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Radiotherapy for prevention or management of gynecomastia recurrence: Future role for general gynecomastia patients in plastic surgery given current role in management of high-risk prostate cancer patients on anti-androgenic therapy. J Plast Reconstr Aesthet Surg 2021; 74:3128-3140. [PMID: 34001449 DOI: 10.1016/j.bjps.2021.03.098] [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: 05/22/2020] [Revised: 01/09/2021] [Accepted: 03/13/2021] [Indexed: 11/23/2022]
Abstract
PURPOSE Several technologies and innovative approaches continue to emerge for the optimal management of gynecomastia by plastic surgeons; the present study investigates the role of radiation therapy in this context. METHODS A systematic review was performed to evaluate the utility of radiotherapy for the prevention and treatment of gynecomastia incidence or recurrence by plastic surgeons. RESULTS Fifteen articles met the inclusion criteria for review. The mean incidence of gynecomastia was 70% in the high-risk population examined representing prostate cancer patients on estrogen or anti-androgen therapy. Radiotherapy was shown to significantly reduce the incidence to a median of 23%, with all six randomized control studies assessed demonstrating a statistically significant decrease in incidence following radiotherapy prophylaxis. Doses examined ranged from 8 to 16 Gy, delivered between 1 and 11 fractions. Complications following radiotherapy were minor and self-limiting in all cases, restricted to minor skin reactions, and associated with larger radiotherapy doses delivered in fewer fractions. The median complication rate was 12.4% with no major complications, such as neoplastic, pulmonary, or adverse cardiac outcomes. While the efficacy of radiation therapy as a treatment modality for gynecomastia was also established, it was shown to be less effective than other available options. CONCLUSIONS Low-dose radiotherapy to the male breast might be a safe and effective strategy to prevent gynecomastia incidence or recurrence in high-risk patients; further studies are indicated within the common gynecomastia population managed by plastic surgeons to assess the clinical and economical utility of this intervention before a recommendation for its ubiquitous adoption in plastic surgery can be made to continue improving outcomes for high-risk gynecomastia patients.
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Aksnessæther BY, Myklebust TÅ, Solberg A, Klepp OH, Skovlund E, Hoff SR, Fosså SD, Widmark A, Lund JÅ. In Reply to Sari et al. Int J Radiat Oncol Biol Phys 2020; 107:388-389. [PMID: 32112877 DOI: 10.1016/j.ijrobp.2020.02.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Accepted: 02/18/2020] [Indexed: 10/24/2022]
Affiliation(s)
- Bjørg Y Aksnessæther
- Department of Oncology, Ålesund Hospital, Møre and Romsdal Hospital Trust, Norway; Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, NTNU, Norwegian University of Science and Technology, Trondheim, Norway
| | - Tor Åge Myklebust
- Department of Research and Innovation, Møre and Romsdal Hospital Trust, Norway; Department of Registration, Cancer Registry of Norway, Oslo, Norway
| | - Arne Solberg
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, NTNU, Norwegian University of Science and Technology, Trondheim, Norway; Cancer Clinic, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Olbjørn H Klepp
- Department of Oncology, Ålesund Hospital, Møre and Romsdal Hospital Trust, Norway
| | - Eva Skovlund
- Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, NTNU, Norwegian University of Science and Technology, Trondheim, Norway
| | - Solveig Roth Hoff
- Department of Radiology, Ålesund Hospital, Møre and Romsdal Hospital Trust, Ålesund, Norway; Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, NTNU, Trondheim, Norway
| | - Sophie D Fosså
- Department of Oncology, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Anders Widmark
- Department of Radiation Sciences, Oncology, Umeå University, Umeå, Sweden
| | - Jo-Åsmund Lund
- Department of Oncology, Ålesund Hospital, Møre and Romsdal Hospital Trust, Norway; Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, NTNU, Norwegian University of Science and Technology, Trondheim, Norway
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Aksnessæther BY, Myklebust TÅ, Solberg A, Klepp OH, Skovlund E, Hoff SR, Fosså SD, Widmark A, Lund JÅ. Second Cancers in Patients With Locally Advanced Prostate Cancer Randomized to Lifelong Endocrine Treatment With or Without Radical Radiation Therapy: Long-Term Follow-up of the Scandinavian Prostate Cancer Group-7 Trial. Int J Radiat Oncol Biol Phys 2020; 106:706-714. [PMID: 31786279 DOI: 10.1016/j.ijrobp.2019.11.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 11/07/2019] [Accepted: 11/21/2019] [Indexed: 01/01/2023]
Abstract
BACKGROUND Curative radiation therapy (RT) constitutes a cornerstone in prostate cancer (PC) treatment. We present long-term follow-up estimates for second cancer (SC) risk and overall survival (OS) in patients randomized to hormone therapy (ET) alone or combined with 70 Gy prostatic RT in the Scandinavian Prostate Cancer Group-7 (SPCG-7) study. We explored the effect of salvage RT (≥60 Gy to the ET group) and reported causes of death. METHODS AND MATERIALS The SPCG-7 study (1996-2002) was a randomized controlled trial that included 875 men with locally advanced nonmetastatic PC. In this analysis, including data from the Norwegian and Swedish Cancer and Cause of Death registries for 651 Norwegian and 209 Swedish study patients, we estimated hazard ratios (HRs) for SC and death, and cumulative incidences of SC. RESULTS Median follow-up of the 860 (431 ET and 429) ET + RT patients was 12.2 years for SC risk analysis and 12.6 years for the OS analysis. Eighty-three of the Norwegian ET patients received salvage RT, and median time to salvage RT was 5.9 years. We found 125 and 168 SCs in the ET and ET + RT patients, respectively. With ET alone as reference, ET + RT patients had an HR of 1.19 (95% confidence interval [CI], 0.92-1.54) for all SCs and 2.54 (95% CI, 1.14-5.69) for urinary bladder cancer (UBC). The total number of UBC was 31 (23 in ET + RT; 8 in ET), and the vast majority (85%) were superficial. The HR for SC in salvage RT patients was 0.48 (95% CI, 0.24-0.94). Median OS was 12.8 (95% CI, 11.8-13.8) and 15.3 (95%, CI 14.3-16.4) years in the ET and ET + RT groups, respectively. Compared with ET alone, the risk of death was reduced in ET + RT patients (HR, 0.73; 95% CI, 0.62-0.86) and in ET patients receiving salvage RT (HR, 0.44; 95% CI, 0.30-0.65). CONCLUSIONS Although the risk of UBC was increased in PC patients who received RT in addition to ET, this disadvantage is outweighed by the OS benefit of RT confirmed in our study. The risk of SC, and especially UBC, should be discussed with patients and be reflected in follow-up programs.
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Affiliation(s)
- Bjørg Y Aksnessæther
- Department of Oncology, Ålesund Hospital, Møre and Romsdal Hospital Trust, Ålesund; Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, NTNU, Norwegian University of Science and Technology, Trondheim.
| | - Tor Åge Myklebust
- Department of Research and Innovation, Møre and Romsdal Hospital Trust; Department of Registration, Cancer Registry of Norway, Oslo
| | - Arne Solberg
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, NTNU, Norwegian University of Science and Technology, Trondheim; Cancer Clinic, St. Olavs Hospital, Trondheim University Hospital, Trondheim
| | - Olbjørn H Klepp
- Department of Oncology, Ålesund Hospital, Møre and Romsdal Hospital Trust, Ålesund
| | - Eva Skovlund
- Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, NTNU, Norwegian University of Science and Technology, Trondheim
| | - Solveig Roth Hoff
- Department of Radiology, Ålesund Hospital, Møre and Romsdal Hospital Trust, Ålesund; Department of circulation and medical imaging, Faculty of Medicine and Health Sciences, NTNU, Trondheim
| | - Sophie D Fosså
- Department of Oncology, Oslo University Hospital, Oslo; Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Anders Widmark
- Department of Radiation Sciences, Oncology, Umeå University, Umeå, Sweden
| | - Jo-Åsmund Lund
- Department of Oncology, Ålesund Hospital, Møre and Romsdal Hospital Trust, Ålesund; Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, NTNU, Norwegian University of Science and Technology, Trondheim
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Treatment strategies to prevent and reduce gynecomastia and/or breast pain caused by antiandrogen therapy for prostate cancer : Statement from the DEGRO working group prostate cancer. Strahlenther Onkol 2020; 196:589-597. [PMID: 32166452 PMCID: PMC7305090 DOI: 10.1007/s00066-020-01598-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 02/18/2020] [Indexed: 11/23/2022]
Abstract
Aim To provide an overview on the available treatments to prevent and reduce gynecomastia and/or breast pain caused by antiandrogen therapy for prostate cancer. Methods The German Society of Radiation Oncology (DEGRO) expert panel summarized available evidence published and assessed the validity of the information on efficacy and treatment-related toxicity. Results Eight randomized controlled trials and one meta-analysis were identified. Two randomized trials demonstrated that prophylactic radiation therapy (RT) using 1 × 10 Gy or 2 × 6 Gy significantly reduced the rate of gynecomastia but not breast pain, as compared to observation. A randomized dose-finding trial identified the daily dose of 20 mg tamoxifen (TMX) as the most effective prophylactic dose and another randomized trial described that daily TMX use was superior to weekly use. Another randomized trial showed that prophylactic daily TMX is more effective than TMX given at the onset of gynecomastia. Two other randomized trials described that TMX was clearly superior to anastrozole in reducing the risk for gynecomastia and/or breast pain. One comparative randomized trial between prophylactic RT using 1 × 12 Gy and TMX concluded that prophylactic TMX is more effective compared to prophylactic RT and furthermore that TMX appears to be more effective to treat gynecomastia and/or breast pain when symptoms are already present. A meta-analysis confirmed that both prophylactic RT and TMX can reduce the risk of gynecomastia and/or breast pain with TMX being more effective; however, the rate of side effects after TMX including dizziness and hot flushes might be higher than after RT and must be taken into account. Less is known regarding the comparative effectiveness of different radiation fractionation schedules and more modern RT techniques. Conclusions Prophylactic RT as well as daily TMX can significantly reduce the incidence of gynecomastia and/or breast pain. TMX appears to be an effective alternative to RT also as a therapeutic treatment in the presence of gynecomastia but its side effects and off-label use must be considered.
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Eng TY, Abugideiri M, Chen TW, Madden N, Morgan T, Tanenbaum D, Wandrey N, Westergaard S, Xu K, Jane Sudmeier L. Radiation Therapy for Benign Disease. Hematol Oncol Clin North Am 2020; 34:205-227. [DOI: 10.1016/j.hoc.2019.09.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Kvåle R, Myklebust TÅ, Fosså SD, Aas K, Ekanger C, Helle SI, Honoré A, Møller B. Impact of positive surgical margins on secondary treatment, palliative radiotherapy and prostate cancer-specific mortality. A population-based study of 13 198 patients. Prostate 2019; 79:1852-1860. [PMID: 31566779 DOI: 10.1002/pros.23911] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Accepted: 09/12/2019] [Indexed: 11/06/2022]
Abstract
BACKGROUND The results of studies evaluating the impact of positive surgical margins on prostate cancer-specific mortality have been inconsistent. We, therefore, evaluated the impact of surgical margin status on subsequent secondary treatment, palliative radiotherapy, and prostate cancer-specific mortality. METHODS A total of 14 837 men treated with radical prostatectomy (RP) during the period 2001 to 2015 were identified from the Cancer Registry of Norway. Of those, 13 198 (89%) patients had complete data on the preoperative prostate-specific antigen level, pathological T-category, Gleason score in the prostatectomy specimen, and margin status. Multivariable Cox proportional hazards models were used to evaluate the risk, and flexible parametric models for the cumulative incidence were fitted to predict the probabilities of secondary treatment (salvage radiotherapy or prophylactic breast radiation), palliative radiotherapy, and prostate cancer-specific mortality. RESULTS After a median follow-up time of 5.2 years (3591 patients with ≥8 years of follow-up), positive surgical margins (PSMs) were independently predictive of secondary treatment (hazard ratio [HR] = 2.43, 95% confidence interval [CI] = 2.21-2.66) and palliative radiotherapy (HR = 1.45, 95% CI = 1.03-2.05). After 10 years, the absolute increased risk for palliative radiotherapy in patients with PSMs after RP varied between 0.1% in pT2 tumors with a Gleason score of 6, to 12% for pT3b tumors with a Gleason score of 9 to 10. PSMs were not independently associated with prostate cancer-specific mortality (HR = 1.14, 95% CI = 0.82-1.59). CONCLUSION PSMs were associated with increased application of secondary treatment and palliative radiotherapy but were not predictive of prostate cancer-specific mortality. As the use of palliative radiotherapy was only marginally increased in patients with PSMs and the lowest-risk disease characteristics, avoiding PSMs may be of greatest prognostic relevance in patients with higher-risk disease characteristics.
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Affiliation(s)
- Rune Kvåle
- Department of Oncology, Haukeland University Hospital, Bergen, Norway
- Department of Health Registry Research and Development, Norwegian Institute of Public Health, Bergen, Norway
- Cancer Registry of Norway, Institute of Population-based Cancer Research, Oslo, Norway
| | - Tor Å Myklebust
- Cancer Registry of Norway, Institute of Population-based Cancer Research, Oslo, Norway
- Department of Research and Innovation, Møre and Romsdal Hospital Trust, Ålesund, Norway
| | - Sophie D Fosså
- Cancer Registry of Norway, Institute of Population-based Cancer Research, Oslo, Norway
- Department of Oncology, Oslo University Hospital, Oslo, Norway
- Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Kirsti Aas
- Department of Surgery, Vestre Viken Hospital Trust, Drammen, Norway
| | - Christian Ekanger
- Department of Oncology, Haukeland University Hospital, Bergen, Norway
| | - Svein I Helle
- Department of Oncology, Haukeland University Hospital, Bergen, Norway
| | - Alfred Honoré
- Department of Urology, Haukeland University Hospital, Bergen, Norway
| | - Bjørn Møller
- Cancer Registry of Norway, Institute of Population-based Cancer Research, Oslo, Norway
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