24) for AMBI, and 0% (0/12) for A-PHDRBT-boost patients. Both instances of IBTR were confirmed G3 tumors in pre-operative biopsies; no IBTR was documented in G1-2 tumors. Cosmetic outcomes were excellent/good in 96% of AMBI vs. 67% in A-PHDRBT-boost (p = 0.034). Conclusions The MITBI-PHDRBT program allows selection of patients with excellent prognoses (G1-2 DCIS with negative margins and no multifocality), for whom AMBI could be a good alternative with low recurrence rate, decrease of unnecessary radiation, treatment logistics improvement, and over-treatment reduction. Patients whose pre-operative biopsy showed G3 tumor, presents with inferior local control and more risk of reoperation due to positive margins.
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Mills MN, Russo NW, Nanda RH, Wilson JP, Altoos TA, Caldwell DL, Stout LL, Dube S, Blumencranz PW, Allen KG, Diaz R. Management of ductal carcinoma in situ with accelerated partial breast irradiation brachytherapy: Implications for guideline expansion. Brachytherapy 2020; 20:345-352. [PMID: 33317964 DOI: 10.1016/j.brachy.2020.11.002] [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: 08/21/2020] [Revised: 11/09/2020] [Accepted: 11/10/2020] [Indexed: 11/17/2022]
Abstract
PURPOSE Accelerated partial breast irradiation (APBI) for patients with ductal carcinoma in situ (DCIS) is controversial, and the suitability criteria from the American Brachytherapy Society (ABS), American Society of Therapeutic Radiology and Oncology (ASTRO), and the European Society for Radiotherapy and Oncology (GEC-ESTRO) have important differences. METHODS AND MATERIALS This is a single-institution retrospective review of 169 consecutive patients with DCIS who underwent lumpectomy followed by APBI intracavitary brachytherapy from 2003 to 2018. Outcomes, including overall survival, recurrence-free survival (RFS), ipsilateral breast tumor recurrence, and distant metastasis, were estimated with the Kaplan-Meier method. RESULTS The median followup time was 62.5 months. Median age was 66 years (47-89 years). The majority of patients had estrogen receptor-positive disease (89%). Fifty patients (30%) had Grade 3 disease. Of the 142 patients with adequate pathology interpretation, 91 and 108 cases had margins ≥ 3 mm and ≥2 mm, respectively. Most patients (72%) were prescribed and started endocrine therapy. Of the patients evaluable for ABS criteria (N = 130), 97 met the suitability criteria. Of the patients evaluable for ASTRO criteria (N = 129), 42 were deemed cautionary and 33 were deemed unsuitable. Of the patients evaluable for GEC-ESTRO criteria (N = 143), 141 cases were at intermediate risk and two were at high risk. Five-year ipsilateral breast tumor recurrence, RFS, and overall survival were 0.6%, 97.7%, and 97.2%, respectively. The ABS, ASTRO, and GEC-ESTRO criteria failed to significantly predict for RFS. CONCLUSIONS These results, although limited by short-term followup, indicate that expansion of the eligibility criteria of APBI for patients with DCIS should be considered.
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Affiliation(s)
- Matthew N Mills
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Nicholas W Russo
- University of South Florida Morsani College of Medicine, Tampa, FL
| | - Ronica H Nanda
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Jason P Wilson
- Comprehensive Breast Cancer Center of Tampa Bay, Morton Plant Hospital, Clearwater, FL
| | | | | | - Lisa L Stout
- Lykes Radiation Pavilion, Morton Plant Hospital, Clearwater, FL
| | - Scott Dube
- Lykes Radiation Pavilion, Morton Plant Hospital, Clearwater, FL
| | - Peter W Blumencranz
- Comprehensive Breast Cancer Center of Tampa Bay, Morton Plant Hospital, Clearwater, FL
| | - Kathleen G Allen
- Comprehensive Breast Cancer Center of Tampa Bay, Morton Plant Hospital, Clearwater, FL
| | - Roberto Diaz
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL.
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Arenas M, Selek U, Kaidar-Person O, Perrucci E, Montero Luis A, Boersma L, Coles C, Offersen B, Meattini I, Bölükbaşı Y, Leonardi MC, Pfeffer R, Cutuli B, Vidali C, Franco P, Kouloulias V, Masiello V, Rivera S, Bourgier C, Ciabattoni A, Lancellotta V, Trigo L, Valentini V, Poortmans P, Aristei C. The 2018 assisi think tank meeting on breast cancer: International expert panel white paper. Crit Rev Oncol Hematol 2020; 151:102967. [PMID: 32450277 DOI: 10.1016/j.critrevonc.2020.102967] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 03/27/2020] [Accepted: 04/15/2020] [Indexed: 01/13/2023] Open
Abstract
We report on the second Assisi Think Tank Meeting (ATTM) on breast cancer which was held under the auspices of the European Society for RadioTherapy & Oncology (ESTRO). In discussing in-depth current evidence and practice it was designed to identify grey areas in diverse forms of the disease. It aimed at addressing uncertainties and proposing future trials to improve patient care. Before the meeting, three key topics were selected: 1) primary systemic therapy, mastectomy, breast reconstruction and post-mastectomy radiation therapy, 2) therapeutic options in ductal carcinoma in situ, and 3) therapy de-escalation in early stage breast cancer. Clinical practice in these areas was investigated by means of an online questionnaire. The time lapse period between the survey and the meeting was used to review the literature and on-going clinical trials. At the ATTM both were discussed in depth and research protocols were proposed.
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Affiliation(s)
| | - Ugur Selek
- Radiation Oncology, Koc University School of Medicine, Istambul, Turkey
| | - Orit Kaidar-Person
- Radiation Oncology, Oncology Institute, Rambam Medical Center, Haifa, Israel
| | | | | | - Liesbeth Boersma
- Radiation Oncology (Maastro), GROW School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Charlotte Coles
- Radiation Oncology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | | | - Icro Meattini
- Radiation Oncology, Azienda Ospedaliero-Universitaria Careggi (AOUC), Florence, Italy
| | - Yasemin Bölükbaşı
- Radiation Oncology, Koc University School of Medicine, Istambul, Turkey
| | | | - Raphael Pfeffer
- Radiation Oncology, Assuta Medical Centres, Tel Aviv, Israel
| | - Bruno Cutuli
- Radiation Oncology, Institut du Cancer Courlancy, Reims, France
| | - Cristiana Vidali
- Radiation Oncology, Azienda Sanitaria Universitaria Integrata di Trieste (ASUITS), Trieste, Italy
| | - Pierfrancesco Franco
- Radiation Oncology, Department of Oncology, University of Turin School of Medicine, Turin, Italy
| | - Vassilis Kouloulias
- Radiation Oncology, National and Kapodistrian University of Athens, Medical School, Attikon University Hospital, Athens, Greece
| | - Valeria Masiello
- Radiation Oncology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Sofia Rivera
- Radiation Oncology, Institut Gustave Roussy, Villejuif, France
| | - Céline Bourgier
- Radiation Oncology, ICM-Val d'Aurelle, University Montpellier, Montpellier, France
| | | | - Valentina Lancellotta
- Radiation Oncology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Lurdes Trigo
- Radiation Oncology, Instituto Portugues de Oncologia Francisco Martins Porto E.P.E, Porto, Portugal
| | - Vincenzo Valentini
- Radiation Oncology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Philip Poortmans
- Radiation Oncology, Iridium Kankernetwerk, Wilrijk-Antwerp - University of Antwerp, Faculty of Medicine and Health Sciences, Wilrijk-Antwerp, Belgium
| | - Cynthia Aristei
- Radiation Oncology, University of Perugia and Perugia General Hospital, Perugia, Italy.
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Leonardi MC, Corrao G, Frassoni S, Vingiani A, Dicuonzo S, Lazzeroni M, Fodor C, Morra A, Gerardi MA, Rojas DP, Dell'Acqua V, Marvaso G, Bassi FD, Galimberti VE, Veronesi P, Miglietta E, Cattani F, Zurrida S, Bagnardi V, Viale G, Orecchia R, Jereczek-Fossa BA. Ductal carcinoma in situ and intraoperative partial breast irradiation: Who are the best candidates? Long-term outcome of a single institution series. Radiother Oncol 2019; 133:68-76. [PMID: 30935584 DOI: 10.1016/j.radonc.2018.12.030] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 12/30/2018] [Accepted: 12/31/2018] [Indexed: 12/27/2022]
Abstract
AIMS To report the long-term outcome of a single institution series of pure ductal carcinoma in situ (DCIS) treated with accelerated partial irradiation using intraoperative electrons (IOERT). METHODS From 2000 to 2010, 180 DCIS patients, treated with quadrantectomy and 21 Gy IOERT, were analyzed in terms of ipsilateral breast recurrences (IBRs) and survival outcomes by stratification in two subgroups. The low-risk group included patients who fulfilled the suitable definition according to American Society of Radiation Oncology (ASTRO) Guidelines (size ≤2.5 cm, grade 1-2 and surgical margins ≥3 mm) (Suitable), while the remaining ones formed the high-risk group (Non-Suitable). RESULTS Eighty-four and 96 patients formed the Suitable and Non-Suitable groups, respectively. In the whole population, the cumulative incidence of IBR at 5, 7 and 10 years was 19%, 21%, and 25%, respectively. In the Suitable group, the cumulative incidence of IBR remained constant at 11% throughout the years, while in the Non-Suitable group increased from 26% at 5 years to 36% at 10 years (p < 0.0001). When hormonal positivity and HER2 absence of expression were added to the selection of the Suitable group, the cumulative incidence of IBR dropped and stabilized at 4% at 10 years. None died of breast cancer. In the whole population, 5-year and 10-year overall survival rate was 98% and 96.5%, respectively, without any difference between the two groups. CONCLUSIONS The overall and by group IBR rates were high and stricter criteria are required for acceptable local control for Suitable DCIS. Because of the concerns raised, IOERT should not be used in clinical practice.
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Affiliation(s)
| | - Giulia Corrao
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, Milan, Italy; Department of Oncology and Hemato-oncology, University of Milan, Italy
| | - Samuele Frassoni
- Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Italy
| | - Andrea Vingiani
- Department of Pathology, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Samantha Dicuonzo
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, Milan, Italy.
| | - Matteo Lazzeroni
- Division of Cancer Prevention and Genetics, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Cristiana Fodor
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Anna Morra
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | | | - Damaris Patricia Rojas
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, Milan, Italy; Department of Oncology and Hemato-oncology, University of Milan, Italy
| | - Veronica Dell'Acqua
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Giulia Marvaso
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Fabio Domenico Bassi
- Division of Breast Surgery, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | | | - Paolo Veronesi
- Department of Oncology and Hemato-oncology, University of Milan, Italy; Division of Breast Surgery, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Eleonora Miglietta
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Federica Cattani
- Unit of Medical Physics, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Stefano Zurrida
- Department of Oncology and Hemato-oncology, University of Milan, Italy
| | - Vincenzo Bagnardi
- Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Italy
| | - Giuseppe Viale
- Department of Oncology and Hemato-oncology, University of Milan, Italy; Department of Pathology, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Roberto Orecchia
- Scientific Direction, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Barbara Alicja Jereczek-Fossa
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, Milan, Italy; Department of Oncology and Hemato-oncology, University of Milan, Italy
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Banks A, Coronado G, Zimmerman R, Iyengar G, Holmes DR. Breast conserving surgery with targeted intraoperative radiotherapy for the management of ductal carcinoma in situ. J Surg Oncol 2018; 119:409-420. [DOI: 10.1002/jso.25347] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Accepted: 12/07/2018] [Indexed: 11/11/2022]
Affiliation(s)
- Alexandra Banks
- Department of Surgery; Helen Rey Breast Cancer Research Foundation; Los Angeles California
| | - Gerald Coronado
- Department of Surgery; Helen Rey Breast Cancer Research Foundation; Los Angeles California
| | - Robert Zimmerman
- Department of Radiation Oncology; Los Angeles Radiation Oncology Center; Los Angeles California
| | - Geeta Iyengar
- Department of Radiology; Medical Imaging Center of Southern California; Santa Monica California
| | - Dennis R. Holmes
- Department of Surgery; Helen Rey Breast Cancer Research Foundation; Los Angeles California
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Doke K, Butler S, Mitchell MP. Current Therapeutic Approaches to DCIS. J Mammary Gland Biol Neoplasia 2018; 23:279-291. [PMID: 30267199 DOI: 10.1007/s10911-018-9415-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Accepted: 09/18/2018] [Indexed: 12/21/2022] Open
Abstract
Treatment for ductal carcinoma in-situ (DCIS) has historically been extrapolated from studies of invasive breast cancer. Accepted local therapy approaches range from small local excisions, with or without radiation, to bilateral mastectomies. Systemic treatment with endocrine therapy is often recommended for hormone positive patients. With improvements in imaging, pathologic review, and treatment techniques in the modern era, combined with new information regarding tumor biology, the management of DCIS is rapidly evolving. A multidisciplinary approach to treatment is now more important than ever, with a shift towards de-escalating therapy to reduce treatment related toxicity. This review focuses on nuances of clinical management of DCIS in the modern era, highlighting key differences between DCIS as compared to invasive breast cancer. The American Cancer Society (ACS) currently recommends beginning screening with annual mammograms for women age 45, with the option to start at age 40. As treatment of DCIS has not been shown to impact survival, the USPSTF has more conservative screening recommendations of biennial mammograms from age 50-74. Unlike invasive breast cancer, DCIS is almost exclusively diagnosed by mammographic detection, and lymph node evaluation is not recommended. Pathologic review of biopsy specimens should follow the guidelines of the College of American Pathologists. Surgical management options include breast conservation, mastectomy, or possibly nipple sparing mastectomy, with upfront sentinel lymph node evaluation in the case of mastectomy. Radiation therapy is generally recommended as a component of breast conserving therapy for patients with DCIS, though in some low risk patients, there is trial data to suggest that adjuvant radiation may be omitted. Techniques for minimizing radiation toxicity should always be emphasized. Endocrine therapy is offered to women with hormone positive DCIS who have undergone lumpectomy for risk reduction, and has the benefit of decreasing incidence of events in both the ipsilateral and contralateral breast. More recent studies have explored use of targeted treatments such as trastuzumab in DCIS for HER2 overexpression. Future directions include tailoring therapy based on patient characteristics and tumor biology. With so many different options for treatment, it is also critical to engage in a discussion with the patient to arrive at a treatment decision that balances patient preferences for disease control versus treatment toxicity, financial toxicity, cosmesis, and quality of life.
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Affiliation(s)
- Kaleigh Doke
- Department of Radiation Oncology, The Kansas University Medical Center, 3901 Rainbow Blvd., Mailstop 4033, Kansas City, KS, 66160, USA
| | - Shirley Butler
- Department of Radiation Oncology, The Kansas University Medical Center, 3901 Rainbow Blvd., Mailstop 4033, Kansas City, KS, 66160, USA
| | - Melissa P Mitchell
- Department of Radiation Oncology, The Kansas University Medical Center, 3901 Rainbow Blvd., Mailstop 4033, Kansas City, KS, 66160, USA.
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Partial breast irradiation with interstitial multi-catheter high-dose-rate brachytherapy. Long-term results of a phase II prospective study. Radiother Oncol 2017; 124:208-213. [PMID: 28764924 DOI: 10.1016/j.radonc.2017.07.015] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Revised: 07/11/2017] [Accepted: 07/12/2017] [Indexed: 01/23/2023]
Abstract
PURPOSE We report the long-term results of phase II prospective study with accelerated partial breast irradiation (APBI) using interstitial multi-catheter high-dose-rate brachytherapy. METHODS 240 patients received APBI (4Gy, twice daily; total dose 32Gy). RESULTS Median follow-up was 96months. Recurrences in the treated breast developed in 8 patients (3.3%) at a median of 73months after APBI. The 5- and 10-year cumulative incidences were respectively, 1.8% (95%CI: 0.6-4.3) and 6.6% (95%CI: 2.7-12.9). Regional recurrences developed in 5 patients (2%) at a median of 28months and distant metastases in 8 (3.3%) at a median of 32.5months. Breast cancer specific mortality occurred in 6 patients (2.5%) at a median of 60months. Acute toxicity developed in 71 (29.6%) patients (G1 in 60 and G2 in 11). Almost all were skin toxicity and hematomas. Late toxicity was observed in 90 patients (37.5%), G1 in 97 cases and G2 in 11. Some patients presented with more than one type of toxicity. Teleangectasia and fibrosis were the most common (48 and 44 cases respectively), followed by fat necrosis (in 18 patients) Tamoxifen emerged as the only risk factor for breast fibrosis (p=0.007). Cosmetic results were judged by the physicians as excellent in 174 (83.7%) patients, good in 25 (12%) fair in 8 (3.8%) and poor in 1 (0.5%); 174 patients (83.7%) judged outcomes as excellent, 26 (12.4%) as good, 7 (3.4%) as fair and 1 (0.5%) as poor. Physician/patient agreement was good (weighted k-value 0.72). CONCLUSIONS APBI with interstitial multi-catheter brachytherapy was associated with good outcomes, low relapse and toxicity rates. Few events during this long-term follow-up preclude identifying specific features of patients at risk of relapse and illustrate the need for a large data-base.
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Haque W, Verma V, Haque A, Butler EB, Teh BS. Trends in the use of implantable accelerated partial breast irradiation for ductal carcinoma in situ: Implications of the recent amendments to the American Society for Radiation Oncology consensus guidelines. Brachytherapy 2017; 16:402-408. [PMID: 28063816 DOI: 10.1016/j.brachy.2016.12.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Revised: 12/07/2016] [Accepted: 12/08/2016] [Indexed: 11/26/2022]
Abstract
PURPOSE In 2009, the American Society for Radiation Oncology (ASTRO) published consensus recommendations that stated ductal carcinoma in situ (DCIS) patients were in a "cautionary" group for accelerated partial breast irradiation (APBI) and should not receive APBI outside of a clinical trial. However, very recently, ASTRO placed low-risk DCIS patients in the "suitable" category. Given this recent change, we aimed to use the Surveillance, Epidemiology, and End Results (SEER) database to evaluate past patterns of implantable APBI (IAPBI) utilization in women with DCIS. METHODS AND MATERIALS The Surveillance, Epidemiology, and End Results database was queried for patients from 2000 to 2012 with DCIS that underwent lumpectomy and adjuvant radiation therapy. Patients receiving IAPBI were differentiated from those receiving whole breast radiation therapy. Trends based on treatment year and patient demographics were collected, and multivariable logistic regression determined factors independently predictive of use of IAPBI. RESULTS Of 52,012 eligible patients, 49,450 (95%) underwent external beam radiation and 2562 (5%) received APBI. Though IAPBI utilization steadily increased from 2000 (0.2% of the study population) to 2008 (9.4%), it abruptly declined in 2009 (7.9%, p = 0.009) and yearly thereafter. The 40-49 age group was proportionally most associated with this decline (8.6% in 2008 to 4.3% in 2009). Factors independently associated with IAPBI receipt included increasing age, hormone receptor negative status, and women living in the South. CONCLUSIONS Patterns of IAPBI administration in DCIS are described. These trends are important to consider as a benchmark going forward, in light of the very recent change in ASTRO recommendations to include low-risk DCIS patients.
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Affiliation(s)
- Waqar Haque
- Department of Radiation Oncology, Greater Houston Physicians Medical Association, Houston, TX.
| | - Vivek Verma
- Department of Radiation Oncology, University of Nebraska Medical Center, Omaha, NE
| | - Anam Haque
- College of Natural Science and Mathematics, University of Houston, Houston, TX
| | - E Brian Butler
- Department of Radiation Oncology, Houston Methodist Hospital, Houston, TX
| | - Bin S Teh
- Department of Radiation Oncology, Houston Methodist Hospital, Houston, TX
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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
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11
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Rivera R, Banks A, Casillas-Lopez A, Rashtian A, Lewinsky B, Sheth P, Hovannesian-Larsen L, Brousseau D, Iyengar G, Holmes DR. Targeted Intraoperative Radiotherapy for the Management of Ductal Carcinoma In Situ of the Breast. Breast J 2015; 22:63-74. [PMID: 26534876 DOI: 10.1111/tbj.12516] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Multiple long-term studies have demonstrated a propensity for breast cancer recurrences to develop near the site of the original breast cancer. Recognition of this local recurrence pattern laid the foundation for the development of accelerated partial breast irradiation (APBI) approaches designed to limit the radiation treatment field to the site of the malignancy. However, there is a paucity of data regarding the efficacy of APBI in general, and intraoperative radiotherapy (IORT), in particular, for the management of ductal carcinoma in situ (DCIS). As a result, use of APBI, remains controversial. A prospective nonrandomized trial was designed to determine if patients with pure DCIS considered eligible for concurrent IORT based on preoperative mammography and contrast-enhanced magnetic resonance imaging (CE-MRI) could be successfully treated using IORT with minimal need for additional therapy due to inadequate surgical margins or excessive tumor size. Between November 2007 and June 2014, 35 women underwent bilateral digital mammography and bilateral breast CE-MRI prior to selection for IORT. Patients were deemed eligible for IORT if their lesion was ≤4 cm in maximal diameter on both digital mammography and CE-MRI, pure DCIS on minimally invasive breast biopsy or wide local excision, and considered resectable with clear surgical margins using breast-conserving surgery (BCS). Postoperatively, the DCIS lesion size determined by imaging was compared with lesion size and surgical margin status obtained from the surgical pathology specimen. Thirty-five patients completed IORT. Median patient age was 57 years (range 42-79 years) and median histologic lesion size was 15.6 mm (2-40 mm). No invasive cancer was identified. In more than half of the patients in our study (57.1%), MRI failed to detect a corresponding lesion. Nonetheless, 30 patients met criteria for negative margins (i.e., margins ≥2 mm) whereas five patients had positive margins (<2 mm). Two of the five patients with positive margins underwent mastectomy due to extensive imaging-occult DCIS. Three of the five patients with positive margins underwent successful re-excision at a subsequent operation prior to subsequent whole breast irradiation. A total of 14.3% (5/35) of patients required some form of additional therapy. At 36 months median follow-up (range of 2-83 months, average 42 months), only two patients experienced local recurrences of cancer (DCIS only), yielding a 5.7% local recurrence rate. No deaths or distant recurrences were observed. Imaging-occult DCIS is a challenge for IORT, as it is for all forms of breast-conserving therapy. Nonetheless, 91.4% of patients with DCIS were successfully managed with BCS and IORT alone, with relatively few patients requiring additional therapy.
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Affiliation(s)
- Ronald Rivera
- University of California, Los Angeles - David Geffen School of Medicine, Los Angeles, California
| | - Alexandra Banks
- California Hospital Medical Center - Los Angeles Center for Women's Health, Los Angeles, California
| | - America Casillas-Lopez
- University of Southern California - Norris Comprehensive Cancer Center, Los Angeles, California
| | - Afshin Rashtian
- Cancer Center Riverside Community Hospital, Los Angeles, California
| | - Bernie Lewinsky
- California Hospital Medical Center - Los Angeles Center for Women's Health, Los Angeles, California
| | - Pulin Sheth
- University of Southern California - Norris Comprehensive Cancer Center, Los Angeles, California
| | | | - David Brousseau
- California Hospital Medical Center - Los Angeles Center for Women's Health, Los Angeles, California
| | - Geeta Iyengar
- Medical Imaging Center of Southern California, Los Angeles, California
| | - Dennis R Holmes
- California Hospital Medical Center - Los Angeles Center for Women's Health, Los Angeles, California
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12
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Merino Lara TR, Fleury E, Mashouf S, Helou J, McCann C, Ruschin M, Kim A, Makhani N, Ravi A, Pignol JP. Measurement of mean cardiac dose for various breast irradiation techniques and corresponding risk of major cardiovascular event. Front Oncol 2014; 4:284. [PMID: 25374841 PMCID: PMC4205812 DOI: 10.3389/fonc.2014.00284] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2014] [Accepted: 09/30/2014] [Indexed: 12/04/2022] Open
Abstract
After breast conserving surgery, early stage breast cancer patients are currently treated with a wide range of radiation techniques including whole breast irradiation (WBI), accelerated partial breast irradiation (APBI) using high-dose rate (HDR) brachytherapy, or 3D-conformal radiotherapy (3D-CRT). This study compares the mean heart’s doses for a left breast irradiated with different breast techniques. An anthropomorphic Rando phantom was modified with gelatin-based breast of different sizes and tumors located medially or laterally. The breasts were treated with WBI, 3D-CRT, or HDR APBI. The heart’s mean doses were measured with Gafchromic films and controlled with optically stimulated luminescent dosimeters. Following the model reported by Darby (1), major cardiac were estimated assuming a linear risk increase with the mean dose to the heart of 7.4% per gray. WBI lead to the highest mean heart dose (2.99 Gy) compared to 3D-CRT APBI (0.51 Gy), multicatheter (1.58 Gy), and balloon HDR (2.17 Gy) for a medially located tumor. This translated into long-term coronary event increases of 22, 3.8, 11.7, and 16% respectively. The sensitivity analysis showed that the tumor location had almost no effect on the mean heart dose for 3D-CRT APBI and a minimal impact for HDR APBI. In case of WBI large breast size and set-up errors lead to sharp increases of the mean heart dose. Its value reached 10.79 Gy for women with large breast and a set-up error of 1.5 cm. Such a high value could increase the risk of having long-term coronary events by 80%. Comparison among different irradiation techniques demonstrates that 3D-CRT APBI appears to be the safest one with less probability of having cardiovascular events in the future. A sensitivity analysis showed that WBI is the most challenging technique for patients with large breasts or when significant set-up errors are anticipated. In those cases, additional heart shielding techniques are required.
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Affiliation(s)
- Tomas Rodrigo Merino Lara
- Radiotherapy Unit, School of Medicine, Pontificia Universidad Católica de Chile , Santiago , Chile ; Department of Radiation Oncology, Sunnybrook Odette Cancer Centre , Toronto, ON , Canada ; Department of Radiation Oncology, University of Toronto , Toronto, ON , Canada
| | - Emmanuelle Fleury
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre , Toronto, ON , Canada ; Department of Radiation Oncology, University of Toronto , Toronto, ON , Canada
| | - Shahram Mashouf
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre , Toronto, ON , Canada ; Department of Radiation Oncology, University of Toronto , Toronto, ON , Canada
| | - Joelle Helou
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre , Toronto, ON , Canada ; Department of Radiation Oncology, University of Toronto , Toronto, ON , Canada
| | - Claire McCann
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre , Toronto, ON , Canada ; Department of Radiation Oncology, University of Toronto , Toronto, ON , Canada
| | - Mark Ruschin
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre , Toronto, ON , Canada ; Department of Radiation Oncology, University of Toronto , Toronto, ON , Canada
| | - Anthony Kim
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre , Toronto, ON , Canada ; Department of Radiation Oncology, University of Toronto , Toronto, ON , Canada
| | - Nadiya Makhani
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre , Toronto, ON , Canada ; Department of Radiation Oncology, University of Toronto , Toronto, ON , Canada
| | - Ananth Ravi
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre , Toronto, ON , Canada ; Department of Radiation Oncology, University of Toronto , Toronto, ON , Canada
| | - Jean-Philippe Pignol
- Department of Radiation Oncology, University of Toronto , Toronto, ON , Canada ; Department of Radiation Oncology, Erasmus MC , Rotterdam , Netherlands
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13
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Greenberg CC, Habel LA, Hughes ME, Nekhlyudov L, Achacoso N, Acton L, Schrag D, Jiang W, Edge S, Weeks JC, Punglia RS. Characterization and treatment of local recurrence following breast conservation for ductal carcinoma in situ. Ann Surg Oncol 2014; 21:3766-73. [PMID: 24859938 DOI: 10.1245/s10434-014-3802-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2014] [Indexed: 11/18/2022]
Abstract
PURPOSE The optimal treatment strategy for ductal carcinoma in situ (DCIS) continues to evolve and should consider the consequences of initial treatment on the likelihood, type, and treatment of recurrences. METHODS We conducted a retrospective cohort study using two data sources of patients who experienced a recurrence (DCIS or invasive cancer) following breast-conserving surgery (BCS) for index DCIS: patients with an index DCIS diagnosed from 1997 to 2008 at the academic institutions of the National Comprehensive Cancer Network (NCCN; N = 88) and patients with an index DCIS diagnosed from 1990 to 2001 at community-based integrated healthcare delivery sites of the Health Maintenance Organization Cancer Research Network (CRN) (N = 182). RESULTS Just under half of local recurrences in both cohorts were invasive cancer. While 40 % of patients in both cohorts underwent mastectomy alone at recurrence, treatment of the remaining patients varied. In the earlier CRN cohort, most other patients underwent repeat BCS (39 %) with only 18 % receiving mastectomy with reconstruction, whereas only 16 % had repeat BCS and 44 % had mastectomy with reconstruction in the NCCN cohort. Compared with patients not treated with radiation, those who received radiation for index DCIS were less likely to undergo repeat BCS (NCCN: 6.6 vs. 37 %, p = 0.001; CRN: 20 vs. 48 %, p = 0.0004) and more likely to experience surgical complications after treatment of recurrence (NCCN: 15 vs. 4 %, p = 0.17; CRN: 40 vs. 25 %, p = 0.09). CONCLUSION We found that treatment of recurrences after BCS and subsequent complications may be affected by the use of radiotherapy for the index DCIS. Initial treatment of DCIS may have long-term implications that should be considered.
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Affiliation(s)
- Caprice C Greenberg
- Wisconsin Surgical Outcomes Research (WiSOR) Program, Department of Surgery, University of Wisconsin Hospitals and Clinics, Madison, WI, USA,
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Wong FY, Wang F, Chen JJ, Tan CH, Tan PH. Outcomes of Low-Risk Ductal Carcinoma In Situ in Southeast Asian Women Treated With Breast Conservation Therapy. Int J Radiat Oncol Biol Phys 2014; 88:998-1003. [DOI: 10.1016/j.ijrobp.2014.01.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2013] [Revised: 12/27/2013] [Accepted: 01/15/2014] [Indexed: 11/15/2022]
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15
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Souchon R, Sautter-Bihl ML, Sedlmayer F, Budach W, Dunst J, Feyer P, Fietkau R, Haase W, Harms W, Wenz F, Sauer R. DEGRO practical guidelines: radiotherapy of breast cancer II. Strahlenther Onkol 2013; 190:8-16. [DOI: 10.1007/s00066-013-0502-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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16
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Aristei C, Palumbo I, Capezzali G, Farneti A, Bini V, Falcinelli L, Margaritelli M, Lancellotta V, Zucchetti C, Perrucci E. Outcome of a phase II prospective study on partial breast irradiation with interstitial multi-catheter high-dose-rate brachytherapy. Radiother Oncol 2013; 108:236-41. [PMID: 24044802 DOI: 10.1016/j.radonc.2013.08.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2012] [Revised: 07/23/2013] [Accepted: 08/05/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND AND PURPOSE Partial breast irradiation (PBI) is an alternative to whole-breast irradiation after breast-conserving surgery in selected patients. Until the results of randomized phase III studies are available, phase II studies inform about PBI. We report the 5 year results of a phase II prospective study with PBI using interstitial multi-catheter high-dose-rate brachytherapy (ClinicalTrials.gov Identifier: NCT00499057). METHODS Hundred patients received PBI (4 Gy, twice a day for 4 days, until 32 Gy). Inclusion criteria were: age ≥ 40years, infiltrating carcinoma without lobular histology, ductal in situ carcinoma, tumor size ≤ 2.5 cm, negative surgical margins and axillary lymph nodes. RESULTS At a median follow-up of 60 months late toxicity occurred in 25 patients; the 5-year probability of freedom from late toxicity was 72.6% (95% CI: 63.7-81.7). Tamoxifen was the only significant risk factor for late toxicity. Cosmetic results, judged by physicians and patients, were good/excellent in 98 patients. Three local relapses (1 true, 2 elsewhere) and 1 regional relapse occurred. The 5-year probability of local or regional relapse-free survival was 97.7% (95% CI: 91.1-99.4) and 99.0% (95% CI: 92.9-99.8), respectively. CONCLUSION PBI with interstitial multi-catheter brachytherapy is associated with low relapse and late toxicity rates.
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Affiliation(s)
- Cynthia Aristei
- Radiation Oncology Section, University of Perugia and Santa Maria della Misericordia Hospital, Italy.
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Yang TJ, Tao R, Elkhuizen PH, van Vliet-Vroegindeweij C, Li G, Powell SN. Tumor bed delineation for external beam accelerated partial breast irradiation: A systematic review. Radiother Oncol 2013; 108:181-9. [DOI: 10.1016/j.radonc.2013.05.028] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2012] [Revised: 05/12/2013] [Accepted: 05/12/2013] [Indexed: 11/15/2022]
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DCIS and LCIS are confusing and outdated terms. They should be abandoned in favor of ductal intraepithelial neoplasia (DIN) and lobular intraepithelial neoplasia (LIN). Breast 2013; 22:431-5. [PMID: 23643807 DOI: 10.1016/j.breast.2013.04.010] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2013] [Accepted: 04/03/2013] [Indexed: 11/22/2022] Open
Abstract
The terms ductal and lobular intraepithelial neoplasia (DIN and LIN) were introduced by Tavossoli 15 years ago, who proposed they should replace, respectively, ductal and lobular carcinoma in situ (DCIS and LCIS). This proposal has been slowly gaining ground. We argue that DCIS and LCIS should now be definitively abandoned. Bringing together 'in situ' and other entities into the simpler and more logical DIN/LIN framework--as has been done with intraepithelial neoplasias of cervix, vagina, vulva, prostate, and pancreas--would eliminate the artificial and illogical distinctions between 'not cancers' (e.g. flat epithelial atypia, atypical ductal hyperplasia--now classified as low grade DIN) and 'cancers' (e.g. DCIS--now considered medium-high grade DIN). Elimination of the term 'carcinoma' from entities that cannot metastasize will reduce confusion among health professionals and patients, and contribute to reducing the risk of overtreatment, as well as reducing adverse psychological reactions in patients.
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Breast conservation therapy utilizing partial breast brachytherapy for early-stage cancer of the breast: a retrospective review from the Saint Luke's Cancer Institute. Am J Clin Oncol 2013; 38:174-8. [PMID: 23608831 DOI: 10.1097/coc.0b013e31828f5b1f] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Accelerated partial breast irradiation (APBI) is a convenient alternative to whole-breast irradiation, as less overall time is needed for completion. The use of APBI outside the framework of large prospective clinical trials has markedly increased. To our knowledge, no high-volume, community-based breast program has published their experience with APBI. METHODS The records of 93 consecutive patients who underwent APBI utilizing Mammosite Radiation Therapy System from 2005 to 2010 at Saint Luke's Cancer Institute in Kansas City, MO, were retrospectively reviewed. The Kaplan-Meier method was used to estimate the ipsilateral breast recurrence rate and recurrence-free survival. RESULTS Median age at diagnosis was 63 years (range, 45 to 86 y) and mean follow-up was 29 months. Patient stratification ASTRO consensus classifications for APBI was 37% suitable, 57% cautionary, and 6% unsuitable. The 3-year breast control rate was 98.7%. Three-year overall recurrence-free survival was 94.4%, and 3-year mastectomy-free survival was 97.4%. Using univariate analysis, no tumor or patient factors were associated with ipsilateral breast recurrence. However, tumor grade (P<0.05), stage (P=0.04), estrogen receptor status (P<0.001), progesterone receptor status (P<0.001), tumor size (P<0.001), and ASTRO suitability criteria (P=0.027) were associated with overall recurrence-free survival. No differences were observed when outcomes of patients with ductal carcinoma in situ were compared with those with invasive disease. CONCLUSIONS In our high-volume community-based program, APBI outcomes are comparable with those reported from large academic institutions. We also found relationships between tumor stage, grade, negative estrogen receptor status, and ASTRO suitability criteria with overall recurrence rates. The continued careful application of APBI in appropriately selected patients appears warranted until phase III trials comparing this modality to whole-breast irradiation have matured.
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20
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Shah C, Vicini F, Wazer DE, Arthur D, Patel RR. The American Brachytherapy Society consensus statement for accelerated partial breast irradiation. Brachytherapy 2013; 12:267-77. [PMID: 23619524 DOI: 10.1016/j.brachy.2013.02.001] [Citation(s) in RCA: 130] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2012] [Revised: 01/21/2013] [Accepted: 02/01/2013] [Indexed: 01/08/2023]
Abstract
PURPOSE To develop clinical guidelines for the quality practice of accelerated partial breast irradiation (APBI) as part of breast-conserving therapy for women with early-stage breast cancer. METHODS AND MATERIALS Members of the American Brachytherapy Society with expertise in breast cancer and breast brachytherapy in particular devised updated guidelines for appropriate patient evaluation and selection based on an extensive literature search and clinical experience. RESULTS Increasing numbers of randomized and single and multi-institution series have been published documenting the efficacy of various APBI modalities. With more than 10-year followup, multiple series have documented excellent clinical outcomes with interstitial APBI. Patient selection for APBI should be based on a review of clinical and pathologic factors by the clinician with particular attention paid to age (≥50 years old), tumor size (≤3cm), histology (all invasive subtypes and ductal carcinoma in situ), surgical margins (negative), lymphovascular space invasion (not present), and nodal status (negative). Consistent dosimetric guidelines should be used to improve target coverage and limit potential for toxicity following treatment. CONCLUSIONS These guidelines have been created to provide clinicians with appropriate patient selection criteria to allow clinicians to use APBI in a manner that will optimize clinical outcomes and patient satisfaction. These guidelines will continue to be evaluated and revised as future publications further stratify optimal patient selection.
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Affiliation(s)
- Chirag Shah
- Department of Radiation Oncology, Washington University School of Medicine, Saint Louis, MO, USA
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21
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Vicini F, Shah C, Ben Wilkinson J, Keisch M, Beitsch P, Lyden M. Should Ductal Carcinoma-in-situ (DCIS) Be Removed from the ASTRO Consensus Panel Cautionary Group for Off-protocol Use of Accelerated Partial Breast Irradiation (APBI)? A Pooled Analysis of Outcomes for 300 Patients with DCIS Treated with APBI. Ann Surg Oncol 2012; 20:1275-81. [DOI: 10.1245/s10434-012-2694-7] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2012] [Indexed: 11/18/2022]
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Clinical Outcomes Using Accelerated Partial Breast Irradiation in Patients With Ductal Carcinoma In Situ. Clin Breast Cancer 2012; 12:259-63. [DOI: 10.1016/j.clbc.2012.04.006] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2012] [Revised: 04/13/2012] [Accepted: 04/16/2012] [Indexed: 11/18/2022]
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23
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Radiotherapy after conservative surgery in ductal carcinoma in situ of the breast: a review. Int J Surg Oncol 2012; 2012:635404. [PMID: 22655186 PMCID: PMC3359679 DOI: 10.1155/2012/635404] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2011] [Accepted: 03/06/2012] [Indexed: 12/02/2022] Open
Abstract
Several large prospective and retrospective studies have demonstrated excellent long-term outcomes after breast conservative treatment with radiation in invasive breast cancer. Breast-conserving surgery (BCS) followed by radiotherapy (RT) is an accepted management strategy for patients with DCIS. Adding radiation treatment after conservative surgery enables to reduce, without any significant risks, the rate of local recurrence (LR) by approximately 50% in retrospective and randomized clinical trials. As about 50% of LRs are invasive and have a negative psychological impact, minimizing recurrence is important. Local and local-regional recurrences after initial breast conservation treatment with radiation can be salvaged with high rates of survival and freedom from distant metastases.
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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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Abstract
In the last four decades breast-conserving surgery followed by whole breast irradiation has become the standard of care for the treatment of early-stage (0-I-II) breast carcinoma. With the advent of breast-screening, incidence of breast carcinomas with more favorable prognostic characteristics has increased significantly. This change in the prognostic profile of newly diagnosed breast cancers opened a new horizon for clinical research seeking for individual risk-adapted protocols of breast cancer radiotherapy. Several groups have been tested the efficacy of accelerated (partial or whole) breast irradiation, which has become the new treatment paradigm in the radiotherapy of early-stage breast cancers. Furthermore, others have attempted to identify subgroups of patients for whom radiotherapy after breast-conserving surgery could be safely omitted. Recently molecular gene expression assays have emerged as promising prognostic and predictive markers for local recurrence. This article reviews the results of these studies focusing on individual risk-adapted radiotherapy after breast-conserving surgery for patients with early-stage breast carcinoma.
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Affiliation(s)
- Csaba Polgár
- Országos Onkológiai Intézet Budapest Ráth Gy. u. 7-9. 1122.
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Liao L, Han G, Li Y, Wang Z, Liu D, Pi Z. A primary experience of conventional fractionated three-dimensional conformal partial breast irradiation for early-stage breast cancer. Exp Ther Med 2011; 2:551-555. [PMID: 22977539 DOI: 10.3892/etm.2011.223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2010] [Accepted: 02/22/2011] [Indexed: 11/06/2022] Open
Abstract
Recently, a number of clinical trials assessing partial breast irradiation (PBI), in particular accelerated partial breast irradiation, have been conducted in patients with early-stage breast cancer after breast-conserving surgery (BCS) in Europe and the US. By contrast, PBI is rarely performed in Eastern countries. In general, there are many physiological differences between Eastern and Western populations, and whether PBI is suitable for Eastern populations remains uncertain. Moreover, PBI is still in the stage of clinical research, and numerous questions have yet to be resolved. Thus, we designed a PBI trial to explore its feasibility and effectiveness for Eastern patients. According to the study criteria, 12 patients were enrolled between June 2003 and March 2007. Using three-dimensional conformal partial breast irradiation, they received a conventional fraction of 2 Gy/fraction/day, 5 fractions/week, DT60 Gy. According to follow-up data collected in August 2010, the rates of local recurrence and distant metastasis were 0%. The most common adverse reactions included grade 2 radioactive erythema in 2 (17%) cases and pigment deposition in 10 (83%). The results revealed that the patients exhibited good local tumor control, with minor adverse reactions and satisfactory cosmetic results. More samples and long-term observations are required to further assess the validity and feasibility of PBI.
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Affiliation(s)
- Lingxia Liao
- Department of Radiotherapy, Hubei Cancer Hospital, Wuhan 430079, P.R. China
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