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Hahn E, Sutradhar R, Paszat L, Nguyen L, Rodin D, Nofech-Mozes S, Trebinjac S, Jerzak KJ, Fong C, Rakovitch E. Molecular Expression Assays Improve the Prediction of Local and Invasive Local Recurrence After Breast-Conserving Surgery for Ductal Carcinoma In Situ. J Clin Oncol 2024; 42:3196-3206. [PMID: 38941575 DOI: 10.1200/jco.23.02276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 04/05/2024] [Accepted: 04/17/2024] [Indexed: 06/30/2024] Open
Abstract
PURPOSE Ductal carcinoma in situ (DCIS) is routinely treated with adjuvant radiotherapy (RT) after breast-conserving surgery (BCS). The inability to accurately estimate an individual's risk of local recurrence (LR) and invasive LR using clinicopathologic factors (CPF) contributes to the overtreatment of DCIS. We examined the impact of the 12-gene DCIS Score (DS) and the 21-gene Recurrence Score (RS) on the accuracy of predicting LR and invasive LR. METHODS A population-based cohort diagnosed with pure DCIS treated with BCS ± RT from 1994 to 2003 was used. All patients had expert pathology review and assessment of the DS and RS. Predictive models (CPF alone, DS + CPF, and RS + CPF) were developed using multivariable Cox regression analyses to predict 10-year LR and invasive LR risks. Models were evaluated on the basis of c-statistic, -2log likelihood estimate (-2LLE), and Akaike information criterion. Calibration was performed using bootstrap resamples, with replacement. RESULTS The cohort includes 1,226 women treated with BCS; 712 received RT. 194 women (15.8%) experienced ipsilateral LR as a first event; 112 were invasive. Models including the DS or RS performed better in predicting the 10-year risk of LR compared with models on the basis of CPF alone with excellent calibration. The two molecular-based models also performed better in predicting invasive LR compared with the CPF model but the model incorporating the RS did not perform better in the prediction of invasive LR compared with the DS-based model. CONCLUSION Models incorporating the DS or RS more accurately predicted the 10-year risk of LR and invasive LR after BCS compared with models on the basis of CPF alone. Inclusion of the RS, compared with DS, did not improve the prediction of the 10-year risk of invasive LR.
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MESH Headings
- Humans
- Female
- Breast Neoplasms/surgery
- Breast Neoplasms/genetics
- Breast Neoplasms/pathology
- Mastectomy, Segmental
- Neoplasm Recurrence, Local/genetics
- Neoplasm Recurrence, Local/pathology
- Middle Aged
- Carcinoma, Intraductal, Noninfiltrating/surgery
- Carcinoma, Intraductal, Noninfiltrating/pathology
- Carcinoma, Intraductal, Noninfiltrating/genetics
- Aged
- Radiotherapy, Adjuvant
- Adult
- Neoplasm Invasiveness
- Gene Expression Profiling
- Predictive Value of Tests
- Risk Assessment
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Affiliation(s)
- Ezra Hahn
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Rinku Sutradhar
- ICES, Toronto, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Lawrence Paszat
- Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
- ICES, Toronto, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | | | - Danielle Rodin
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Sharon Nofech-Mozes
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
- Department of Pathology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Sabina Trebinjac
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Katarzyna J Jerzak
- Department of Medical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | | | - Eileen Rakovitch
- Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
- ICES, Toronto, ON, Canada
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
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Yoshimura M, Yamauchi C, Sanuki N, Hamamoto Y, Hirata K, Kawamori J, Kawamura M, Ogita M, Yamamoto Y, Iwata H, Saji S. The Japanese breast cancer society clinical practice guidelines for radiation treatment of breast cancer, 2022 edition. Breast Cancer 2024; 31:347-357. [PMID: 38578563 PMCID: PMC11045565 DOI: 10.1007/s12282-024-01568-4] [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: 11/13/2023] [Accepted: 03/11/2024] [Indexed: 04/06/2024]
Abstract
The Breast Cancer Clinical Practice Guidelines, organized by the Japanese Breast Cancer Society (JBCS), were published in 2022. We present the English version of the Radiation Therapy (RT) section of the guidelines. The JBCS formed a task force to update the 2018 version of the JBCS Clinical Practice Guidelines. The Background Questions (BQs) contain the standard treatments for breast cancer in clinical practice, whereas the Clinical Questions (CQs) address daily clinical questions that remain controversial. Future Research Questions (FRQs) explore the subjects that are considered important issues, despite there being insufficient data for inclusion as CQs. The task force selected the 12 BQs, 8 CQs, and 6 FRQs for the RT section. For each CQ, systematic literature reviews and meta-analyses were conducted according to the Minds Manual for Guideline Development 2020, version 3.0. The recommendations, strength of recommendation, and strength of evidence for each CQ were determined based on systematic reviews and meta-analyses, and finalized by voting at the recommendation decision meeting.
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Affiliation(s)
- Michio Yoshimura
- Department of Radiation Oncology and Image-Applied Therapy, Kyoto University Graduate School of Medicine, 54 Shogoin-kawahara‑cho, Sakyo‑ku, Kyoto, 606‑8507, Japan.
| | - Chikako Yamauchi
- Department of Radiation Oncology, Shiga General Hospital, Moriyama, Japan
| | - Naoko Sanuki
- Department of Radiology, Yokkaichi Municipal Hospital, Yokkaichi, Japan
| | - Yasushi Hamamoto
- Department of Radiation Oncology, National Hospital Organization Shikoku Cancer Center, Matsuyama, Japan
| | - Kimiko Hirata
- Department of Radiation Oncology, Kyoto City Hospital, Kyoto, Japan
| | - Jiro Kawamori
- Department of Radiation Oncology, St. Luke's International Hospital, Tokyo, Japan
| | - Mariko Kawamura
- Department of Radiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Mami Ogita
- Department of Radiology, The University of Tokyo Hospital, Tokyo, Japan
| | - Yutaka Yamamoto
- Department of Breast and Endocrine Surgery, Kumamoto University Graduate School of Medical Science, Kumamoto, Japan
| | - Hiroji Iwata
- Department of Breast Oncology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Shigehira Saji
- Department of Medical Oncology, Fukushima Medical University, Fukushima, Japan
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Dreyfuss AD, Max D, Flynn J, Zhang Z, Gillespie EF, Xu A, Cuaron J, Mueller B, Khan AJ, Cahlon O, Powell SN, McCormick B, Braunstein LZ. Locoregional Control Benefit of a Tumor Bed Boost for Ductal Carcinoma In Situ. Adv Radiat Oncol 2023; 8:101254. [PMID: 37250283 PMCID: PMC10220256 DOI: 10.1016/j.adro.2023.101254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 04/12/2023] [Indexed: 05/31/2023] Open
Abstract
Purpose Radiation therapy (RT) after breast-conserving surgery (BCS) for ductal carcinoma in situ (DCIS) reduces invasive and in situ recurrences. Whereas landmark studies suggest that a tumor bed boost improves local control for invasive breast cancer, the benefit in DCIS remains less certain. We evaluated outcomes of patients with DCIS treated with or without a boost. Methods and Materials The study cohort comprised patients with DCIS who underwent BCS at our institution from 2004 to 2018. Clinicopathologic features, treatment parameters, and outcomes were ascertained from medical records. Patient and tumor characteristics were evaluated relative to outcomes using univariable and multivariable Cox models. Recurrence-free survival (RFS) estimates were generated using the Kaplan-Meier method. Results We identified 1675 patients who underwent BCS for DCIS (median age, 56 years; interquartile range, 49-64 years). Boost RT was used in 1146 cases (68%) and hormone therapy in 536 (32%). At a median follow-up of 4.2 years (interquartile range, 1.4-7.0 years), we observed 61 locoregional recurrence events (56 local, 5 regional) and 21 deaths. Univariable logistic regression demonstrated that boost RT was more common among younger patients (P < .001) with positive or close margins (P < .001) and with larger tumors (P < .001) of higher grade (P = .025). The 10-year RFS rate was 88.8% among those receiving a boost and 84.3% among those without a boost (P = .3), and neither univariable nor multivariable analyses revealed an association between boost RT and locoregional recurrence. Conclusions Among patients with DCIS who underwent BCS, use of a tumor bed boost was not associated with locoregional recurrence or RFS. Despite a preponderance of adverse features among the boost cohort, outcomes were similar to those of patients not receiving a boost, suggesting that a boost may mitigate risk of recurrence among patients with high-risk features. Ongoing studies will elucidate the extent to which a tumor bed boost influences disease control rates.
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Affiliation(s)
- Alexandra D. Dreyfuss
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Danielle Max
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
- Department of Radiation Oncology, UCLA Health, Los Angeles, California
| | - Jessica Flynn
- Department of Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Zhigang Zhang
- Department of Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Erin F. Gillespie
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Amy Xu
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - John Cuaron
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Boris Mueller
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Atif J. Khan
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Oren Cahlon
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Simon N. Powell
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Beryl McCormick
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Lior Z. Braunstein
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
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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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[Decision making factors of the management of ductal carcinoma in situ of the breast with microinvasion]. Bull Cancer 2019; 106:1000-1007. [PMID: 31351573 DOI: 10.1016/j.bulcan.2019.05.005] [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: 12/07/2018] [Revised: 05/02/2019] [Accepted: 05/11/2019] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Microinvasive in situ ductal carcinomas of the breast are rare and of good prognosis. They are grouped with early stage invasive carcinomas in the TNM 2017 classification. This study assessed practitioners' treatment decisions and their justifications in comparison to the literature. MATERIALS AND METHODS Three clinical cases were evaluated by anonymous forms regarding sentinel node decisions, tumour bed boost irradiation and hormone therapy. RESULTS Sentinel lymph node was performed by 93.1%, 100% and 44.4% of the practitioners respectively. Radiation boost was a treatment option chosen by 62.1% and 61.1% of practitioners in both clinical cases. Hormone therapy was advocated for 65.5%, 94.7% and 50.0% patients depending on the clinical case. CONCLUSION The therapeutic attitude proposed in microinvasive breast carcinomas was heterogeneous in this study, reflecting the absence of specific recommendations. In view of the existing literature, it is not currently possible to propose recommendations for these three therapeutic options. Prospective cohorts and meta-analyses of the microinvasive subgroup could provide answers.
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Multiple foci of microinvasion is associated with an increased risk of invasive local recurrence in women with ductal carcinoma in situ treated with breast-conserving surgery. Breast Cancer Res Treat 2019; 178:169-176. [PMID: 31325071 DOI: 10.1007/s10549-019-05364-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Accepted: 07/15/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE The impact of Ductal Carcinoma in Situ (DCIS) with multiple foci of microinvasion (MI) (≤ 1 mm) on the risks of local recurrence (LR) and invasive LR is unknown, leading to uncertainty if DCIS with multiple foci of MI requires more aggressive treatment. We report a population-based analysis of the impact of multiple foci of MI, confirmed by pathology review, on the 15-year risks of LR and invasive LR treated with breast-conserving surgery (BCS) ± radiotherapy (RT). METHODS Cohort includes all women diagnosed with DCIS ± MI from 1994 to 2003 treated with BCS ± RT. Cox proportional hazards model was used to evaluate the impact of multiple foci of MI on the risks of LR and invasive LR, adjusting for covariates. The 15-year local and invasive local recurrence-free survival rates were calculated using the Kaplan-Meier method with differences compared by log-rank test. RESULTS The cohort includes 2988 women treated by BCS; 2721 had pure DCIS (51% received RT), 267 had DCIS with one or more foci of MI (58% had RT). Median follow-up was 13 years. Median age at diagnosis was 58 years. On multivariable analyses, the presence of multiple foci of MI was associated with an increased risk of invasive LR (HR = 1.59, 95% CI 1.01-2.49, p = 0.04) but not DCIS LR (HR = 0.89, 95% CI 0.46, 1.76, p = 0.7). The 15-year invasive LRFS risks for cases with pure DCIS, with 1 focus or multiple foci of MI were 85.7%, 85.6%, 74.7% following treatment by BCS alone, 87.2%, 89.9%, and 77% for those treated with BCS + RT without boost and 89.2%, 91.3%, and 95% for women treated with BCS + RT and boost. CONCLUSIONS The presence of multiple foci of MI in DCIS is associated with higher 15-year risks of invasive LR after breast-conserving therapy compared to women with pure DCIS but treatment with whole breast and boost RT can mitigate this risk.
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A national multicenter study on 1072 DCIS patients treated with breast-conserving surgery and whole breast radiotherapy (COBCG-01 study). Radiother Oncol 2018; 131:208-214. [PMID: 30075864 DOI: 10.1016/j.radonc.2018.07.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2018] [Revised: 07/17/2018] [Accepted: 07/18/2018] [Indexed: 01/21/2023]
Abstract
BACKGROUND AND PURPOSE Breast-conserving surgery (BCS) and whole breast radiation (RT) with or without endocrine therapy (ET) represent the standard of care for ductal carcinoma in situ (DCIS). The use of adjuvant treatments after surgery is still controversial in this setting. We performed a retrospective multicenter analysis on a series of DCIS patients treated with BCS and adjuvant RT. MATERIALS AND METHODS We collected clinical data from nine Italian centers on 1072 women having a diagnosis of DCIS and treated between 1997 and 2012. We reported on the 5- and 10-year local recurrence (LR) rates, overall survival, and breast cancer specific survival (BCSS) employing the Kaplan-Meier method. RESULTS At a median follow-up of 8.4 years, 67 LR (6.3%) and 47 deaths (4.4%) were observed. LR rates at 5 and 10 years were 3.4% and 7.6%, respectively. BCSS rates at 5 and 10 years were 99.7% and 99.1%, respectively. At univariate regression analysis, postmenopausal state (p = 0.009), estrogen receptor (ER) (p = 0.0001) and progesterone receptor (p = 0.018) positivity and ET (p = 0.006) were inversely correlated with LR. Final surgical margins (FSM) status <1 mm was significantly correlated with higher LR (p = 0.003). At multivariate regression analysis postmenopausal state (p = 0.03), and ER positive (p = 0.045) maintained the significant favorable feature, while FSM <1 mm (p = 0.024) confirmed its negative impact on LR. CONCLUSIONS Our real-life study pointed out the significant favorable prognostic role of postmenopausal state and ER positive status on LR occurrence. FSM <1 mm was significantly correlated to a higher chance to experience LR.
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Breast-conserving therapy for primary Ductal Carcinoma in Situ in The Netherlands: A multi-center study and population-based analysis. Breast 2018; 42:3-9. [PMID: 30118902 DOI: 10.1016/j.breast.2018.07.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Revised: 06/24/2018] [Accepted: 07/16/2018] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE The aim of this study was to analyse the efficacy of breast-conserving therapy (BCT) for women with primary DCIS in a population-based setting. METHODS Data were used from five Radiotherapy centres in The Netherlands from 2000 to 2010, all treated with BCT. Of all the cases, 59.2% received a boost of radiotherapy after their whole breast irradiation (WBI), irrespective of margin status. RESULTS A total of 1248 cases with primary DCIS were analysed. The 10-years LRFS was 92.9%. Age ≤50 years and a positive margin were significantly related to local relapse free survival (LRFS). Having a boost had no impact on LRFS, showing a nearly equal recurrence pattern in patients with and without a boost. Separate analyses were done on patients who had received and not received a boost of radiotherapy after WBI. We noted 9.1% contra-lateral breast tumours. The 10-years disease specific survival (DSS) rate was 99.0%. CONCLUSIONS DCIS of the breast and treated with BCT results in excellent LRFS and DSS. Primary surgical lumpectomy with negative margins followed by WBI seems to be the treatment of choice in DCIS treated with BCS with respect to IBTR.
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Park S, Ahn SD, Choi EK, Kim SS. The effect of escalating the boost dose for patients with involved resection margin after breast-conserving surgery. Jpn J Clin Oncol 2018; 48:272-277. [PMID: 29385496 PMCID: PMC6018944 DOI: 10.1093/jjco/hyy002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2017] [Accepted: 01/12/2018] [Indexed: 11/28/2022] Open
Abstract
Background This study aims to investigate the impact of boost dose escalation on ipsilateral breast tumor recurrence (IBTR) in breast cancer patients with involved resection margins following breast-conserving surgery. Methods Between January 1998 and December 2010, 192 patients were treated with a boost dose of over 10 Gy for involved resection margins. We retrospectively analyzed outcomes in 192 patients who underwent whole breast irradiation of 50.4 Gy followed by a median boost dose of 15.0 Gy (range, 12–16 Gy). Boost doses of 12.5 Gy and 15 Gy were delivered to patients with carcinoma in situ and invasive carcinoma, respectively, at the positive margins. We evaluated the impact of the boost dose on the IBTR rate. Results Median follow-up duration was 6.7 years (0.4–15.6 years). The 5-year cumulative risk of IBTR as a first event was 5.0%. IBTR occurred as a first recurrence in 13 of 192 patients. In-boost-field recurrences were found in 11 patients (85%). Five patients (39%) experienced out-of boost field recurrences, and three experienced both types of recurrences. In multivariate analysis, age (<40 years), pT stage, and positive radial resection margin were prognostic factors for IBTR (P = 0.029, P = 0.024 and P = 0.035, respectively). Conclusions A median boost dose of 15 Gy might be insufficient in patients younger than 40 years, with tumor size greater than 2 cm, or with involved radial resection margins. On the other hand, in cases of positive superficial or deep margins, dose-escalated boost or re-excision may not be necessary.
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Affiliation(s)
- Sunmin Park
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seung Do Ahn
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Eun Kyung Choi
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Su Ssan Kim
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Moran MS, Zhao Y, Ma S, Kirova Y, Fourquet A, Chen P, Hoffman K, Hunt K, Wong J, Halasz LM, Freedman G, Prosnitz R, Yassa M, Nguyen DHA, Hijal T, Haffty BG, Wai ES, Truong PT. Association of Radiotherapy Boost for Ductal Carcinoma In Situ With Local Control After Whole-Breast Radiotherapy. JAMA Oncol 2017; 3:1060-1068. [PMID: 28358936 DOI: 10.1001/jamaoncol.2016.6948] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Importance The use of a radiotherapy (RT) boost to the tumor bed after whole-breast RT (WBRT) for ductal carcinoma in situ (DCIS) is largely extrapolated from invasive cancer data, but robust evidence specific to DCIS is lacking. Objective To compare ipsilateral breast tumor recurrence (IBTR) in women with DCIS treated with vs without the RT boost after breast-conserving surgery and WBRT. Design, Setting, and Participants This retrospective analysis pooled deidentified patient-level data from 10 academic institutions in the United States, Canada, and France from January 1, 1980, through December 31, 2010. All patients had newly diagnosed pure DCIS (no microinvasion), underwent breast-conserving surgery, and received WBRT with or without the boost with a minimum of 5 years of follow-up required for inclusion in the analysis. Given the limited events after WBRT, an a priori power analysis was conducted to estimate the DCIS sample size needed to detect the anticipated benefit of the boost. Data were uniformly recoded at the host institution and underwent primary and secondary reviews before analysis. Sample size calculations (ratio of patients who received the boost dose to those who did not, 2:1; α = .05; power = 80%) estimated that 2982 cases were needed to detect a difference of at least 3%. The final analysis included 4131 patients (2661 in the boost group and 1470 in the no-boost group) with a median follow-up of 9 years and media boost dose of 14 Gy. Data were collected from July 2011 through February 2014 and analyzed from March 2014 through August 2015. Interventions Radiotherapy boost vs no boost. Main Outcomes and Measures Ipsilateral breast tumor recurrence. Results The analysis included 4131 patients (median [SD] age, 56.1 [10.9] years; range, 24-88 years). Patients with positive margins, unknown estrogen receptor status, and comedo necrosis were more likely to have received an RT boost. For the entire cohort, the boost was significantly associated with lower IBTR (hazard ratio [HR], 0.73; 95% CI, 0.57-0.94; P = .01) and with IBTR-free survival (boost vs no-boost groups) of 97.1% (95% CI, 0.96-0.98) vs 96.3% (95% CI, 0.95-0.97) at 5 years, 94.1% (95% CI, 0.93-0.95) vs 92.5% (95% CI, 0.91-0.94) at 10 years, and 91.6% (95% CI, 0.90-0.93) vs 88.0% (95% CI, 0.85-0.91) at 15 years. On multivariable analysis accounting for confounding factors, the boost remained significantly associated with reduced IBTR (HR compared with no boost, 0.68; 95% CI, 0.50-0.91; P = .01) independent of age and tamoxifen citrate use. Conclusions and Relevance This patient-level analysis suggests that the RT boost confers a statistically significant benefit in decreasing IBTR across all DCIS age groups, similar to that seen in patients with invasive breast cancer. These findings suggest that a DCIS RT boost to the tumor bed could be considered to provide an added incremental benefit in decreasing IBTR after a shared discussion between the patient and her radiation oncologist.
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Affiliation(s)
- Meena S Moran
- Smilow Cancer Center, Department of Therapeutic Radiology, Yale School of Medicine, New Haven, Connecticut
| | - Yinjun Zhao
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut
| | - Shuangge Ma
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut
| | - Youlia Kirova
- Department of Radiation Therapy, Institut Curie, Paris, France
| | - Alain Fourquet
- Department of Radiation Therapy, Institut Curie, Paris, France
| | - Peter Chen
- Department of Radiation Therapy, Oakland University William Beaumont School of Medicine, Royal Oak, Michigan
| | - Karen Hoffman
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston
| | - Kelly Hunt
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston
| | - Julia Wong
- Department of Radiation Oncology, Harvard Medical School, Dana Farber Cancer Institute, Boston, Massachusetts
| | - Lia M Halasz
- Department of Radiation Oncology, Harvard Medical School, Dana Farber Cancer Institute, Boston, Massachusetts
| | - Gary Freedman
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia
| | - Robert Prosnitz
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia
| | - Michael Yassa
- Department of Radiation Oncology, University of Montreal, Hôpital Maisonneuve-Rosemont, Montreal, Quebec, Canada
| | - David H A Nguyen
- Department of Radiation Oncology, University of Montreal, Hôpital Maisonneuve-Rosemont, Montreal, Quebec, Canada
| | - Tarek Hijal
- Department of Radiation Oncology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Bruce G Haffty
- Department of Radiation Therapy, Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Elaine S Wai
- Department of Radiation Oncology, British Columbia Cancer Agency, Victoria, British Columbia, Canada
| | - Pauline T Truong
- Department of Radiation Oncology, British Columbia Cancer Agency, Victoria, British Columbia, Canada
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11
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Stokes WA, Amini A, Jackson MW, Plimpton SR, Kounalakis N, Kabos P, Rabinovitch RA, Rusthoven CG, Fisher CM. Patterns of Fractionation and Boost Usage in Adjuvant External Beam Radiotherapy for Ductal Carcinoma in Situ in the United States. Clin Breast Cancer 2017; 18:220-228. [PMID: 28797765 DOI: 10.1016/j.clbc.2017.06.009] [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: 05/12/2017] [Revised: 06/06/2017] [Accepted: 06/23/2017] [Indexed: 11/26/2022]
Abstract
BACKGROUND While the roles of hypofractionated (HFxn) radiotherapy and lumpectomy boost in the adjuvant management of invasive breast cancer are supported by the results of clinical trials, randomized data supporting their use for ductal carcinoma in situ (DCIS) are forthcoming. We sought to evaluate current national trends and identify factors associated with HFxn and boost usage using the National Cancer Database. PATIENTS AND METHODS We queried the National Cancer Database for women diagnosed with DCIS from 2004 to 2014 undergoing external beam radiotherapy after breast conservation surgery. Patients were categorized as receiving either conventional fractionation (CFxn) or HFxn and as either receiving or not receiving a boost. Multiple logistic regression was performed to identify demographic, clinical, and treatment factor associations. RESULTS A total of 101,615 women were identified, with 87,641 (86.2%) receiving CFxn, 13,974 (13.8%) receiving HFxn, and most patients in each group (84.9% and 57.7%, respectively) receiving a boost. Implementation of HFxn increased from 4.3% in 2004 to 33.0% in 2014, and the use of a boost declined from 83.3% to 74.6%. HFxn receipt was independently associated with later year of diagnosis, older age, higher income, greater distance from treatment facility, greater facility volume, academic facility type, Western residence, smaller lesions, and nonreceipt of a boost. Factors associated with boost receipt included earlier year of diagnosis, younger age, higher income, community facility type, adverse pathologic features, and nonreceipt of HFxn. CONCLUSION Although CFxn with a boost remains the most common external beam radiotherapy strategy for DCIS, implementation of HFxn without a boost appears to be increasing. Practice patterns at present seem to be driven by guidelines for invasive breast cancer and nonclinical factors.
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Affiliation(s)
- William A Stokes
- Department of Radiation Oncology, University of Colorado Denver School of Medicine, Aurora, CO
| | - Arya Amini
- Department of Radiation Oncology, University of Colorado Denver School of Medicine, Aurora, CO
| | - Matthew W Jackson
- Department of Radiation Oncology, University of Colorado Denver School of Medicine, Aurora, CO
| | - S Reed Plimpton
- Department of Radiation Oncology, University of California, Irvine, School of Medicine, Irvine, CA
| | - Nicole Kounalakis
- Department of Surgery, University of Colorado Denver School of Medicine, Aurora, CO
| | - Peter Kabos
- Department of Medicine, University of Colorado Denver School of Medicine, Aurora, CO
| | - Rachel A Rabinovitch
- Department of Radiation Oncology, University of Colorado Denver School of Medicine, Aurora, CO
| | - Chad G Rusthoven
- Department of Radiation Oncology, University of Colorado Denver School of Medicine, Aurora, CO
| | - Christine M Fisher
- Department of Radiation Oncology, University of Colorado Denver School of Medicine, Aurora, CO.
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12
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Breast-conserving treatment for ductal carcinoma in situ: Impact of boost and tamoxifen on local recurrences. Cancer Radiother 2016; 20:292-8. [PMID: 27344537 DOI: 10.1016/j.canrad.2016.04.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2015] [Revised: 04/02/2016] [Accepted: 04/05/2016] [Indexed: 11/21/2022]
Abstract
PURPOSE Ductal carcinoma in situ represents 15 to 20% of all breast cancers. Breast-conserving surgery and whole breast irradiation was performed in about 60% of the cases. This study reports local recurrence rates in patients with ductal carcinoma in situ treated by breast-conserving surgery and whole breast irradiation with or without boost and/or tamoxifen and compares different therapeutic options in two European countries. PATIENTS AND METHODS From 1998 to 2007, 819 patients with pure ductal carcinoma in situ were collected, both in France (266) and Italy (553). Median age was 56. All underwent breast-conserving surgery and whole breast irradiation; 391 (48%) received a boost (55% in France and 45% in Italy, P=0.017) and 173 (22.5%) tamoxifen (4.5% in France and 32% in Italy, P<0.0001). RESULTS With a 90-month median follow-up, there were 51 local recurrences (6.2%), including 27 invasive (53%). The 5- and 10-year local recurrence rates were 4% and 8.6%. Two patients developed axillary recurrence and 12 (1.5%) metastases (seven after invasive local recurrence); 41 (5%) patients had contralateral breast cancer. In the multivariate analysis, high nuclear grade and lack of tamoxifen are the most powerful predictors of local recurrence, with 2.6 (95% confidence interval [95% CI]: 1.74-3.89, P=0.0012) and 2.85 (95% CI: 1.42-5.72, P=0.04) odds ratio (OR) estimates, respectively. Age, margin status and boost did not influence local recurrence rates. CONCLUSIONS This study confirms the ductal carcinoma in situ treatment heterogeneity among countries and the unfavourable prognostic role of nuclear grade. Tamoxifen reduces local recurrence rates and might be considered for some subgroups of patients, but further confirmation is required. The boost usefulness still remains unclear.
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13
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Shaikh T, Li T, Murphy CT, Zaorsky NG, Bleicher RJ, Sigurdson ER, Carlson R, Hayes SB, Anderson P. Importance of Surgical Margin Status in Ductal Carcinoma In Situ. Clin Breast Cancer 2016; 16:312-8. [PMID: 26952595 DOI: 10.1016/j.clbc.2016.02.002] [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: 09/08/2015] [Revised: 01/11/2016] [Accepted: 02/03/2016] [Indexed: 10/22/2022]
Abstract
BACKGROUND The purpose of the study was to identify the effect of final surgical margin (SM) status and re-excision on outcomes in patients with ductal carcinoma in situ (DCIS) who underwent breast conservation therapy (BCT). PATIENTS AND METHODS The study population consisted of women diagnosed with DCIS who underwent BCT between 1989 and 2014. All women received adjuvant whole breast radiation and a boost. The primary end point was local control (LC). Final SMs were defined according to margin width: negative SM was defined as > 2 mm, close SM was defined as > 0 to ≤ 2 mm, and a positive SM was defined as tumor on ink. The Cox proportional hazards model was used to determine predictors of outcomes on multivariable analysis. Actuarial incidence of LC was estimated using the Kaplan-Meier method. RESULTS A total of 498 patients were included; 400 patients had a final negative SM, 87 had a close SM, and 11 had a positive SM. A total of 172 patients received adjuvant hormonal therapy, 265 patients required ≥ 1 re-excision. Patients with positive or close SMs were more likely to receive a radiation dose > 60 Gy (P < .001) and undergo re-excision (P < .01). The 10-year LC rates were not significantly different between patients with a negative (93.5%), close (91.8%), or positive (100%) SM (P = .57). There was no difference in LC in patients who underwent re-excision for initial close or positive SMs (P = .55). CONCLUSION This single-institution experience showed that risks of local recurrence remain poorly characterized. Re-excision and whole breast radiation with boost resulted in excellent LC for women with DCIS. Trials aimed at personalized deintensified local therapy are warranted.
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Affiliation(s)
- Talha Shaikh
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA
| | - Tianyu Li
- Department of Biostatistics, Fox Chase Cancer Center, Philadelphia, PA
| | - Colin T Murphy
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA
| | - Nicholas G Zaorsky
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA
| | - Richard J Bleicher
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA
| | - Elin R Sigurdson
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA
| | - Robert Carlson
- Department of Medical Oncology, Fox Chase Cancer Center, Philadelphia, PA
| | - Shelly B Hayes
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA
| | - Penny Anderson
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA.
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14
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Oar AJ, Boxer MM, Papadatos G, Delaney GP, Phan P, Descallar J, Duggan K, Tran K, Yap ML. Hypofractionated versus conventionally fractionated radiotherapy for ductal carcinoma in situ (DCIS) of the breast. J Med Imaging Radiat Oncol 2016; 60:407-13. [DOI: 10.1111/1754-9485.12428] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Accepted: 11/28/2015] [Indexed: 11/29/2022]
Affiliation(s)
- Andrew J Oar
- Liverpool Cancer Therapy Centre; Liverpool Hospital; Liverpool NSW Australia
- Macarthur Cancer Therapy Centre; Campbelltown Hospital; Campbelltown NSW Australia
- Western Sydney University; Campbelltown NSW Australia
| | - Miriam M Boxer
- Liverpool Cancer Therapy Centre; Liverpool Hospital; Liverpool NSW Australia
- University of NSW; Kensington NSW Australia
| | - George Papadatos
- Liverpool Cancer Therapy Centre; Liverpool Hospital; Liverpool NSW Australia
- Macarthur Cancer Therapy Centre; Campbelltown Hospital; Campbelltown NSW Australia
- Western Sydney University; Campbelltown NSW Australia
| | - Geoff P Delaney
- Liverpool Cancer Therapy Centre; Liverpool Hospital; Liverpool NSW Australia
- Western Sydney University; Campbelltown NSW Australia
- University of NSW; Kensington NSW Australia
- Ingham Institute for Applied Medical Research; Liverpool NSW Australia
| | - Penny Phan
- Liverpool Cancer Therapy Centre; Liverpool Hospital; Liverpool NSW Australia
- Macarthur Cancer Therapy Centre; Campbelltown Hospital; Campbelltown NSW Australia
| | - Joseph Descallar
- University of NSW; Kensington NSW Australia
- Ingham Institute for Applied Medical Research; Liverpool NSW Australia
| | - Kirsten Duggan
- Ingham Institute for Applied Medical Research; Liverpool NSW Australia
- South Western Sydney and Sydney Local Health Districts Clinical Cancer Registry; Liverpool NSW Australia
| | - Kelvin Tran
- Western Sydney University; Campbelltown NSW Australia
| | - Mei Ling Yap
- Liverpool Cancer Therapy Centre; Liverpool Hospital; Liverpool NSW Australia
- Macarthur Cancer Therapy Centre; Campbelltown Hospital; Campbelltown NSW Australia
- Western Sydney University; Campbelltown NSW Australia
- University of NSW; Kensington NSW Australia
- Ingham Institute for Applied Medical Research; Liverpool NSW Australia
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15
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Stuart KE, Houssami N, Taylor R, Hayen A, Boyages J. Long-term outcomes of ductal carcinoma in situ of the breast: a systematic review, meta-analysis and meta-regression analysis. BMC Cancer 2015; 15:890. [PMID: 26555555 PMCID: PMC4641372 DOI: 10.1186/s12885-015-1904-7] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Accepted: 11/03/2015] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND To summarize data on long-term ipsilateral local recurrence (LR) and breast cancer death rate (BCDR) for patients with ductal carcinoma in situ (DCIS) who received different treatments. METHODS Systematic review and study-level meta-analysis of prospective (n = 5) and retrospective (n = 21) studies of patients with pure DCIS and with median or mean follow-up time of ≥10 years. Meta-regression was performed to assess and adjust for effects of potential confounders - the average age of women, period of initial treatment, and of bias - follow-up duration on recurrence- and death-rates in each treatment group. LR and BCDR rates by local treatment used were reported. Outside of randomized trials, remaining studies were likely to have tailored patient treatment according to the clinical situation. RESULTS Nine thousand four hundred and four DCIS cases in 9391 patients with 10-year follow-up were included. The adjusted meta-regression LR rate for mastectomy was 2.6 % (95 % CI, 0.8-4.5); breast-conserving surgery with radiotherapy (RT), 13.6 % (95 % CI, 9.8-17.4); breast-conserving surgery without RT, 25.5 % (95 % CI, 18.1-32.9); and biopsy-only (residual predominately low-grade DCIS following inadequate excision), 27.8 % (95 % CI, 8.4-47.1). RT + tamoxifen (TAM) in conservation surgery (CS) patients resulted in lower LR compared to one or no adjuvant treatments: LR rate for CS + RT + TAM, 9.7 %; CS + RT(no TAM), 14.1 %; CS + TAM(no RT), 24.7 %; CS(alone), 25.1 % (linear trend for treatment P < 0.0001). Compared to CS + RT + TAM, a significantly higher invasive LR was observed for CS(alone), odds ratio (OR) 2.61 (P < 0.0001); CS + TAM(no RT), OR 2.52 (P = 0.001); CS + RT(no TAM), OR 1.59 (P = 0.022). BCDR was similar for mastectomy, breast-conserving surgery with or without RT (1.3-2.0 %) and non-significantly higher for biopsy-only (2.7 %). Additionally, the 15-year follow-up was reported where all like-studies had ≥ 15-year data sets; the biopsy-only patients had a meta-analysed total LR rate of 40.2 % and the invasive LR rate was 28.1 %. The biopsy-only patients had a ≥ 15-year BCDR (that included women with metastatic disease) of 17.9 %; the ≥ 15-year BCDR was 55.2 % for those with invasive LR. CONCLUSIONS More local intervention was associated with greater local control for patients with DCIS at long-term follow-up. For patients undergoing breast-conservation, invasive LR was significantly lower when two rather than one adjuvant treatment modalities were given.
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MESH Headings
- Breast Neoplasms/epidemiology
- Breast Neoplasms/pathology
- Breast Neoplasms/therapy
- Carcinoma, Intraductal, Noninfiltrating/drug therapy
- Carcinoma, Intraductal, Noninfiltrating/pathology
- Carcinoma, Intraductal, Noninfiltrating/radiotherapy
- Carcinoma, Intraductal, Noninfiltrating/surgery
- Female
- Humans
- Neoplasm Recurrence, Local/drug therapy
- Neoplasm Recurrence, Local/pathology
- Neoplasm Recurrence, Local/radiotherapy
- Neoplasm Recurrence, Local/surgery
- Radiotherapy, Adjuvant
- Regression Analysis
- Retrospective Studies
- Treatment Outcome
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Affiliation(s)
- Kirsty E Stuart
- Westmead Breast Cancer Institute, Westmead Hospital, PO Box 143, Westmead, NSW, 2145, Australia.
- Crown Princess Mary Cancer Centre, Westmead Hospital, Westmead, Australia.
- Sydney Medical School, University of Sydney, Sydney, Australia.
| | - Nehmat Houssami
- School of Public Health, Sydney Medical School, University of Sydney, Sydney, Australia.
| | - Richard Taylor
- Westmead Breast Cancer Institute, Westmead Hospital, PO Box 143, Westmead, NSW, 2145, Australia.
- School of Public Health and Community Medicine, Faculty of Medicine, University of New South Wales, Sydney, Australia.
| | - Andrew Hayen
- School of Public Health and Community Medicine, Faculty of Medicine, University of New South Wales, Sydney, Australia.
| | - John Boyages
- Westmead Breast Cancer Institute, Westmead Hospital, PO Box 143, Westmead, NSW, 2145, Australia.
- Australian School of Advanced Medicine, Macquarie University, Sydney, NSW, Australia.
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16
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Shikama N, Sekiguchi K, Nakamura N, Sekine H, Nakayama Y, Imanaka K, Akiba T, Aoki M, Hatayama Y, Ogo E, Kagami Y, Kawashima M, Karasawa K. Final results from a multicenter prospective study ( JROSG 05-5) on postoperative radiotherapy for patients with ductal carcinoma in situ with an involved surgical margin or close margin widths of 1 mm or less. JOURNAL OF RADIATION RESEARCH 2015; 56:830-834. [PMID: 26093369 PMCID: PMC4577003 DOI: 10.1093/jrr/rrv034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/24/2015] [Revised: 04/15/2015] [Accepted: 05/20/2015] [Indexed: 06/04/2023]
Abstract
This multicenter prospective study ( Japanese Radiation Oncology Study Group: JROSG 05-5) aimed to evaluate the effectiveness of postoperative radiotherapy (PORT) in patients with ductal carcinoma in situ (DCIS) with an involved surgical margin or close margin widths of ≤1 mm or less. PORT consisted of whole-breast irradiation (50 Gy in 25 fractions) followed by boost irradiation (10 Gy in 5 fractions). Eligibility criteria were as follows: (i) DCIS without an invasive carcinoma component, (ii) age between 20 and 80 years old, (iii) involved margin or close margin widths of ≤1 mm, (iv) refusal of re-resection, (v) performance status of 0-2, and (vi) written informed consent. The primary endpoint was ipsilateral breast tumor recurrence (IBTR), and secondary endpoints were overall survival (OS), relapse-free survival (RFS), recurrence patterns, and adverse events. A total of 37 patients from 12 institutions were enrolled from January 2007 to May 2009. The median follow-up time was 62 months (range, 28-85 months). The median pathological tumor size was 2.5 cm (range, 0.3-8.5 cm). Of the 37 patients, 21 had involved margins, and 16 had close margins. The 5-year IBTR, OS and RFS rates were 6% (95% confidence interval [CI]: 2-21), 97% (95% CI: 83-99) and 91% (95% CI: 77-97), respectively. Two patients developed local recurrence at the original site after 39 and 58 months. No severe adverse events were found. Our study suggests that this PORT regimen could be a treatment option for patients with DCIS with involved margin or close margin who don't desire re-resection.
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Affiliation(s)
- Naoto Shikama
- Department of Radiation Oncology, Saitama Medical University, International Medical Center, 1397-1 Yamane, Hidaka-City, Saitama, 350-1298 Japan
| | - Kenji Sekiguchi
- Department of Radiation Oncology, St Luke's International Hospital, 9-1 Akashi-cho, Chuo-ku, Tokyo, 104-8560, Japan
| | - Naoki Nakamura
- Department of Radiation Oncology, National Cancer Center East, 6-5-1 Kashiwanoha, Kashiwa-shi, Chiba, 277-8577, Japan
| | - Hiroshi Sekine
- Department of Radiology, The Jikei University Third Hospital, 4-11-1 Izumihonmachi, Komae-shi, Tokyo, 201-8601, Japan
| | - Yuko Nakayama
- Department of Radiation Oncology, Kanagawa Cancer Center, 2-3-2 Nakao, Asahi-ku, Yokohama, Kanagawa, 241-8515, Japan
| | - Kazufumi Imanaka
- Department of Radiology, Nishikobe Medical Center, 5-7-1 Kojidai, Nishi-ku, Kobe, Shogo, 651-2273, Japan
| | - Takeshi Akiba
- Department of Radiation Oncology, Tokai University, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan
| | - Masahiko Aoki
- Department of Radiology, Hirosaki University School of Medicine and Hospital, 53 Honmachi, Hirosaki, Aomori, 036-8563, Japan
| | - Yoshiomi Hatayama
- Department of Radiology, Hirosaki University School of Medicine and Hospital, 53 Honmachi, Hirosaki, Aomori, 036-8563, Japan
| | - Etsuyo Ogo
- Department of Radiation Oncology, Kurume University Hospital, 67 Asahimachi, Kurume-shi, Fukuoka, 830-0011, Japan
| | - Yoshikazu Kagami
- Department of Radiation Oncology, Showa University Hospital, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo, 142-8666, Japan
| | - Miho Kawashima
- Department of Radiology, Dokkyo Medical University, Koshigaya Hospital, 2-1-50 Mimamikoshigaya, Koshigaya-shi, Saitama, 343-8555, Japan
| | - Kumiko Karasawa
- Research Center for Charged Particle Therapy, National Institute of Radiological Sciences, 4-9-1 Anagawa, Inage-ku, Chiba-shi, Chiba, 263-8555, Japan
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17
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Cutuli B, De Lafontan B, Kirova Y, Auvray H, Tallet A, Avigdor S, Brunaud C, Delva C. Lobular carcinoma in situ (LCIS) of the breast: is long-term outcome similar to ductal carcinoma in situ (DCIS)? Analysis of 200 cases. Radiat Oncol 2015; 10:110. [PMID: 25944033 PMCID: PMC4428244 DOI: 10.1186/s13014-015-0379-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2015] [Accepted: 03/16/2015] [Indexed: 01/01/2023] Open
Abstract
Background Lobular carcinomas in situ (LCIS) represent 1-2% of all breast cancers. Both significance and treatment remain widely debated, as well as the possible similarities with DCIS. Materials and methods Two hundred patients with pure LCIS were retrospectively analyzed in seven centres from 1990 to 2008. Median age was 52 years; 176 patients underwent breast-conserving surgery (BCS) and 24 mastectomy. Seventeen patients received whole breast irradiation (WBRT) after BCS and 20 hormonal treatment (15 by tamoxifen). Results With a 144-month median follow-up (FU), there were no local recurrences (LR) among 24 patients treated by mastectomy. With the same FU, 3 late LR out of 17 (17%) occurred in patients treated by BCS and WBRT (with no LR at 10 years). Among 159 patients treated by BCS alone, 20 developed LR (13%), but with only a 72-month FU (17.5% at 10 years). No specific LR risk factors were identified. Three patients developed metastases, two after invasive LR; 22 patients (11%) developed contralateral BC (59% invasive) and another five had second cancer. Conclusions LCIS is not always an indolent disease. The long-term outcome is quite similar to most ductal carcinomas in situ (DCIS). The main problems are the accuracy of pathological definition and a clear identification of more aggressive subtypes, in order to avoid further invasive LR. BCS + WBRT should be discussed in some selected cases, and the long-term results seem comparable to DCIS.
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Affiliation(s)
| | | | | | | | | | | | - Claire Brunaud
- Institut de Cancerologie de Lorraine, Vandoeuvre-les-Nancy, France.
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18
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Carcinomes canalaires in situ du sein traités par chirurgie conservatrice et irradiation avec complément dans le lit opératoire. Cancer Radiother 2015; 19:175-9. [DOI: 10.1016/j.canrad.2015.01.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Revised: 01/13/2015] [Accepted: 01/27/2015] [Indexed: 11/19/2022]
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The role of boost and hypofractionation as adjuvant radiotherapy in patients with DCIS: a meta-analysis of observational studies. Radiother Oncol 2015; 114:50-5. [PMID: 25596912 DOI: 10.1016/j.radonc.2015.01.001] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2014] [Accepted: 01/02/2015] [Indexed: 12/31/2022]
Abstract
PURPOSE The purpose of this meta-analysis is to summarize the current evidence on the role of boost and the efficacy of hypofractionated radiotherapy in patients with ductal cancer in situ (DCIS) after surgery and grade the quality of evidence. MATERIALS AND METHODS A comprehensive systematic electronic search through MEDLINE and the Cochrane Library as well as through the major international congresses' proceedings was conducted. Studies were considered eligible if they investigated the efficacy of hypofractionated vs. standard radiotherapy or the efficacy of boost vs. no boost in patients with DCIS. The outcome of interest was the number of local recurrences. Pooled estimates were calculated by using standard meta-analytic procedures. RESULTS Thirteen trials were considered eligible and were further analyzed. No difference in the risk of local recurrence was observed between the patients that received boost vs. no boost in the general cohort (12 studies, 6943 patients; Odds Ratio (OR): 0.91, 95% confidence interval (CI): 0.77-1.08, very low level of evidence). However, we found a reduced risk for local recurrence when boost was administered in patients with positive margins compared to no boost (6 studies, 811 patients; OR: 0.56, 95% CI: 0.36-0.87, very low level of evidence). No difference in local recurrence rate between patients who received hypofractionated versus standard radiotherapy was observed (4 studies, 2534 patients; OR: 0.78, 95% CI: 0.58-1.03, low level of evidence). CONCLUSION Hypofractionated radiotherapy seems to be a safe option in patients with DCIS after breast-conserving surgery while the addition of boost reduces the risk for local recurrence in the presence of positive margins. However, the level of evidence for these observations ranges between very low and low and the results of the ongoing randomized trials are necessary to confirm the results with higher level of evidence.
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20
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Dimassi K, Gharsa A, Chanoufi MB, Sfar E, Chelli D. [Conservative treatment of breast cancer: experience of a Tunisian team]. Pan Afr Med J 2014; 19:148. [PMID: 25810795 PMCID: PMC4345226 DOI: 10.11604/pamj.2014.19.148.4195] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2014] [Accepted: 09/22/2014] [Indexed: 01/17/2023] Open
Abstract
En Tunisie, le cancer du sein touche des femmes jeunes avec une taille moyenne au moment du diagnostic à 5 cm. Ces particularités font que la chirurgie radicale reste prédominante. Nous présentons dans ce travail l'expérience de notre équipe en matière de chirurgie conservatrice du cancer du sein. Le but de ce travail est d’évaluer les résultats de ce traitement. Etude rétrospective longitudinale, sur une période de 75 mois. Nous avons inclus toutes les patientes ayant bénéficié d'un traitement conservateur pour une tumeur maligne du sein. Ont été analysés: les caractéristiques épidémiologiques, les aspects radiologiques et histologiques. Le suivi des malades s'est basé sur la détection des récidives. Nous avons évalué le résultat esthétique à la fin de la radiothérapie. Le traitement conservateur a été réalisé dans 23.8% des cas. Le taux de récidives locales était de 6.8% avec une corrélation significative pour une taille tumorale > 30 mm (p= 0.009), l'association d'une composante intracanalaire (p= 0.035), le statut triple négatif (p= 0.003) et des marges d'exérèse < 5mm sans recoupes per-opératoires (p = 0.045). Les facteurs suivants étaient significativement liés au risque de survenue de métastases à distance: le statut triple négatif (p= 0.003), taille tumorale > 30mm (p = 0.006) et l'atteinte ganglionnaire (p = 0.001). Le résultat esthétique était satisfaisant dans 90% des cas. L'augmentation du nombre de patientes pouvant bénéficier d'une chirurgie conservatrice, doit passer impérativement par le développement et la promotion du diagnostic précoce et du dépistage par la mammographie.
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Affiliation(s)
| | - Anissa Gharsa
- Service de Gynécologie-Obstétrique A du centre de Maternité et de Néonatologie, Tunis, Tunisie
| | - Mohammed Badis Chanoufi
- Faculté de Médecine de Tunis EL MANAR, Tunisie ; Service de Gynécologie-Obstétrique A du centre de Maternité et de Néonatologie, Tunis, Tunisie
| | - Ezzeddine Sfar
- Faculté de Médecine de Tunis EL MANAR, Tunisie ; Service de Gynécologie-Obstétrique A du centre de Maternité et de Néonatologie, Tunis, Tunisie
| | - Dalenda Chelli
- Faculté de Médecine de Tunis EL MANAR, Tunisie ; Service de Gynécologie-Obstétrique A du centre de Maternité et de Néonatologie, Tunis, Tunisie
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21
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Lalani N, Paszat L, Sutradhar R, Thiruchelvam D, Nofech-Mozes S, Hanna W, Slodkowska E, Done SJ, Miller N, Youngson B, Tuck A, Sengupta S, Elavathil L, Chang MC, Jani PA, Bonin M, Rakovitch E. Long-term outcomes of hypofractionation versus conventional radiation therapy after breast-conserving surgery for ductal carcinoma in situ of the breast. Int J Radiat Oncol Biol Phys 2014; 90:1017-24. [PMID: 25220719 DOI: 10.1016/j.ijrobp.2014.07.026] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2014] [Revised: 07/09/2014] [Accepted: 07/19/2014] [Indexed: 11/16/2022]
Abstract
PURPOSE Whole-breast radiation therapy (XRT) after breast-conserving surgery (BCS) for ductal carcinoma in situ (DCIS) may decrease the risk of local recurrence, but the optimal dose regimen remains unclear. Past studies administered 50 Gy in 25 fractions (conventional); however, treatment pattern studies report that hypofractionated (HF) regimens (42.4 Gy in 16 fractions) are frequently used. We report the impact of HF (vs conventional) on the risk of local recurrence after BCS for DCIS. METHODS AND MATERIALS All women with DCIS treated with BCS and XRT in Ontario, Canada from 1994 to 2003 were identified. Treatment and outcomes were assessed through administrative databases and validated by chart review. Survival analyses were performed. To account for systematic differences between women treated with alternate regimens, we used a propensity score adjustment approach. RESULTS We identified 1609 women, of whom 971 (60%) received conventional regimens and 638 (40%) received HF. A total of 489 patients (30%) received a boost dose, of whom 143 (15%) received conventional radiation therapy and 346 (54%) received HF. The median follow-up time was 9.2 years. The median age at diagnosis was 56 years (interquartile range [IQR], 49-65 years). On univariate analyses, the 10-year actuarial local recurrence-free survival was 86% for conventional radiation therapy and 89% for HF (P=.03). On multivariable analyses, age <45 years (hazard ratio [HR] = 2.4; 95% CI: 1.6-3.4; P<.0001), high (HR=2.9; 95% CI: 1.2-7.3; P=.02) or intermediate nuclear grade (HR=2.7; 95% CI: 1.1-6.6; P=.04), and positive resection margins (HR=1.4; 95% CI: 1.0-2.1; P=.05) were associated with an increased risk of local recurrence. HF was not significantly associated with an increased risk of local recurrence compared with conventional radiation therapy on multivariate analysis (HR=0.8; 95% CI: 0.5-1.2; P=.34). CONCLUSIONS The risk of local recurrence among individuals treated with HF regimens after BCS for DCIS was similar to that among individuals treated with conventional radiation therapy.
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Affiliation(s)
- Nafisha Lalani
- University of Toronto, Toronto, Ontario, Canada; Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Lawrence Paszat
- University of Toronto, Toronto, Ontario, Canada; Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Rinku Sutradhar
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Deva Thiruchelvam
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Sharon Nofech-Mozes
- University of Toronto, Toronto, Ontario, Canada; Department of Anatomic Pathology, Sunnybrook Health Sciences Centre and Department of Laboratory Medicine and Pathobiology, Toronto, Ontario, Canada
| | - Wedad Hanna
- University of Toronto, Toronto, Ontario, Canada; Department of Anatomic Pathology, Sunnybrook Health Sciences Centre and Department of Laboratory Medicine and Pathobiology, Toronto, Ontario, Canada
| | - Elzbieta Slodkowska
- University of Toronto, Toronto, Ontario, Canada; Department of Anatomic Pathology, Sunnybrook Health Sciences Centre and Department of Laboratory Medicine and Pathobiology, Toronto, Ontario, Canada
| | - Susan J Done
- University of Toronto, Toronto, Ontario, Canada; Laboratory Medicine Program, University Health Network and Department of Laboratory Medicine and Pathobiology, Campbell Family Institute for Breast Cancer Research, Toronto, Ontario, Canada
| | - Naomi Miller
- University of Toronto, Toronto, Ontario, Canada; Laboratory Medicine Program, University Health Network and Department of Laboratory Medicine and Pathobiology, Toronto, Ontario, Canada
| | - Bruce Youngson
- University of Toronto, Toronto, Ontario, Canada; Laboratory Medicine Program, University Health Network and Department of Laboratory Medicine and Pathobiology, Toronto, Ontario, Canada
| | - Alan Tuck
- Pathology and Laboratory Medicine, London Health Sciences Centre and Saint Joseph's Health Care, London, Ontario, Canada
| | - Sandip Sengupta
- Department of Pathology and Molecular Medicine, Kingston General Hospital, Kingston, Ontario, Canada
| | - Leela Elavathil
- Department of Anatomical Pathology, Juravinski Hospital, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Martin C Chang
- Department of Pathology and Laboratory Medicine, Mount Sinai Hospital and Department of Laboratory Medicine and Pathobiology, Toronto, Ontario, Canada
| | - Prashant A Jani
- Department of Anatomical Pathology, Thunder Bay Regional Health Sciences Centre, Thunder Bay, Ontario, Canada
| | - Michel Bonin
- Pathology and Laboratory Medicine, Sudbury Regional Hospital, Sudbury, Ontario, Canada
| | - Eileen Rakovitch
- University of Toronto, Toronto, Ontario, Canada; Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.
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22
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Radiotherapy in DCIS, an underestimated benefit? Radiother Oncol 2014; 112:1-8. [DOI: 10.1016/j.radonc.2014.06.011] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2014] [Revised: 05/18/2014] [Accepted: 06/15/2014] [Indexed: 12/28/2022]
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Quintayo MA, Starczynski J, Yan FJ, Wedad H, Nofech-Mozes S, Rakovitch E, Bartlett JMS. Virtual tissue microarrays: a novel and viable approach to optimizing tissue microarrays for biomarker research applied to ductal carcinoma in situ. Histopathology 2014; 65:2-8. [PMID: 24267587 DOI: 10.1111/his.12336] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2013] [Accepted: 11/21/2013] [Indexed: 12/15/2022]
Abstract
AIMS Tissue microarrays (TMAs) are effective tools for performing high-throughput standardization analyses of biomarkers, but evidence indicating the core number required to be representative of the whole tumour is lacking. Ductal carcinoma in situ (DCIS) is a non-obligate precursor of invasive breast cancer. The number and size of cores that can best represent a DCIS lesion are unknown. Rather than performing extensive experiments using several variants of physical TMAs, the aim of this study was to develop a 'virtual TMA' approach that is effective at optimizing biomarker discovery and validation. METHODS AND RESULTS Whole DCIS sections from 95 patients were evaluated by immunohistochemistry for oestrogen receptor (ER), progesterone receptor (PgR), HER2, and Ki67. Histoscores were generated manually for ER, PgR, and HER2, as well as percentage positivity for Ki67. Slides were scanned using the FDA-approved Ariol SL50 Image Analysis system, and the virtual array (V-Array) module was used. Virtual cores created virtual TMAs, and our validated scoring classifiers were applied. Automated histoscores and percentage positivity were determined, and compared against increasing numbers of cores. The optimal number of cores was based on concordant results between virtual TMAs and corresponding whole sections. CONCLUSIONS We have shown that virtual arrays constitute an important tool in digital pathology in both research and clinical settings.
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Lim YJ, Kim K, Chie EK, Han W, Noh DY, Ha SW. Treatment outcome of ductal carcinoma in situ patients treated with postoperative radiation therapy. Radiat Oncol J 2014; 32:1-6. [PMID: 24724045 PMCID: PMC3977126 DOI: 10.3857/roj.2014.32.1.1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2013] [Revised: 12/23/2013] [Accepted: 01/02/2014] [Indexed: 11/22/2022] Open
Abstract
Purpose To evaluate the outcome of ductal carcinoma in situ (DCIS) patients who underwent surgery followed by radiation therapy (RT). Materials and Methods We retrospectively reviewed 106 DCIS patients who underwent surgery followed by postoperative RT between 1994 and 2006. Ninety-four patients underwent breast-conserving surgery, and mastectomy was performed in 12 patients due to extensive DCIS. Postoperative RT was delivered to whole breast with 50.4 Gy/28 fx. Tumor bed boost was offered to 7 patients (6.6%). Patients with hormonal receptor-positive tumors were treated with hormonal therapy. Results The median follow-up duration was 83.4 months (range, 33.4 to 191.5 months) and the median age was 47.8 years. Ten patients (9.4%) had resection margin <1 mm and high-grade and estrogen receptor-negative tumors were observed in 39 (36.8%) and 20 (18.9%) patients, respectively. The 7-year ipsilateral breast tumor recurrence (IBTR)-free survival rate was 95.3%. Resection margin (<1 or ≥1 mm) was the significant prognostic factor for IBTR in univariate and multivariate analyses (p < 0.001 and p = 0.016, respectively). Conclusion Postoperative RT for DCIS can achieve favorable treatment outcome. Resection margin was the important prognostic factor for IBTR in the DCIS patients who underwent postoperative RT.
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Affiliation(s)
- Yu Jin Lim
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, Korea
| | - Kyubo Kim
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, Korea
| | - Eui Kyu Chie
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, Korea. ; Institute of Radiation Medicine, Medical Research Center, Seoul National University, Seoul, Korea
| | - Wonshik Han
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Dong Young Noh
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Sung W Ha
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, Korea. ; Institute of Radiation Medicine, Medical Research Center, Seoul National University, Seoul, Korea
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25
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Kong I, Narod SA, Taylor C, Paszat L, Saskin R, Nofech-Moses S, Thiruchelvam D, Hanna W, Pignol JP, Sengupta S, Elavathil L, Jani PA, Done SJ, Metcalfe S, Rakovitch E. Age at diagnosis predicts local recurrence in women treated with breast-conserving surgery and postoperative radiation therapy for ductal carcinoma in situ: a population-based outcomes analysis. ACTA ACUST UNITED AC 2014; 21:e96-e104. [PMID: 24523627 DOI: 10.3747/co.21.1604] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE The main goal of treating ductal carcinoma in situ (dcis) is to prevent the development of invasive breast cancer. Most women are treated with breast-conserving surgery (bcs) and radiotherapy. Age at diagnosis may be a risk factor for recurrence, leading to concerns that additional treatment may be necessary for younger women. We report a population-based study of women with dcis treated with bcs and radiotherapy and an evaluation of the effect of age on local recurrence (lr). METHODS All women diagnosed with dcis in Ontario from 1994 to 2003 were identified. Treatments and outcomes were collected through administrative databases and validated by chart review. Women treated with bcs and radiotherapy were included. Survival analyses were performed to evaluate the effect of age on outcomes. RESULTS We identified 5752 cases of dcis; 1607 women received bcs and radiotherapy. The median follow-up was 10.0 years. The 10-year cumulative lr rate was 27% for women younger than 45 years, 14% for women 45-50 years, and 11% for women more than 50 years of age (p < 0.0001). The 10-year cumulative invasive lr rate was 22% for women younger than 45 years, 10% for women 45-50 years, and 7% for women more than 50 years of age (p < 0.0001). On multivariate analyses, young age (<45 years) was significantly associated with lr and invasive lr [hazard ratio (hr) for lr: 2.6; 95% confidence interval (ci): 1.9 to 3.7; p < 0.0001; hr for invasive lr: 3.0; 95% ci: 2.0 to 4.4; p < 0.0001]. An age of 45-50 years was also significantly associated with invasive lr (hr: 1.6; 95% ci: 1.0 to 2.4; p = 0.04). CONCLUSIONS Age at diagnosis is a strong predictor of lr in women with dcis after treatment with bcs and radiotherapy.
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Affiliation(s)
- I Kong
- Department of Radiation Oncology, Women's College Research Institute, Toronto, ON. ; Sunnybrook Health Sciences Centre, Toronto, ON. ; University of Toronto, Toronto, ON
| | - S A Narod
- University of Toronto, Toronto, ON. ; Women's College Research Institute, Toronto, ON
| | - C Taylor
- Institute for Clinical Evaluative Sciences, Sunnybrook Health Sciences Centre, Toronto, ON
| | - L Paszat
- Department of Radiation Oncology, Women's College Research Institute, Toronto, ON. ; Sunnybrook Health Sciences Centre, Toronto, ON. ; University of Toronto, Toronto, ON. ; Institute for Clinical Evaluative Sciences, Sunnybrook Health Sciences Centre, Toronto, ON
| | - R Saskin
- Institute for Clinical Evaluative Sciences, Sunnybrook Health Sciences Centre, Toronto, ON
| | - S Nofech-Moses
- University of Toronto, Toronto, ON. ; Department of Pathology, University of Toronto, Toronto, ON
| | - D Thiruchelvam
- Institute for Clinical Evaluative Sciences, Sunnybrook Health Sciences Centre, Toronto, ON
| | - W Hanna
- University of Toronto, Toronto, ON. ; Department of Pathology, University of Toronto, Toronto, ON
| | - J P Pignol
- Department of Radiation Oncology, Women's College Research Institute, Toronto, ON. ; Sunnybrook Health Sciences Centre, Toronto, ON. ; University of Toronto, Toronto, ON
| | - S Sengupta
- Department of Pathology, University of Toronto, Toronto, ON. ; Kingston General Hospital, Kingston, ON
| | - L Elavathil
- Department of Pathology, University of Toronto, Toronto, ON. ; Henderson General Hospital, Hamilton, ON
| | - P A Jani
- Department of Pathology, University of Toronto, Toronto, ON. ; Thunder Bay Regional Health Sciences Centre, Thunder Bay, ON
| | - S J Done
- Campbell Family Institute for Breast Cancer Research, University Health Network, Toronto, ON
| | - S Metcalfe
- Sunnybrook Health Sciences Centre, Toronto, ON
| | - E Rakovitch
- Department of Radiation Oncology, Women's College Research Institute, Toronto, ON. ; Sunnybrook Health Sciences Centre, Toronto, ON. ; Institute for Clinical Evaluative Sciences, Sunnybrook Health Sciences Centre, Toronto, ON. ; University of Toronto, Toronto, ON
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26
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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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Boxer M, Delaney G, Chua B. A review of the management of ductal carcinoma in situ following breast conserving surgery. Breast 2013; 22:1019-25. [DOI: 10.1016/j.breast.2013.08.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2013] [Revised: 08/13/2013] [Accepted: 08/30/2013] [Indexed: 10/26/2022] Open
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Hathout L, Hijal T, Théberge V, Fortin B, Vulpe H, Hogue JC, Lambert C, Bahig H, Provencher L, Vavassis P, Yassa M. Hypofractionated radiation therapy for breast ductal carcinoma in situ. Int J Radiat Oncol Biol Phys 2013; 87:1058-63. [PMID: 24113057 DOI: 10.1016/j.ijrobp.2013.08.026] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2013] [Revised: 08/06/2013] [Accepted: 08/23/2013] [Indexed: 11/15/2022]
Abstract
PURPOSE Conventional radiation therapy (RT) administered in 25 fractions after breast-conserving surgery (BCS) is the standard treatment for ductal carcinoma in situ (DCIS) of the breast. Although accelerated hypofractionated regimens in 16 fractions have been shown to be equivalent to conventional RT for invasive breast cancer, few studies have reported results of using hypofractionated RT in DCIS. METHODS AND MATERIALS In this multicenter collaborative effort, we retrospectively reviewed the records of all women with DCIS at 3 institutions treated with BCS followed by hypofractionated whole-breast RT (WBRT) delivered in 16 fractions. RESULTS Between 2003 and 2010, 440 patients with DCIS underwent BCS followed by hypofractionated WBRT in 16 fractions for a total dose of 42.5 Gy (2.66 Gy per fraction). Boost RT to the surgical bed was given to 125 patients (28%) at a median dose of 10 Gy in 4 fractions (2.5 Gy per fraction). After a median follow-up time of 4.4 years, 14 patients had an ipsilateral local relapse, resulting in a local recurrence-free survival of 97% at 5 years. Positive surgical margins, high nuclear grade, age less than 50 years, and a premenopausal status were all statistically associated with an increased occurrence of local recurrence. Tumor hormone receptor status, use of adjuvant hormonal therapy, and administration of additional boost RT did not have an impact on local control in our cohort. On multivariate analysis, positive margins, premenopausal status, and nuclear grade 3 tumors had a statistically significant worse local control rate. CONCLUSIONS Hypofractionated RT using 42.5 Gy in 16 fractions provides excellent local control for patients with DCIS undergoing BCS.
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Affiliation(s)
- Lara Hathout
- Department of Radiation Oncology, Hôpital Maisonneuve-Rosemont, Centre affilié à l'Université de Montréal, Montreal, Quebec, Canada
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