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Wang J, Wu SG. Breast Cancer: An Overview of Current Therapeutic Strategies, Challenge, and Perspectives. BREAST CANCER (DOVE MEDICAL PRESS) 2023; 15:721-730. [PMID: 37881514 PMCID: PMC10596062 DOI: 10.2147/bctt.s432526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 10/11/2023] [Indexed: 10/27/2023]
Abstract
Breast cancer is the most commonly diagnosed cancer and the leading cause of death among female patients, which seriously threatens the health of women in the whole world. The treatments of breast cancer require the cooperation of a multidisciplinary setting and taking tumor load and molecular makers into account. For early breast cancer, breast-conserving surgery with radiotherapy or mastectomy alone remains the standard management, and the administration of adjuvant systemic therapy is decided by the status of lymph nodes, hormone receptors, and human epidermal growth factor receptor-2. For metastatic breast cancer, the goal of treatments is to prolong survival and maintain quality of life. This review will present the current advances and controversies of surgery, chemotherapy, radiotherapy, endocrine therapy, targeted therapy, immunotherapy, gene therapy, and other innovative treatment strategies in early-stage and metastatic breast cancer.
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Affiliation(s)
- Jun Wang
- Department of Head and Neck Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu, Sichuan, People’s Republic of China
| | - San-Gang Wu
- Department of Radiation Oncology, the First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, 361003, People’s Republic of China
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Hanna SA, Bevilacqua JLB, de Barros ACSD, de Andrade FEM, Piato JRM, Pelosi EL, Martella E, da Silva JLF, Carvalho HDA, Jacomo AL. Long-Term Results of Intraoperative Radiation Therapy for Early Breast Cancer Using a Nondedicated Linear Accelerator. Adv Radiat Oncol 2023; 8:101233. [PMID: 37408678 PMCID: PMC10318249 DOI: 10.1016/j.adro.2023.101233] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 03/10/2023] [Indexed: 07/07/2023] Open
Abstract
Purpose To present the long-term results of intraoperative radiation therapy (IORT) for early breast cancer using a nondedicated linear accelerator. Methods and Materials The eligibility criteria were biopsy-proven invasive carcinoma, age ≥40 years, tumor size ≤3 cm, and N0M0. We excluded multifocal lesions and sentinel lymph node involvement. All patients had previously undergone breast magnetic resonance imaging. Breast-conserving surgery with margins and sentinel lymph node evaluation using frozen sections were performed in all cases. If there were no margins or involved sentinel lymph nodes, the patient was transferred from the operative suite to the linear accelerator room, where IORT was delivered (21 Gy). Results A total of 209 patients who were followed up for ≥1.5 years from 2004 to 2019 were included. The median age was 60.3 years (range, 40-88.6), and the mean pT was 1.3 cm (range, 0.2-4). There were 90.5% pN0 cases (7.2% of micrometastases and 1.9% of macrometastases). Ninety-seven percent of the cases were margin free. The rate of lymphovascular invasion was 10.6%. Twelve patients were negative for hormonal receptors, and 28 patients were HER2 positive. The median Ki-67 index was 29% (range, 0.1-85). Intrinsic subtype stratification was as follows: luminal A, 62.7% (n = 131); luminal B, 19.1% (n = 40); HER2 enriched 13.4% (n = 28); and triple negative, 4.8% (n = 10). Within the median follow-up of 145 months (range, 12.8-187.1), the 5-year, 10-year, and 15-year overall survival rates were 98%, 94.7%, and 88%, respectively. The 5-year, 10-year, and 15-year disease-free rates were 96.3%, 90%, and 75.6%, respectively. The 15-year local recurrence-free rate was 76%. Fifteen local recurrences (7.2%) occurred throughout the follow-up period. The mean time to local recurrence was 145 months (range, 12.8-187.1). As a first event, 3 cases of lymph node recurrence, 3 cases of distant metastasis, and 2 cancer-related deaths were recorded. Tumor size >1 cm, grade III, and lymphovascular invasion were identified as risk factors. Conclusions Despite approximately 7% of recurrences, we may infer that IORT may still be a reasonable option for selected cases. However, these patients require a longer follow-up as recurrences may occur after 10 years.
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Affiliation(s)
| | | | | | | | - José Roberto Morales Piato
- Gynecology Department, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | | | - Eduardo Martella
- Radiation Oncology Department, Escola Paulista de Medicina, São Paulo, Brazil
| | | | | | - Alfredo Luiz Jacomo
- Surgery Department, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
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Roeder F, Jensen AD, Lindel K, Mattke M, Wolf F, Gerum S. Geriatric Radiation Oncology: What We Know and What Can We Do Better? Clin Interv Aging 2023; 18:689-711. [PMID: 37168037 PMCID: PMC10166100 DOI: 10.2147/cia.s365495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 04/22/2023] [Indexed: 05/13/2023] Open
Abstract
Elderly patients represent a growing subgroup of cancer patients for whom the role of radiation therapy is poorly defined. Older patients are still clearly underrepresented in clinical trials, resulting in very limited high-level evidence. Moreover, elderly patients are less likely to receive radiation therapy in similar clinical scenarios compared to younger patients. However, there is no clear evidence for a generally reduced radiation tolerance with increasing age. Modern radiation techniques have clearly reduced acute and late side effects, thus extending the boundaries of the possible regarding treatment intensity in elderly or frail patients. Hypofractionated regimens have further decreased the socioeconomic burden of radiation treatments by reducing the overall treatment time. The current review aims at summarizing the existing data for the use of radiation therapy or chemoradiation in elderly patients focusing on the main cancer types. It provides an overview of treatment tolerability and outcomes with current standard radiation therapy regimens, including possible predictive factors in the elderly population. Strategies for patient selection for standard or tailored radiation therapy approaches based on age, performance score or comorbidity, including the use of prediction tests or geriatric assessments, are discussed. Current and future possibilities for improvements of routine care and creation of high-level evidence in elderly patients receiving radiation therapy are highlighted.
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Affiliation(s)
- Falk Roeder
- Department of Radiation Therapy and Radiation Oncology, Paracelsus Medical University Hospital, Salzburg, Austria
- Correspondence: Falk Roeder, Department of Radiation Therapy and Radiation Oncology, Paracelsus Medical University Hospital, Müllner Hauptstrasse 48, Salzburg, 5020, Austria, Tel +43 57255 55569, Email
| | - Alexandra D Jensen
- Department of Radiation Oncology, University Hospital Marburg-Giessen, Giessen, Germany
| | - Katja Lindel
- Department of Radiation Oncology, Städtisches Klinikum, Karlsruhe, Germany
| | - Matthias Mattke
- Department of Radiation Therapy and Radiation Oncology, Paracelsus Medical University Hospital, Salzburg, Austria
| | - Frank Wolf
- Department of Radiation Therapy and Radiation Oncology, Paracelsus Medical University Hospital, Salzburg, Austria
| | - Sabine Gerum
- Department of Radiation Therapy and Radiation Oncology, Paracelsus Medical University Hospital, Salzburg, Austria
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Chen X, Yang TX, Xia YX, Shen Q, Hou Y, Wang L, Li L, Chang L, Li WH. Optimal radiotherapy after breast-conserving surgery for early breast cancer: A network meta-analysis of 23,418 patients. Cancer Radiother 2022; 26:1054-1063. [PMID: 36036359 DOI: 10.1016/j.canrad.2022.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 03/09/2022] [Accepted: 04/08/2022] [Indexed: 11/25/2022]
Abstract
PURPOSE In order to explore whether partial breast irradiation can replace hypofractionated whole breast irradiation and whether the former two are superior to conventional fractionated whole breast irradiation, we conducted a network meta-analysis based on the data from the latest randomized controlled trials to evaluate the efficacy of these radiotherapy modalities. MATERIAL AND METHODS Data from eligible studies were analyzed to determine the published events for ipsilateral breast tumor recurrence, distant metastasis, total deaths, and non-breast cancer-related deaths. In the case of low or high heterogeneity, the fixed-effect or random-effect model was used for statistical analysis respectively. NMA was performed by using the node-splitting model for two-category data among three radiotherapies based on a Bayesian method. RESULTS A total of 23,418 patients were included in 16 studies. For ipsilateral breast tumor recurrence, both pairwise (OR=1.9; CI95%: 1.2 -2.8; p<0.05) and indirect (OR=1.7; CI95%: 1.2 -2.4; p<0.05) comparison of three radiotherapies by network meta-analysis showed that conventional fractionated whole breast irradiation was significantly better than partial breast irradiation. Indirect comparison of three radiotherapies by network meta-analysis showed that hypofractionated whole breast irradiation was significantly better than partial breast irradiation (OR=1.6; CI95%: 1.0 -2.5; p<0.05). Network and paired meta-analyses found no significant differences in other endpoints among the three radiotherapies. CONCLUSION Overall, this network meta-analysis showed that partial breast irradiation was related to the increase of ipsilateral breast tumor recurrence compared with hypofractionated or conventional fractionated whole breast irradiation in patients with early-stage breast cancer.
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Affiliation(s)
- X Chen
- Department of Radiation Oncology, The Third Affiliated Hospital of Kunming Medical University, Tumor Hospital of Yunnan Province, NO. 519 Kunzhou Road, Kunming, Yunnan, 650101, PR China
| | - T-X Yang
- Department of Urology, The Second Affiliated Hospital of Kunming Medical University, Yunnan Institute of Urology, No. 374 Dian-Mian Avenue, Kunming, Yunnan, 650101, PR China
| | - Y-X Xia
- Department of Radiation Oncology, The Third Affiliated Hospital of Kunming Medical University, Tumor Hospital of Yunnan Province, NO. 519 Kunzhou Road, Kunming, Yunnan, 650101, PR China
| | - Q Shen
- Department of Radiation Oncology, The Third Affiliated Hospital of Kunming Medical University, Tumor Hospital of Yunnan Province, NO. 519 Kunzhou Road, Kunming, Yunnan, 650101, PR China
| | - Y Hou
- Department of Radiation Oncology, The Third Affiliated Hospital of Kunming Medical University, Tumor Hospital of Yunnan Province, NO. 519 Kunzhou Road, Kunming, Yunnan, 650101, PR China
| | - L Wang
- Department of Radiation Oncology, The Third Affiliated Hospital of Kunming Medical University, Tumor Hospital of Yunnan Province, NO. 519 Kunzhou Road, Kunming, Yunnan, 650101, PR China
| | - L Li
- Department of Radiation Oncology, The Third Affiliated Hospital of Kunming Medical University, Tumor Hospital of Yunnan Province, NO. 519 Kunzhou Road, Kunming, Yunnan, 650101, PR China
| | - L Chang
- Department of Radiation Oncology, The Third Affiliated Hospital of Kunming Medical University, Tumor Hospital of Yunnan Province, NO. 519 Kunzhou Road, Kunming, Yunnan, 650101, PR China.
| | - W-H Li
- Department of Radiation Oncology, The Third Affiliated Hospital of Kunming Medical University, Tumor Hospital of Yunnan Province, NO. 519 Kunzhou Road, Kunming, Yunnan, 650101, PR China.
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Accelerated Partial Breast Irradiation with Intraoperative Radiotherapy Is Effective in Luminal Breast Cancer Patients Aged 60 Years and Older. J Pers Med 2022; 12:jpm12071116. [PMID: 35887613 PMCID: PMC9322635 DOI: 10.3390/jpm12071116] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 06/26/2022] [Accepted: 07/06/2022] [Indexed: 11/16/2022] Open
Abstract
Adjuvant whole breast irradiation (AWBI) improves local control and survival in breast cancer patients after breast-conserving surgery. Between 2010 and 2017, 823 patients ≥ 60 years with ER-positive, Her-2 negative, clinically N0 breast cancer underwent breast-conserving surgery (BCS) at the West Pomeranian Oncology Center. Intraoperative radiotherapy (IORT) with kV photons was applied to 199 (24.2%) patients according to the IORT protocol, and AWBI only was applied to 624 (75.8%). IORT patients in cases with lymph node metastasis, lobular type presence, extensive in situ components, lymphatic vessel invasion, or resection margin < 2 mm, additionally underwent AWBI. Median follow-up was 74 months. There were two (1%) breast relapses in the IORT protocol group and one (0.2%) in the AWBI-only group. In each group, one axillary lymph node relapse was diagnosed (0.5% and 0.2%, respectively). There were two local relapses in the IORT-only group, and they were treated further with BCS and AWBI. Although locoregional relapse-free survival differed between the AWBI-only and IORT protocol groups (98.5% vs. 99.7%, p = 0.048), the local control, distant metastasis-free survival, and breast cancer-specific survival were similar. IORT is a reasonable option to avoid AWBI in ER-positive, Her-2 negative, cN0 women with breast cancer aged ≥ 60 years.
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Steen-Olsen EB, Stormoen DR, Kristensen CA, Vogelius IR, Holländer-Mieritz C, Pappot H. Patient-reported outcome during radiotherapy for head and neck cancer: the use of different PRO questionnaires. Eur Arch Otorhinolaryngol 2022; 279:4199-4206. [PMID: 35357578 DOI: 10.1007/s00405-022-07364-0] [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: 01/20/2022] [Accepted: 03/16/2022] [Indexed: 11/26/2022]
Abstract
PURPOSE Head and neck cancer (HNC) patients are typically treated with radiotherapy (RT), which might lead to side effects and deterioration of quality of life (QoL). Studies in other cancers indicate that systematic use of patient-reported outcome (PRO) can be a tool to increase awareness of patients' symptoms and improve QoL. Multiple PRO questionnaires have been developed and validated for HNC, complicating the interpretation of results from scientific studies. In this exploratory study, symptom scores from four essential symptoms present in four different HNC-specific PRO questionnaires were evaluated. METHODS Four HNC-specific PRO questionnaires (EORTC QLQ-H&N35, FACT-H&N, MDASI-HN, and PRO-CTCAE) for patients undergoing radiotherapy were completed by eligible HNC patients up to ten times during and after RT. Four essential symptoms (pain, dysphagia, hoarseness, and dry mouth) were present in all questionnaires. The symptom scores for these symptoms were aligned and evaluated. RESULTS Twelve patients were included and completed a total of 328 PRO questionnaires out of 420. Similarity between symptom score for the four symptoms was found, when the symptom scores were aligned. The symptom scores increased during RT and decreased afterwards for all four symptoms and in all four questionnaires. CONCLUSION Four HNC-specific PRO questionnaires are found similar in reflecting symptom scores over time concerning four important HNC symptoms (pain, dysphagia, hoarseness, and dry mouth). PRO can contribute with targetable information about symptoms, and PRO questionnaires might be a valuable add on to clinical practice enabling a varied picture of patients' symptoms during radiotherapy.
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Affiliation(s)
| | - Dag Rune Stormoen
- Department of Oncology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | | | - Ivan Richter Vogelius
- Department of Oncology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | | | - Helle Pappot
- Department of Oncology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
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Garduño-Sánchez S, Villanego-Beltrán I, de Las Peñas-Cabrera MD, Jaén-Olasolo J. Response to letter to the Editor. Clin Transl Oncol 2022; 24:1831-1832. [PMID: 35355156 DOI: 10.1007/s12094-022-02828-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 03/16/2022] [Indexed: 11/26/2022]
Affiliation(s)
- Sara Garduño-Sánchez
- Department of Radiation Oncology, Puerta del Mar University Hospital, Ana de Viya 21 Avenue, 11009, Cádiz, Spain.
- Biomedical Research and Innovation Institute of Cádiz (INiBICA) Research Unit, Puerta del Mar University Hospital, Cádiz, Spain.
| | - Isabel Villanego-Beltrán
- Department of Radiation Oncology, Puerta del Mar University Hospital, Ana de Viya 21 Avenue, 11009, Cádiz, Spain
- Biomedical Research and Innovation Institute of Cádiz (INiBICA) Research Unit, Puerta del Mar University Hospital, Cádiz, Spain
| | - María Dolores de Las Peñas-Cabrera
- Department of Radiation Oncology, Puerta del Mar University Hospital, Ana de Viya 21 Avenue, 11009, Cádiz, Spain
- Department of Radiation Oncology, Rey Juan Carlos University Hospital, Gladiolo s/n, 28933, Madrid, Spain
| | - Javier Jaén-Olasolo
- Department of Radiation Oncology, Puerta del Mar University Hospital, Ana de Viya 21 Avenue, 11009, Cádiz, Spain
- Biomedical Research and Innovation Institute of Cádiz (INiBICA) Research Unit, Puerta del Mar University Hospital, Cádiz, Spain
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Hickey BE, Lehman M. Partial breast irradiation versus whole breast radiotherapy for early breast cancer. Cochrane Database Syst Rev 2021; 8:CD007077. [PMID: 34459500 PMCID: PMC8406917 DOI: 10.1002/14651858.cd007077.pub4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Breast-conserving therapy for women with breast cancer consists of local excision of the tumour (achieving clear margins) followed by radiotherapy (RT). Most true recurrences occur in the same quadrant as the original tumour. Whole breast radiotherapy (WBRT) may not protect against the development of a new primary cancer developing in other quadrants of the breast. In this Cochrane Review, we investigated the delivery of radiation to a limited volume of the breast around the tumour bed (partial breast irradiation (PBI)) sometimes with a shortened treatment duration (accelerated partial breast irradiation (APBI)). OBJECTIVES To determine whether PBI/APBI is equivalent to or better than conventional or hypofractionated WBRT after breast-conserving therapy for early-stage breast cancer. SEARCH METHODS On 27 August 2020, we searched the Cochrane Breast Cancer Group Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL and three trial databases. We searched for grey literature: OpenGrey (September 2020), reference lists of articles, conference proceedings and published abstracts, and applied no language restrictions. SELECTION CRITERIA Randomised controlled trials (RCTs) without confounding, that evaluated conservative surgery plus PBI/APBI versus conservative surgery plus WBRT. Published and unpublished trials were eligible. DATA COLLECTION AND ANALYSIS Two review authors (BH and ML) performed data extraction, used Cochrane's risk of bias tool and resolved any disagreements through discussion, and assessed the certainty of the evidence for main outcomes using GRADE. Main outcomes were local recurrence-free survival, cosmesis, overall survival, toxicity (subcutaneous fibrosis), cause-specific survival, distant metastasis-free survival and subsequent mastectomy. We entered data into Review Manager 5 for analysis. MAIN RESULTS We included nine RCTs that enrolled 15,187 women who had invasive breast cancer or ductal carcinoma in-situ (6.3%) with T1-2N0-1M0 Grade I or II unifocal tumours (less than 2 cm or 3 cm or less) treated with breast-conserving therapy with negative margins. This is the second update of the review and includes two new studies and 4432 more participants. Local recurrence-free survival is probably slightly reduced (by 3/1000, 95% CI 6 fewer to 0 fewer) with the use of PBI/APBI compared to WBRT (hazard ratio (HR) 1.21, 95% confidence interval (CI) 1.03 to 1.42; 8 studies, 13,168 participants; moderate-certainty evidence). Cosmesis (physician/nurse-reported) is probably worse (by 63/1000, 95% CI 35 more to 92 more) with the use of PBI/APBI (odds ratio (OR) 1.57, 95% CI 1.31 to 1.87; 6 studies, 3652 participants; moderate-certainty evidence). Overall survival is similar (0/1000 fewer, 95% CI 6 fewer to 6 more) with PBI/APBI and WBRT (HR 0.99, 95% CI 0.88 to 1.12; 8 studies, 13,175 participants; high-certainty evidence). Late radiation toxicity (subcutaneous fibrosis) is probably increased (by 14/1000 more, 95% CI 102 more to 188 more) with PBI/APBI (OR 5.07, 95% CI 3.81 to 6.74; 2 studies, 3011 participants; moderate-certainty evidence). The use of PBI/APBI probably makes little difference (1/1000 less, 95% CI 6 fewer to 3 more) to cause-specific survival (HR 1.06, 95% CI 0.83 to 1.36; 7 studies, 9865 participants; moderate-certainty evidence). We found the use of PBI/APBI compared with WBRT probably makes little or no difference (1/1000 fewer (95% CI 4 fewer to 6 more)) to distant metastasis-free survival (HR 0.95, 95% CI 0.80 to 1.13; 7 studies, 11,033 participants; moderate-certainty evidence). We found the use of PBI/APBI in comparison with WBRT makes little or no difference (2/1000 fewer, 95% CI 20 fewer to 20 more) to mastectomy rates (OR 0.98, 95% CI 0.78 to 1.23; 3 studies, 3740 participants, high-certainty evidence). AUTHORS' CONCLUSIONS It appeared that local recurrence-free survival is probably worse with PBI/APBI; however, the difference was small and nearly all women remain free of local recurrence. Overall survival is similar with PBI/APBI and WBRT, and we found little to no difference in other oncological outcomes. Some late effects (subcutaneous fibrosis) may be worse with PBI/APBI and its use is probably associated with worse cosmetic outcomes. The limitations of the data currently available mean that we cannot make definitive conclusions about the efficacy and safety or ways to deliver PBI/APBI. We await completion of ongoing trials.
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Affiliation(s)
- Brigid E Hickey
- Radiation Oncology Raymond Terrace, Princess Alexandra Hospital, Brisbane, Australia
- School of Medicine, The University of Queensland, Brisbane, Australia
| | - Margot Lehman
- School of Medicine, The University of Queensland, Brisbane, Australia
- Division of Cancer Services, Princess Alexandra Hospital, Brisbane, Australia
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Wong JHD, Zaili Z, Abdul Malik R, Bustam AZ, Saad M, Jamaris S, Mosiun JA, Mohd Taib NA, Ung NM, See M. Evaluation of skin dose and skin toxicity in patients undergoing intraoperative radiotherapy for early breast cancer. J Appl Clin Med Phys 2021; 22:139-147. [PMID: 34254425 PMCID: PMC8364274 DOI: 10.1002/acm2.13338] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
PURPOSE This study aims to evaluate in vivo skin dose delivered by intraoperative radiotherapy (IORT) and determine the factors associated with an increased risk of radiation-induced skin toxicity. METHODOLOGY A total of 21 breast cancer patients who underwent breast-conserving surgery and IORT, either as IORT alone or IORT boost plus external beam radiotherapy (EBRT), were recruited in this prospective study. EBT3 film was calibrated in water and used to measure skin dose during IORT at concentric circles of 5 mm and 40 mm away from the applicator. For patients who also had EBRT, the maximum skin dose was estimated using the radiotherapy treatment planning system. Mid-term skin toxicities were evaluated at 3 and 6 months post-IORT. RESULTS The average skin dose at 5 mm and 40 mm away from the applicator was 3.07 ± 0.82 Gy and 0.99 ± 0.28 Gy, respectively. Patients treated with IORT boost plus EBRT received an additional skin dose of 41.07 ± 1.57 Gy from the EBRT component. At 3 months post-IORT, 86% of patients showed no evidence of skin toxicity. However, the number of patients suffering from skin toxicity increased from 15% to 38% at 6 months post-IORT. We found no association between the IORT alone or with the IORT boost plus EBRT and skin toxicity. Older age was associated with increased risk of skin toxicities. A mathematical model was derived to predict skin dose. CONCLUSION EBT3 film is a suitable dosimeter for in vivo skin dosimetry in IORT, providing patient-specific skin doses. Both IORT alone and IORT boost techniques resulted in similar skin toxicity rates.
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Affiliation(s)
- Jeannie Hsiu Ding Wong
- Department of Biomedical ImagingFaculty of MedicineUniversity of MalayaKuala LumpurMalaysia
| | - Zainor Zaili
- Department of Biomedical ImagingFaculty of MedicineUniversity of MalayaKuala LumpurMalaysia
| | - Rozita Abdul Malik
- Clinical Oncology UnitFaculty of MedicineUniversity of MalayaKuala LumpurMalaysia
| | - Anita Zarina Bustam
- Clinical Oncology UnitFaculty of MedicineUniversity of MalayaKuala LumpurMalaysia
| | - Marniza Saad
- Clinical Oncology UnitFaculty of MedicineUniversity of MalayaKuala LumpurMalaysia
| | - Suniza Jamaris
- Breast Surgery UnitDepartment of Medicine, Faculty of MedicineUniversity of MalayaKuala LumpurMalaysia
- Department of Surgery, Faculty of MedicineUniversity of MalayaKuala LumpurMalaysia
| | - Joanne Aisha Mosiun
- Department of Surgery, Faculty of MedicineUniversity of MalayaKuala LumpurMalaysia
| | - Nur Aishah Mohd Taib
- Breast Surgery UnitDepartment of Medicine, Faculty of MedicineUniversity of MalayaKuala LumpurMalaysia
| | - Ngie Min Ung
- Clinical Oncology UnitFaculty of MedicineUniversity of MalayaKuala LumpurMalaysia
| | - Mee‐Hoong See
- Breast Surgery UnitDepartment of Medicine, Faculty of MedicineUniversity of MalayaKuala LumpurMalaysia
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Comparison between Accelerated Partial Breast Irradiation with multicatheter interstitial brachytherapy and Whole Breast Irradiation, in clinical practice. Clin Transl Oncol 2021; 24:24-33. [PMID: 34213744 PMCID: PMC8251685 DOI: 10.1007/s12094-021-02664-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 06/07/2021] [Indexed: 11/05/2022]
Abstract
Purpose The aim of this study was to compare accelerated partial breast irradiation (APBI) with multicatheter interstitial brachytherapy (BT) and whole breast irradiation (WBI), in terms of toxicity, aesthetic result, quality of life and survival, in clinical practice.
Materials and methods A comparative study of two prospectively recorded cohorts of 76 breast cancer patients who complied with the recommendations of GEC-ESTRO for APBI was conducted. The main objective was toxicity, quality of life measured through validated questionnaires and the aesthetic results. Secondary objectives were overall survival and disease-free survival.
Results Seventy-six stage I/II breast cancer patients, with a mean age of 66 years entered the study. APBI group showed less acute G1-2 dermatitis (51.4 vs 94.9%, p < 0.001) and late hyperpigmentation (0 vs 17.9%, p = 0.04). There were no differences in aesthetic results, both assessed by the patient herself and by the doctor. Statistically significant differences in measures of quality of life were observed in favour of the APBI, both in EORTC QLQ-BR23 and body image scale questionnaires. With a median follow-up of 72 months (6 years), the estimated overall survival at 5 and 10 years was 96.8 and 77.7%, respectively, and disease-free survival at 5 and 10 years was 91.1 and 69.4%, respectively, without statistically significant differences between groups.
Discussion APBI is an attractive alternative in candidate patients with initial breast cancer, with benefits in acute toxicity and quality of life and fewer visits to the hospital, without compromising tumor control or survival.
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Haussmann J, Budach W, Strnad V, Corradini S, Krug D, Schmidt L, Tamaskovics B, Bölke E, Simiantonakis I, Kammers K, Matuschek C. Comparing Local and Systemic Control between Partial- and Whole-Breast Radiotherapy in Low-Risk Breast Cancer-A Meta-Analysis of Randomized Trials. Cancers (Basel) 2021; 13:2967. [PMID: 34199281 PMCID: PMC8231985 DOI: 10.3390/cancers13122967] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 06/09/2021] [Accepted: 06/09/2021] [Indexed: 11/16/2022] Open
Abstract
PURPOSE/OBJECTIVE The standard treatment for localized low-risk breast cancer is breast-conserving surgery, followed by adjuvant radiotherapy and appropriate systemic therapy. As the majority of local recurrences occur at the site of the primary tumor, numerous trials have investigated partial-breast irradiation (PBI) instead of whole-breast treatment (WBI) using a multitude of irradiation techniques and fractionation regimens. This meta-analysis addresses the impact on disease-specific endpoints, such as local and regional control, as well as disease-free survival of PBI compared to that of WBI in published randomized trials. MATERIAL AND METHODS We conducted a systematic literature review and searched for randomized trials comparing WBI and PBI in early-stage breast cancer with publication dates after 2009. The meta-analysis was based on the published event rates and the effect sizes for available oncological endpoints of at least two trials reporting on them. We evaluated in-breast tumor recurrences (IBTR), local recurrences at the primary site and elsewhere in the ipsilateral breast, regional recurrences (RR), distant metastasis-free interval (DMFI), disease-free survival (DFS), contralateral breast cancer (CBC), and second primary cancer (SPC). Furthermore, we aimed to assess the impact of different PBI techniques and subgroups on IBTR. We performed all statistical analyses using the inverse variance heterogeneity model to pool effect sizes. RESULTS For the intended meta-analysis, we identified 13 trials (overall 15,561 patients) randomizing between PBI and WBI. IBTR was significantly higher after PBI (OR = 1.66; CI-95%: 1.07-2.58; p = 0.024) with an absolute difference of 1.35%. We detected significant heterogeneity in the analysis of the PBI technique with intraoperative radiotherapy resulting in higher local relapse rates (OR = 3.67; CI-95%: 2.28-5.90; p < 0.001). Other PBI techniques did not show differences to WBI in IBTR. Both strategies were equally effective at the primary tumor site, but PBI resulted in statistically more IBTRs elsewhere in the ipsilateral breast. IBTRs after WBI were more likely to be located at the primary tumor bed, whereas they appeared equally distributed within the breast after PBI. RR was also more frequent after PBI (OR = 1.75; CI-95%: 1.07-2.88; p < 0.001), yet we did not detect any differences in DMFI (OR = 1.08; CI-95%: 0.89-1.30; p = 0.475). DFS was significantly longer in patients treated with WBI (OR = 1.14; CI-95%: 1.02-1.27; p = 0.003). CBC and SPC were not different in the test groups (OR = 0.81; CI-95%: 0.65-1.01; p = 0.067 and OR = 1.09; CI-95%: 0.85-1.40; p = 0.481, respectively). CONCLUSION Limiting the target volume to partial-breast radiotherapy appears to be appropriate when selecting patients with a low risk for local and regional recurrences and using a suitable technique.
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Affiliation(s)
- Jan Haussmann
- Department of Radiation Oncology, Heinrich Heine University, 40225 Dusseldorf, Germany; (J.H.); (W.B.); (L.S.); (B.T.); (I.S.); (C.M.)
| | - Wilfried Budach
- Department of Radiation Oncology, Heinrich Heine University, 40225 Dusseldorf, Germany; (J.H.); (W.B.); (L.S.); (B.T.); (I.S.); (C.M.)
| | - Vratislav Strnad
- Department of Radiation Oncology, University Erlangen, 91054 Erlangen, Germany;
| | - Stefanie Corradini
- Department of Radiation Oncology, University Hospital LMU (Ludwig Maximillian), 81377 Munich, Germany;
| | - David Krug
- Department of Radiation Oncology, University Hospital Schleswig-Holstein, 24105 Kiel, Germany;
| | - Livia Schmidt
- Department of Radiation Oncology, Heinrich Heine University, 40225 Dusseldorf, Germany; (J.H.); (W.B.); (L.S.); (B.T.); (I.S.); (C.M.)
| | - Balint Tamaskovics
- Department of Radiation Oncology, Heinrich Heine University, 40225 Dusseldorf, Germany; (J.H.); (W.B.); (L.S.); (B.T.); (I.S.); (C.M.)
| | - Edwin Bölke
- Department of Radiation Oncology, Heinrich Heine University, 40225 Dusseldorf, Germany; (J.H.); (W.B.); (L.S.); (B.T.); (I.S.); (C.M.)
| | - Ioannis Simiantonakis
- Department of Radiation Oncology, Heinrich Heine University, 40225 Dusseldorf, Germany; (J.H.); (W.B.); (L.S.); (B.T.); (I.S.); (C.M.)
| | - Kai Kammers
- Division of Biostatistics and Bioinformatics, Department of Oncology, The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, The Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA;
| | - Christiane Matuschek
- Department of Radiation Oncology, Heinrich Heine University, 40225 Dusseldorf, Germany; (J.H.); (W.B.); (L.S.); (B.T.); (I.S.); (C.M.)
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Mandó P, Hirsch I, Waisberg F, Ostinelli A, Luca R, Pranevicene B, Ferreyra Camacho A, Enrico D, Chacon M. Appraising the quality of meta-analysis for breast cancer treatment in the adjuvant setting: A systematic review. Cancer Treat Res Commun 2021; 27:100358. [PMID: 33957603 DOI: 10.1016/j.ctarc.2021.100358] [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: 05/19/2020] [Revised: 03/16/2021] [Accepted: 03/17/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Breast cancer is the tumor with highest incidence in women worldwide and adjuvant treatment is extremely important to achieve disease control. Given the relevance of systematic reviews, their rigor should be warranted to avoid biased conclusions. Our objective was to investigate the methodological quality of meta-analysis of early breast cancer adjuvant treatment. MATERIAL AND METHODS Comprehensive searches were performed using electronic databases from 1/1/2007 to 11/12/2018. All studies identified as a systematic review with meta-analysis investigating the efficacy of breast cancer adjuvant treatments were included. Two reviewers independently assessed titles and abstracts, then full-texts for eligibility. Quality was assessed using the Assessing the Methodological Quality of Systematic Reviews (AMSTAR) version 2 tool. RESULTS Of 950 citations retrieved, 66 studies (7.0%) were deemed eligible. Methodological quality was highly variable, median AMSTAR score 8.5 (IQR 7-9.5) and range 0-16. There was a weak positive correlation between journal impact factor and AMSTAR score (r = 0.17) and citation rate and AMSTAR score (r = 0.16). Cochrane Systematic Reviews were of higher quality than reviews from other journals. Overall confidence was critically low for 61 (92.4%) studies, and the least well-reported domains were the statement of conflict of interest and funding source for the included studies (4.6%), the report of a pre-defined study protocol (15.2%), and the description of details of excluded studies (6.1%). CONCLUSIONS Our findings reinforce concerns about the design, conduction and interpretation of meta-analysis in current literature. Methodological quality should be carefully considered and journal editors, decision makers and readers in general, must follow a critical approach to this studies.
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Affiliation(s)
- Pablo Mandó
- Argentine Association of Clinical Oncology, Gorostiaga 2450, Ciudad de Buenos Aires, CP1426, Argentina; CEMIC, Galvan 4102, Ciudad de Buenos Aires, CP 1431, Argentina.
| | - Ian Hirsch
- Argentine Association of Clinical Oncology, Gorostiaga 2450, Ciudad de Buenos Aires, CP1426, Argentina; Hospital General de Agudos Teodoro Álvarez, Juan Felipe Aranguren 2701, Ciudad de Buenos Aires, CP1406, Argentina
| | - Federico Waisberg
- Argentine Association of Clinical Oncology, Gorostiaga 2450, Ciudad de Buenos Aires, CP1426, Argentina
| | - Alexis Ostinelli
- Argentine Association of Clinical Oncology, Gorostiaga 2450, Ciudad de Buenos Aires, CP1426, Argentina; Instituto Alexander Fleming, Cramer 1180, Ciudad de Buenos Aires, CP1426, Argentina
| | - Romina Luca
- Argentine Association of Clinical Oncology, Gorostiaga 2450, Ciudad de Buenos Aires, CP1426, Argentina
| | - Belen Pranevicene
- Argentine Association of Clinical Oncology, Gorostiaga 2450, Ciudad de Buenos Aires, CP1426, Argentina
| | - Augusto Ferreyra Camacho
- Argentine Association of Clinical Oncology, Gorostiaga 2450, Ciudad de Buenos Aires, CP1426, Argentina
| | - Diego Enrico
- Argentine Association of Clinical Oncology, Gorostiaga 2450, Ciudad de Buenos Aires, CP1426, Argentina
| | - Matías Chacon
- Argentine Association of Clinical Oncology, Gorostiaga 2450, Ciudad de Buenos Aires, CP1426, Argentina; Instituto Alexander Fleming, Cramer 1180, Ciudad de Buenos Aires, CP1426, Argentina
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Xiang X, Ding Z, Feng L, Li N. A meta-analysis of the efficacy and safety of accelerated partial breast irradiation versus whole-breast irradiation for early-stage breast cancer. Radiat Oncol 2021; 16:24. [PMID: 33531014 PMCID: PMC7856797 DOI: 10.1186/s13014-021-01752-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 01/28/2021] [Indexed: 01/04/2023] Open
Abstract
OBJECTIVE This meta-analysis evaluated the efficacy and safety of accelerated partial breast irradiation versus whole-breast irradiation for early-stage breast cancer after breast-conserving surgery. MATERIALS AND METHODS A systematic search of PubMed, Embase, and the Cochrane libraries was performed according to the PRISMA statement the last 10 years to April 7, 2020 to identify the randomized controlled trials of APBI versus WBI for treating patients with early-stage breast cancer. Two independent observers evaluated the identified studies. The obtained data were analyzed using the RevMan 5.3 software. RESULTS A total of 10 randomized controlled trials involving 15,500 patients with early-stage breast cancer were selected according to the inclusion and exclusion criteria and included in this meta-analysis. In this meta-analysis, we included ten studies that reported local recurrence and found significant differences in local recurrence rates (HR = 1.46; 95% CI 1.20-1.79, P = 0.0002). Further analysis showed that this difference may be related to the choice of treatment methods. No differences in distant metastasis, breast cancer deaths, contralateral breast cancer, disease-free survival, and overall survival rates were observed between WBI and APBI groups. There was no significant difference in late toxicity, cosmetic outcomes and quality of life between the two groups, the compliance and tolerance of the patients were well. Compared to whole breast irradiation, accelerated partial breast irradiation significantly reduced serious (≥ grade 2) early toxicities, especially regarding acute skin toxicity. CONCLUSIONS The analysis showed that patients receiving APBI had a higher local recurrence rate, but no differences in distant metastasis, breast cancer deaths, contralateral breast cancer, disease-free survival, and overall survival rates.
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Affiliation(s)
- Xiaoyong Xiang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital & Shenzhen Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shenzhen, 518116, China
| | - Zhen Ding
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital & Shenzhen Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shenzhen, 518116, China
| | - Lingling Feng
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital & Shenzhen Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shenzhen, 518116, China
| | - Ning Li
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital & Shenzhen Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shenzhen, 518116, China. .,Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China.
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14
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Shah C, Jia X, Hobbs BP, Tendulkar RD, Sittenfeld SMC, Al-Hilli Z, Arthur DW, Keisch ME, Khan AJ, Shaitelman SF, Boyages J, Wazer D, Kundu N, Vicini FA. Outcomes with Partial Breast Irradiation vs. Whole Breast Irradiation: a Meta-Analysis. Ann Surg Oncol 2021; 28:4985-4994. [PMID: 33393051 DOI: 10.1245/s10434-020-09447-w] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 11/03/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Several randomized trials have been performed comparing partial breast irradiation (PBI) and whole breast irradiation (WBI) though controversy remains, including regarding differences by PBI technique. We performed a meta-analysis to compare results between WBI versus PBI and between PBI techniques. METHODS A systematic review was performed to identify modern randomized studies listed in MEDLINE from 2005 to 2020. PBI trials were divided into external beam radiation and brachytherapy techniques, with intraoperative radiation excluded. A Bayesian logistic regression model evaluated the risk of ipsilateral breast tumor recurrence (IBTR) and acute and chronic toxicities. The primary outcome was IBTR at 5 years with WBI compared with PBI. RESULTS A total of 9758 patients from 7 studies were included (4840-WBI, 4918-PBI). At 5 years, no statistically significant difference in the rate of IBTR was noted between PBI (1.8%, 95% HPD 0.68-3.2%) and WBI (1.7%, 95% HPD 0.92-2.4%). By PBI technique, the 5-year rate of IBTR rate for external beam was 1.7% and 2.2% for brachytherapy. Rates of grade 2 + acute toxicity were 7.1% with PBI versus 47.5% with WBI. For late toxicities, grade 2/3 rates were 0%/0% with PBI compared with 1.0%/0% with WBI. CONCLUSIONS IBTR rates were similar between PBI and WBI with no significant differences noted by PBI technique; PBI had reduced acute toxicities compared to WBI. Because studies did not provide toxicity data in a consistent fashion, definitive conclusions cannot be made with additional data from randomized trials needed to compare toxicity profiles between PBI techniques.
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Affiliation(s)
- Chirag Shah
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Xuefei Jia
- Quantitative Health Sciences, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Brian P Hobbs
- Quantitative Health Sciences, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Rahul D Tendulkar
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Sarah M C Sittenfeld
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Zahraa Al-Hilli
- Department of Breast Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Douglas W Arthur
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, VA, USA
| | | | - Atif J Khan
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Simona F Shaitelman
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - David Wazer
- Department of Radiation Oncology, Tufts University School of Medicine, Boston, MA, USA.,Department of Radiation Oncology, Brown University, Providence, RI, USA
| | - Neilendu Kundu
- Department of Plastic Surgery, Mercy Health, Cincinnati, OH, USA
| | - Frank A Vicini
- 21st Century Oncology, Michigan Healthcare Professionals, Farmington Hills, MI, USA.
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15
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Partial-breast irradiation versus whole-breast radiotherapy for early breast cancer: A systematic review and update meta-analysis. Brachytherapy 2020; 19:491-498. [PMID: 32340902 DOI: 10.1016/j.brachy.2020.03.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 03/09/2020] [Accepted: 03/09/2020] [Indexed: 12/20/2022]
Abstract
PURPOSE The purpose of this study was to compare the treatment outcomes of partial-breast irradiation (PBI) versus whole-breast radiotherapy (WBRT) in early breast cancer. METHODS AND MATERIALS Eligible randomized clinical trials were identified on Medline, Embase, the Cochrane Library, and the proceedings of annual meetings through December 2019. A meta-analysis for local recurrence (LR), overall mortality (OM), and non-breast cancer mortality (NBCM) was conducted. When possible, the outcomes were calculated for 5, 7, and 10 years of followup. A subgroup analysis by PBI technique (brachytherapy [BT], external beam radiotherapy [EBRT], intraoperative radiotherapy [IORT], and mixed) was performed. A p value < 0.05 was considered significant. RESULTS Eleven randomized clinical trials with a total of 14,436 patients (7186 PBI vs. 7250 WBRT) were included in the meta-analysis. The odds ratio (OR) for LR in 5 y was 1.46 (95% CI 1.15-2, p = 0.024) for PBI. In the subgroup analysis, no significant difference for LR was observed between PBI and WBRT using BT (p = 0.51), EBRT (p = 0.25), or mixed techniques (p = 0.89). The only subgroup with statistical difference was IORT 3.1 (95% CI 1.2-7.6, p = 0.014). No significant difference in LR was observed with 7 and 10 years among the groups. The OM had no difference at 5, 7, and 10 years of followup for any subgroup. A nonsignificant difference was observed comparing PBI with WBRT for NBCM OR = 1.24 (95% CI 0.98-1.57, p = 0.07). The rates of cardiac death, contralateral breast cancer, and development of second tumor were not significant. CONCLUSIONS The LR with PBI is low and similar to WBRT in selected early breast cancer with a longer followup. The subgroup analysis detected a significant difference for LR associated with IORT and no significant difference for BT and EBRT. Our results confirm a nonsignificant difference for OM and NBCM between PBI and WBRT.
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Mouawad M, Biernaski H, Brackstone M, Lock M, Yaremko B, Shmuilovich O, Kornecki A, Ben Nachum I, Muscedere G, Lynn K, Prato FS, Thompson RT, Gaede S, Gelman N. DCE-MRI assessment of response to neoadjuvant SABR in early stage breast cancer: Comparisons of single versus three fraction schemes and two different imaging time delays post-SABR. Clin Transl Radiat Oncol 2020; 21:25-31. [PMID: 32021911 PMCID: PMC6993055 DOI: 10.1016/j.ctro.2019.12.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Accepted: 12/22/2019] [Indexed: 12/25/2022] Open
Abstract
PURPOSE To determine the effect of dose fractionation and time delay post-neoadjuvant stereotactic ablative radiotherapy (SABR) on dynamic contrast-enhanced (DCE)-MRI parameters in early stage breast cancer patients. MATERIALS AND METHODS DCE-MRI was acquired in 17 patients pre- and post-SABR. Five patients were imaged 6-7 days post-21 Gy/1fraction (group 1), six 16-19 days post-21 Gy/1fraction (group 2), and six 16-18 days post-30 Gy/3 fractions every other day (group 3). DCE-MRI scans were performed using half the clinical dose of contrast agent. Changes in the surrounding tissue were quantified using a signal-enhancement threshold metric that characterizes changes in signal-enhancement volume (SEV). Tumour response was quantified using Ktrans and ve (Tofts model) pre- and post-SABR. Significance was assessed using a Wilcoxin signed-rank test. RESULTS All group 1 and 4/6 group 2 patients' SEV increased post-SABR. All group 3 patients' SEV decreased. The mean Ktrans increased for group 1 by 76% (p = 0.043) while group 2 and 3 decreased 15% (p = 0.028) and 34% (p = 0.028), respectively. For ve, there was no significant change in Group 1 (p = 0.35). Groups 2 showed an increase of 24% (p = 0.043), and Group 3 trended toward an increase (23%, p = 0.08). CONCLUSION Kinetic parameters measured 2.5 weeks post-SABR in both single fraction and three fraction groups were indicative of response but only the single fraction protocol led to enhancement in the surrounding tissue. Our results also suggest that DCE-MRI one-week post-SABR may be too early for response assessment, at least for single fraction SABR, whereas 2.5 weeks appears sufficiently long to minimize confounding acute effects.
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Affiliation(s)
- Matthew Mouawad
- Medical Biophysics, Western University, London, Ontario, Canada
| | | | - Muriel Brackstone
- Medical Biophysics, Western University, London, Ontario, Canada
- Lawson Health Research Institute, London, Ontario, Canada
- London Health Sciences Centre, London, Ontario, Canada
- St. Joseph’s Health Care, London, Ontario, Canada
| | - Michael Lock
- London Health Sciences Centre, London, Ontario, Canada
- Department of Oncology, Western University, London, Ontario, Canada
| | - Brian Yaremko
- London Health Sciences Centre, London, Ontario, Canada
- Department of Oncology, Western University, London, Ontario, Canada
| | - Olga Shmuilovich
- Lawson Health Research Institute, London, Ontario, Canada
- St. Joseph’s Health Care, London, Ontario, Canada
- Department of Medical Imaging, Western University, London, Ontario, Canada
| | - Anat Kornecki
- Lawson Health Research Institute, London, Ontario, Canada
- St. Joseph’s Health Care, London, Ontario, Canada
- Department of Medical Imaging, Western University, London, Ontario, Canada
| | - Ilanit Ben Nachum
- Lawson Health Research Institute, London, Ontario, Canada
- St. Joseph’s Health Care, London, Ontario, Canada
- Department of Medical Imaging, Western University, London, Ontario, Canada
| | - Giulio Muscedere
- Lawson Health Research Institute, London, Ontario, Canada
- St. Joseph’s Health Care, London, Ontario, Canada
- Department of Medical Imaging, Western University, London, Ontario, Canada
| | - Kalan Lynn
- Lawson Health Research Institute, London, Ontario, Canada
- London Health Sciences Centre, London, Ontario, Canada
- St. Joseph’s Health Care, London, Ontario, Canada
| | - Frank S. Prato
- Medical Biophysics, Western University, London, Ontario, Canada
- Lawson Health Research Institute, London, Ontario, Canada
- St. Joseph’s Health Care, London, Ontario, Canada
- Department of Medical Imaging, Western University, London, Ontario, Canada
| | - R. Terry Thompson
- Medical Biophysics, Western University, London, Ontario, Canada
- Lawson Health Research Institute, London, Ontario, Canada
| | - Stewart Gaede
- Medical Biophysics, Western University, London, Ontario, Canada
- Lawson Health Research Institute, London, Ontario, Canada
- London Health Sciences Centre, London, Ontario, Canada
- Department of Oncology, Western University, London, Ontario, Canada
| | - Neil Gelman
- Medical Biophysics, Western University, London, Ontario, Canada
- Lawson Health Research Institute, London, Ontario, Canada
- Department of Medical Imaging, Western University, London, Ontario, Canada
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Forster T, Köhler CVK, Debus J, Hörner-Rieber J. Accelerated Partial Breast Irradiation: A New Standard of Care? Breast Care (Basel) 2020; 15:136-147. [PMID: 32398982 DOI: 10.1159/000506254] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Accepted: 01/29/2020] [Indexed: 01/19/2023] Open
Abstract
Background Breast-conserving therapy including lumpectomy and adjuvant whole breast irradiation (WBI) has become the standard therapy for early-stage breast cancer (EBC). Without WBI, the recurrence rate is significantly increased. However, when selecting patients at a low a priori risk of local recurrence only a small breast-cancer-specific mortality benefit, but no overall survival improvement, was detected for WBI. As most recurrences occur close to the lumpectomy cavity, accelerated partial breast irradiation (APBI) delivered exclusively to a limited volume of tissue around the initial lumpectomy site, has gained increased attention and is now discussed as an alternative to WBI for selected EBC patients. Summary Numerous techniques for APBI (interstitial brachytherapy, external beam-based APBI, intraoperative radiotherapy, MR-guided radiotherapy) allow treatment delivery in a shorter period of time, and radiation oncologists expect to further reduce side effects by using these new techniques, with improvements in cosmetics and quality of life. In this review, we aim to describe the existing evidence for the feasibility and effectiveness of different APBI techniques used in modern radiotherapy. Key Messages APBI has provided outcomes similar to WBI combined with potentially reduced toxicity. While appropriate patient selection persists to be crucial for acceptable recurrence rates, the precise definition of patients suitable for APBI remains a matter of discussion. As long-term data are often still lacking, special attention should be paid to late side effects and long-term outcomes. Decision-making on appropriate treatment techniques should take into account not only local control rates, but also the impact on the patient's quality of life.
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Affiliation(s)
- Tobias Forster
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany.,National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | | | - Jürgen Debus
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany.,National Center for Tumor Diseases (NCT), Heidelberg, Germany.,Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany.,Heidelberg Ion-Beam Therapy Center (HIT), Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,German Cancer Consortium (DKTK), partner site Heidelberg, Heidelberg, Germany
| | - Juliane Hörner-Rieber
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany.,National Center for Tumor Diseases (NCT), Heidelberg, Germany.,Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany
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18
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Brachytherapy in Breast Cancer. Pract Radiat Oncol 2020. [DOI: 10.1007/978-981-15-0073-2_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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19
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Maranzano E, Arcidiacono F, Italiani M, Anselmo P, Casale M, Terenzi S, Di Marzo A, Fabiani S, Draghini L, Trippa F. Accelerated partial-breast irradiation with high-dose-rate brachytherapy: Mature results of a Phase II trial. Brachytherapy 2019; 18:627-634. [PMID: 31285131 DOI: 10.1016/j.brachy.2019.06.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 05/31/2019] [Accepted: 06/04/2019] [Indexed: 11/29/2022]
Abstract
PURPOSE The purpose of this study was to report mature clinical and cosmetic results of accelerated partial-breast irradiation with interstitial multicatheter high-dose-rate brachytherapy (HDR-BRT) in patients with early breast cancer. METHODS AND MATERIALS 133 patients were recruited in a Phase II trial of exclusive HDR-BRT. Inclusion criteria were age ≥40 years, PS 0-2, unifocal invasive ductal cancer, intraductal cancer component <25%, negative axillary nodes, and tumor size ≤2.5 cm. Treatment schedule was 4 Gy twice a day up to a total dose of 32 Gy in eight fractions. RESULTS Median age was 67 years (range, 42-85). There were 7 (5%) pT1a, 48 (36%) pT1b, 72 (54%) pT1c, and 6 (5%) pT2. Estrogen and progesterone receptors were positive in 119 (89%) and 93 (70%) patients, respectively. The median followup was 110 months (range, 12-163). After HDR-BRT, there were 3 (2%) in-field breast recurrences and 1 (1%) out-field breast recurrence. 5 (4%) patients developed contralateral breast cancer, another one (1%) isolated regional relapse in axillary node and 3 (2%) distant progression of disease. 19 (14%) patients reported a second primary cancer. 5-, 10-, and 13-year overall survival and cancer-specific survival were 95% and 100%, 84.5% and 100%, and 81.4% and 100%, respectively. Cosmetic outcome was excellent in 80% of cases. Late toxicity was significantly related to the skin administered doses (≤55% vs. > 55% of the prescribed dose, p < 0.05). CONCLUSIONS Accelerated partial-breast irradiation delivered with HDR-BRT in selected patients with breast cancer was associated to high local control and survival with excellent cosmetic outcomes overall when skin dose was ≤55%.
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Affiliation(s)
| | | | - Marco Italiani
- Radiotherapy Oncology Centre, "S. Maria" Hospital, Terni, Italy
| | - Paola Anselmo
- Radiotherapy Oncology Centre, "S. Maria" Hospital, Terni, Italy
| | | | - Sara Terenzi
- Radiotherapy Oncology Centre, "S. Maria" Hospital, Terni, Italy
| | | | | | - Lorena Draghini
- Radiotherapy Oncology Centre, "S. Maria" Hospital, Terni, Italy
| | - Fabio Trippa
- Radiotherapy Oncology Centre, "S. Maria" Hospital, Terni, Italy
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Morigi C. Highlights of the 16th St Gallen International Breast Cancer Conference, Vienna, Austria, 20-23 March 2019: personalised treatments for patients with early breast cancer. Ecancermedicalscience 2019; 13:924. [PMID: 31281421 PMCID: PMC6546258 DOI: 10.3332/ecancer.2019.924] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2019] [Indexed: 12/15/2022] Open
Abstract
The 16th St Gallen International Breast Cancer Conference took place in Vienna for the third time, from 20–23 March 2019. More than 3000 people from all over the world were invited to take part in this important bi-annual critical review of the ‘state of the art’ in the primary care of breast cancer (BC), independent of political and industrial pressure, with the aim to integrate the most recent research data and most important developments in BC therapies since St Gallen International Breast Cancer Conference 2017, with the ultimate goal of drawing up a consensus for the current optimal treatment and prevention of BC. This year, the St Gallen Breast Cancer Award was won by Monica Morrow (Memorial Sloan Kettering Cancer Center, USA) for her extraordinary contribution in research and practise development in the treatment of BC. She opened the session with the lecture ‘Will surgery be a part of BC treatment in the future?’ Improved systemic therapy has decreased BC mortality and increased pathologic complete response (pCR) rates after neoadjuvant chemotherapy (NACT). Improved imaging and increased screening uptake have led to detect smaller cancers. These factors have highlighted two possible scenarios to omit surgery: for patients with small low-grade ductal carcinoma in situ (DCIS) and for those who have received NACT and had a clinical and radiological complete response. However, considering that 7%–20% of `low-risk’ DCIS patients have co-existing invasive cancer at diagnosis, that surgery has become progressively less morbid and less toxic than some systemic therapies with a lower cost-effectiveness ratio, and that identification of pathologic complete response (pCR) without surgery requires more intensive imaging follow-up (more biopsies, higher cost and more anxiety for the patient), surgery still appears to be an essential treatment for BC. The Umberto Veronesi Memorial Award went to Lesley Fallowfield (Brighton and Sussex Medical School, UK) for her important research and activity in the field of the development of patient outcome, of better communication skills and quality of life for women. In her lecture, she remarked on the importance of improving BC personalised treatments, especially through co-operation between scientists, always considering the whole woman and not just her breast disease. This award was given by Paolo Veronesi, after a moving introduction which culminated with the following words of Professor Umberto Veronesi: ‘It is not possible to take care of the people’s bodies without taking care of their mind. My duty, the duty of all doctors, is to listen and be part of the emotions of those we treat every day’.
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Affiliation(s)
- Consuelo Morigi
- Division of Senology, IRCCS European Institute of Oncology, 20141 Milan, Italy
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Bathily T, Borget I, Rivin Del Campo E, Rivera S, Bourgier C. Partial versus whole breast irradiation: Side effects, patient satisfaction and costs. Cancer Radiother 2019; 23:83-91. [PMID: 30929861 DOI: 10.1016/j.canrad.2018.06.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Revised: 02/16/2018] [Accepted: 06/08/2018] [Indexed: 12/15/2022]
Abstract
PURPOSE Since accelerated partial breast irradiation has demonstrated non-inferiority to whole breast irradiation regarding recurrence rate in patients with early stage breast cancer, our objective was to compare its impact on short-term adverse events, patient satisfaction and costs. MATERIALS AND METHODS Patients with early stage breast cancer treated by breast-conserving surgery between 2007 and 2012 were included: 48 women who received three-dimensional conformal accelerated partial breast irradiation in a multicentre phase-II trial were paired with 48 patients prospectively treated with whole breast irradiation. Adverse events, and patients' opinions concerning cosmesis, satisfaction and pain, were gathered 1 month after treatment. Direct and indirect costs were collected from the French National Health Insurance System perspective until the end of radiotherapy. RESULTS When comparing its impact, skin reactions occurred in 37% of patients receiving three-dimensional conformal accelerated partial breast radiotherapy and 60% of patients receiving whole breast irradiation (P=0.07); 98% were very satisfied in the group three-dimensional conformal accelerated partial breast radiotherapy versus 46% in the group treated with whole breast irradiation (P<0.001); direct costs were significantly lower in the group treated with partial breast irradiation (mean cost: 2510€ versus 5479€/patient), due to less radiation sessions. CONCLUSION In patients with early-stage breast cancer, partial irradiation offered a good alternative to whole breast irradiation, as it was less expensive and satisfactory. These, and the clinical safety and tolerance results, need to be confirmed by long-term accelerated partial breast irradiation results in on-going phase III trials.
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Affiliation(s)
- T Bathily
- Department of Radiation Oncology, Gustave-Roussy Cancer Campus, 114, rue Édouard-Vaillant, 94805 Villejuif, France
| | - I Borget
- Service de biostatistique et d'épidémiologie, Gustave-Roussy, 114, rue Édouard-Vaillant, 94805 Villejuif, France; Inserm U1018, CESP, 114, rue Édouard-Vaillant, 94805 Villejuif, France; Université Paris-Sud, université Paris-Saclay, 114, rue Édouard-Vaillant, 94805 Villejuif, France
| | - E Rivin Del Campo
- Department of Radiation Oncology, Gustave-Roussy Cancer Campus, 114, rue Édouard-Vaillant, 94805 Villejuif, France.
| | - S Rivera
- Department of Radiation Oncology, Gustave-Roussy Cancer Campus, 114, rue Édouard-Vaillant, 94805 Villejuif, France
| | - C Bourgier
- Department of Radiation Oncology, Institut du cancer de Montpellier, 208, avenue des Apothicaires, 34298 Montpellier, France
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Marta GN, Barrett J, Porfirio GJM, Martimbianco ALC, Bevilacqua JLB, Poortmans P, Riera R. Effectiveness of different accelerated partial breast irradiation techniques for the treatment of breast cancer patients: Systematic review using indirect comparisons of randomized clinical trials. Rep Pract Oncol Radiother 2019; 24:165-174. [PMID: 30814916 PMCID: PMC6378667 DOI: 10.1016/j.rpor.2019.01.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Revised: 11/06/2018] [Accepted: 01/27/2019] [Indexed: 01/27/2023] Open
Abstract
AIM This systematic review was conducted to compare the effectiveness of different accelerated partial breast irradiation (APBI) techniques for the treatment of breast cancer patients. BACKGROUND Numerous (APBI) techniques are available for clinical practice. METHODS AND MATERIALS Systematic review of randomized controlled trials of APBI versus whole breast irradiation (WBI). The data from APBI studies were extracted for the analyses. Indirect comparisons were used to compare different APBI techniques. RESULTS Ten studies fulfilled the inclusion criteria. A total of 4343 patients were included, most of them with tumor stage T1-T2 and N0. Regarding APBI techniques, six trials used external beam radiation therapy; one intraoperative electrons; one intraoperative low-energy photons; one brachytherapy; and one external beam radiation therapy or brachytherapy. The indirect comparisons related to 5-years local control and 5-years overall survival were not significantly different between APBI techniques. CONCLUSIONS Based on indirect comparisons, no differences in clinical outcomes were observed among diverse APBI techniques in published clinical trials that formally compared WBI to APBI. However wide confidence intervals and high risk of inconsistency precluded a sound conclusion. Further head-to-head clinical trials comparing different APBI techniques are required to confirm our findings. Studies comparing different techniques using individual participant data and/or real-life data from population-based studies/registries could also provide more robust results.
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Affiliation(s)
- Gustavo Nader Marta
- Department of Radiation Oncology – Hospital Sírio-Libanês, Rua Dona Adma Jafet, 91, Sao Paulo, SP 01308-050, Brazil
- Department of Radiology and Oncology – Radiation Oncology Unit. of University of São Paulo, Instituto do Câncer do Estado de São Paulo (ICESP), Faculdade de Medicina da Universidade de São Paulo, Rua Dona Adma Jafet, 91, Sao Paulo, 01308-050 SP, Brazil
| | - Jessica Barrett
- MRC Biostatistics Unit, University of Cambridge, Cambridge Biomedical Campus, Cambridge CB2 0SR, United Kingdom
| | | | | | | | - Philip Poortmans
- Department of Radiation Oncology – Institut Curie, 6 rue d’Ulm, 75248 Paris cedex 05, France
| | - Rachel Riera
- Cochrane Brazil, Rua Borges Lagoa, 564 – Cj 63, Edifício São Paulo, Vila Clementino, São Paulo, SP 04038-000, Brazil
- Discipline of Emergency Medicine and Evidence-Based Medicine, Universidade Federal de São Paulo – Escola Paulista de Medicina (UNIFESP-EPM), Rua Borges Lagoa, 564 – Cj 63, Edifício São Paulo, Vila Clementino, São Paulo, 04038-000 SP, Brazil
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Calin A, Martin M, Lopez-Tarruella S. Simulation modeling approaches to answer clinically relevant questions in breast cancer low-risk populations. ANNALS OF TRANSLATIONAL MEDICINE 2019; 6:S80. [PMID: 30613655 DOI: 10.21037/atm.2018.10.68] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Ana Calin
- Radiation Oncology Service, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Miguel Martin
- Medical Oncology Service, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Universidad Complutense, CiberOnc, GEICAM, Madrid, Spain
| | - Sara Lopez-Tarruella
- Medical Oncology Service, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Universidad Complutense, CiberOnc, GEICAM, Madrid, Spain
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Miranda FA, Teixeira LAB, Heinzen RN, de Andrade FEM, Hijal T, Buchholz TA, Moraes FY, Poortmans P, Marta GN. Accelerated partial breast irradiation: Current status with a focus on clinical practice. Breast J 2019; 25:124-128. [DOI: 10.1111/tbj.13164] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2017] [Revised: 12/28/2017] [Accepted: 01/03/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Fabiana A. Miranda
- Department of Radiation Oncology Hospital Sírio‐Libanês São Paulo Brazil
| | - Lorine A. B. Teixeira
- Department of Radiation Oncology Hospital Sírio‐Libanês São Paulo Brazil
- Department of Radiology and Oncology of University of São Paulo, Division of Radiation Oncology Instituto do Câncer do Estado de São Paulo (ICESP/FMUSP) São Paulo Brazil
| | - Rebeca N. Heinzen
- Department of Breast Surgery Hospital Sírio‐Libanês São Paulo Brazil
| | | | - Tarek Hijal
- Division of Radiation Oncology McGill University Health Centre Montréal Quebec Canada
| | - Thomas A. Buchholz
- Department of Radiation Oncology University of Texas MD Anderson Cancer Center Houston Texas
| | - Fabio Y. Moraes
- Department of Radiation Oncology Hospital Sírio‐Libanês São Paulo Brazil
- Radiation Medicine Program, Princess Margaret Cancer Centre University Health Network Toronto Ontario Canada
| | | | - Gustavo N. Marta
- Department of Radiation Oncology Hospital Sírio‐Libanês São Paulo Brazil
- Department of Radiology and Oncology of University of São Paulo, Division of Radiation Oncology Instituto do Câncer do Estado de São Paulo (ICESP/FMUSP) São Paulo Brazil
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Aydiner A, Igci A, Cabioglu N, Ozer L, Sen F, Keskin S, Muslumanoglu M, Karanlik H, Arslan Ibis K, Kucucuk S, Dincer M, Yavuz E, Tuzlali S, Soran A. Decision Pathways in Breast Cancer Management. Breast Cancer 2019. [DOI: 10.1007/978-3-319-96947-3_1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Jethwa KR, Park SS, Gonuguntla K, Wick SM, Vallow LA, Deufel CL, Whitaker TJ, Furutani KM, Ruddy KJ, Corbin KS, Hieken TJ, Mutter RW. Three-Fraction Intracavitary Accelerated Partial Breast Brachytherapy: Early Provider and Patient-Reported Outcomes of a Novel Regimen. Int J Radiat Oncol Biol Phys 2018; 104:75-82. [PMID: 30583041 DOI: 10.1016/j.ijrobp.2018.12.025] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Revised: 12/10/2018] [Accepted: 12/13/2018] [Indexed: 01/26/2023]
Abstract
PURPOSE To report early adverse events and patient-reported outcomes (PROs) of 3-fraction intracavitary catheter-based partial breast brachytherapy (ICBB). MATERIALS AND METHODS Eligible women ≥50 years of age with ≤2.5-cm, lymph node-negative invasive or in situ breast cancer underwent breast-conserving surgery and placement of a brachytherapy applicator. ICBB was initiated on the second weekday after surgery and prescribed to 21 Gy in 3 once-daily fractions. Common Terminology Criteria for Adverse Events, version 4.0; 10-point linear analog scale assessment; the PRO version of the Common Terminology Criteria for Adverse Events; and the Harvard Breast Cosmesis Scale were used for provider and patient-reported assessments. RESULTS Seventy-three women were treated for invasive (79%) or in situ (21%) breast cancer. The median time to completion of surgery and radiation therapy was 6 days. After 14-months median follow-up, 2 patients (3%) had developed breast infections that resolved with oral antibiotics. There was no other treatment-associated adverse event grade ≥2. The grade 1 seroma rate at 3 months was 20%, which dropped to 8% at 12 months; no events required intervention. At 12 months, 91% of patients reported an overall quality of life score as ≥8 of 10, and patient-reported cosmesis was good or excellent in 95%. All patients are alive without relapse at the last follow-up. CONCLUSIONS Three-fraction ICBB is associated with low rates of early provider and patient- reported adverse events and compares favorably with early outcomes of more protracted ICBB regimens, including twice-daily (3.4 Gy × 10) fractionation studied in the National Surgical Adjuvant Breast and Bowel Project (NSABP) B-39. Further investigation is warranted.
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Affiliation(s)
- Krishan R Jethwa
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Sean S Park
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | | | - Stephanie M Wick
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Laura A Vallow
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota; Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida
| | | | | | - Keith M Furutani
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Kathryn J Ruddy
- Division of Medical Oncology, Mayo Clinic, Rochester, Minnesota
| | | | - Tina J Hieken
- Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | - Robert W Mutter
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota.
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Pohanková D, Sirák I, Jandík P, Kašaova L, Grepl J, Motyčka P, Asqar A, Paluska P, Ninger V, Bydžovská I, Kopecky V, Petera J. Accelerated partial breast irradiation with perioperative multicatheter interstitial brachytherapy-A feasibility study. Brachytherapy 2018; 17:949-955. [PMID: 30227977 DOI: 10.1016/j.brachy.2018.08.012] [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: 07/25/2018] [Revised: 08/14/2018] [Accepted: 08/15/2018] [Indexed: 11/26/2022]
Abstract
PURPOSE To assess the feasibility of high-dose-rate perioperative multicatheter interstitial brachytherapy to deliver accelerated partial breast irradiation (APBI) in selected patients with early breast cancer. METHODS AND MATERIALS Perioperative multicatheter interstitial brachytherapy for APBI has been used at our department since 2012 for patients with low-risk breast cancer. Interstitial catheters were inserted perioperatively via hollow needles immediately following tumorectomy with sentinel node biopsy. APBI started on Day 6 after surgery. The prescribed dose was 34 Gy (10 fractions of 3.4 Gy bid). Hormonal therapy was prescribed in all cases. RESULTS Between June 2012 and December 2017, 125 patients were scheduled for APBI. Of these, APBI was not performed in 12 patients (9.6%) due to adverse prognostic factors identified on the definitive biopsy. We observed wound dehiscence in 2/113 cases (1.8%), inflammatory complications requiring antibiotics in 7/113 cases (6.2%), transient Grade I radiodermatitis in 6/113 patients (4.4%), and seroma which resolved spontaneously in 3/113 patients (2.7%). With median followup of 39 months (range 3.3-75.3) no relapses were observed. No late complications in Radiation Therapy Oncology Group Grade 3 or higher were documented. Cosmetic outcome in patients with followup > 2 years was excellent or good in 92%. CONCLUSION Our preliminary results show that the perioperative multicatheter interstitial high-dose-rate brachytherapy for APBI in selected patients with early breast cancer is feasible. This treatment schedule reduces treatment duration, spares the patients of repeated anesthesia, and enables precise application of the afterloading tubes under direct visual control.
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Affiliation(s)
- Denisa Pohanková
- Department of Oncology and Radiotherapy, University Hospital and Medical Faculty, Hradec Králové, Czech Republic
| | - Igor Sirák
- Department of Oncology and Radiotherapy, University Hospital and Medical Faculty, Hradec Králové, Czech Republic.
| | - Pavel Jandík
- Department of Surgery, University Hospital, Hradec Králové, Czech Republic
| | - Linda Kašaova
- Department of Oncology and Radiotherapy, University Hospital and Medical Faculty, Hradec Králové, Czech Republic
| | - Jakub Grepl
- Department of Oncology and Radiotherapy, University Hospital and Medical Faculty, Hradec Králové, Czech Republic
| | - Petr Motyčka
- Department of Surgery, University Hospital, Hradec Králové, Czech Republic
| | - Ahmed Asqar
- Department of Surgery, University Hospital, Hradec Králové, Czech Republic
| | - Petr Paluska
- Department of Oncology and Radiotherapy, University Hospital and Medical Faculty, Hradec Králové, Czech Republic
| | - Vladimír Ninger
- Department of Surgery, Hospital Chrudim, Chrudim, Czech Republic
| | - Ivana Bydžovská
- Department of Surgery, Hospital Chrudim, Chrudim, Czech Republic
| | - Viliam Kopecky
- Department of Surgery, Hospital Chrudim, Chrudim, Czech Republic
| | - Jiří Petera
- Department of Oncology and Radiotherapy, University Hospital and Medical Faculty, Hradec Králové, Czech Republic
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Pan XB, Huang ST, Jiang YM, Ma JL, Zhu XD. Secondary malignancies after partial versus whole breast irradiation: a systematic review and meta-analysis. Oncotarget 2018; 7:71951-71959. [PMID: 27713125 PMCID: PMC5342135 DOI: 10.18632/oncotarget.12442] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Accepted: 09/26/2016] [Indexed: 12/30/2022] Open
Abstract
Secondary malignancies are a common complication for patients receiving radiotherapy. Here, we compared rates of secondary malignancies after partial breast irradiation (PBI) and whole breast irradiation (WBI). The MEDLINE, EMBASE, and the Cochrane Library databases were systematically searched to identify relevant randomized clinical trials comparing PBI with WBI in breast cancer patients treated with breast-conserving therapy. Four studies including 2,185 patients were selected. Compared to WBI, the pooled odds ratios (OR) for contralateral breast cancer were 0.86 (95% confidence interval (CI) 0.31–2.42; p = 0.78) after 5 years and 1.15 (95% CI 0.43-3.09; p = 0.78) after 10 years for PBI. The pooled ORs for secondary non-breast cancer were 0.91 (95% CI 0.49-1.67; p = 0.77) after 5 years and 1.20 (95% CI 0.39-3.66; p = 0.75) after 10 years for PBI compared to WBI. These results demonstrate that the risk of secondary malignancies is similar for PBI and WBI after breast-conserving radiotherapy.
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Affiliation(s)
- Xin-Bin Pan
- Department of Radiation Oncology, Cancer Hospital of Guangxi Medical University, Nanning, Guangxi 530021, P.R. China
| | - Shi-Ting Huang
- Department of Radiation Oncology, Cancer Hospital of Guangxi Medical University, Nanning, Guangxi 530021, P.R. China
| | - Yan-Ming Jiang
- Department of Radiation Oncology, Cancer Hospital of Guangxi Medical University, Nanning, Guangxi 530021, P.R. China
| | - Jia-Lin Ma
- Department of Radiation Oncology, Cancer Hospital of Guangxi Medical University, Nanning, Guangxi 530021, P.R. China
| | - Xiao-Dong Zhu
- Department of Radiation Oncology, Cancer Hospital of Guangxi Medical University, Nanning, Guangxi 530021, P.R. China
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Patient-reported outcomes of catheter-based accelerated partial breast brachytherapy and whole breast irradiation, a single institution experience. Breast Cancer Res Treat 2018; 169:189-196. [PMID: 29349713 DOI: 10.1007/s10549-018-4665-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Accepted: 01/09/2018] [Indexed: 01/13/2023]
Abstract
PURPOSE Accelerated partial breast irradiation (APBI) and whole breast irradiation (WBI) are treatment options for early-stage breast cancer. The purpose of this study was to compare patient-reported-outcomes (PRO) between patients receiving multi-channel intra-cavitary brachytherapy APBI or WBI. METHODS Between 2012 and 2015, 131 patients with ductal carcinoma in situ (DCIS) or early stage invasive breast cancer were treated with adjuvant APBI (64) or WBI (67) and participated in a PRO questionnaire. The linear analog scale assessment (LASA), harvard breast cosmesis scale (HBCS), PRO-common terminology criteria for adverse events- PRO (PRO-CTCAE), and breast cancer treatment outcome scale (BCTOS) were used to assess quality of life (QoL), pain, fatigue, aesthetic and functional status, and breast cosmesis. Comparisons of PROs were performed using t-tests, Wilcoxon rank-sum, Chi square, Fisher exact test, and regression methods. RESULTS Median follow-up from completion of radiotherapy and questionnaire completion was 13.3 months. There was no significant difference in QoL, pain, or fatigue severity, as assessed by the LASA, between treatment groups (p > 0.05). No factors were found to be predictive of overall QoL on regression analysis. BCTOS health-related QoL scores were similar between treatment groups (p = 0.52).The majority of APBI and WBI patients reported excellent/good breast cosmesis, 88.5% versus 93.7% (p = 0.37). Skin color change (p = 0.011) and breast elevation (p = 0.01) relative to baseline were more common in the group receiving WBI. CONCLUSIONS APBI and WBI were both associated with favorable patient-reported outcomes in early follow-up. APBI resulted in a lesser degree of patient-reported skin color change and breast elevation relative to baseline.
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Jacobson GM, Siochi RA. Low-Energy Intraoperative Radiation Therapy and Competing Risks of Local Control and Normal Tissue Toxicity. Front Oncol 2017; 7:212. [PMID: 28983466 PMCID: PMC5613079 DOI: 10.3389/fonc.2017.00212] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Accepted: 08/28/2017] [Indexed: 11/17/2022] Open
Affiliation(s)
- Geraldine M Jacobson
- Department of Radiation Oncology, WVU Cancer Institute, West Virginia University, Morgantown, WV, United States
| | - Ramon Alfredo Siochi
- Department of Radiation Oncology, WVU Cancer Institute, West Virginia University, Morgantown, WV, United States
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Zhen X, Zhao B, Wang Z, Timmerman R, Spangler A, Kim N, Rahimi A, Gu X. Comprehensive target geometric errors and margin assessment in stereotactic partial breast irradiation. Radiat Oncol 2017; 12:151. [PMID: 28893302 PMCID: PMC5594509 DOI: 10.1186/s13014-017-0889-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Accepted: 09/06/2017] [Indexed: 11/09/2022] Open
Abstract
Background Recently developed stereotactic partial breast irradiation (S-PBI) allows delivery of a high biologically potent dose to the target while sparing adjacent critical organs and normal tissue. With S-PBI tumoricidal doses, accurate and precise dose delivery is critical to achieve high treatment quality. This study is to investigate both rigid and non-rigid components of target geometric error and their corresponding margins in S-PBI and identify correlated clinical factors. Methods Forty-three early-stage breast cancer patients with implanted gold fiducial markers were enrolled in the study. Fiducial positions recorded on the orthogonal kV images on a Cyberknife system during treatment were used to estimate intra-fraction errors and composite errors (including intra-fraction errors and residual errors after patient setup). Both rigid and non-rigid components of intra-fraction and composite errors were analyzed and used to estimate rigid and non-rigid margins, respectively. Univariate and multivariate linear regressions were conducted to evaluate correlations between clinical factors and errors. Results For the study group, the intra-fraction rigid and non-rigid errors are 2.0 ± 0.6 mm and 0.3 ± 0.2 mm, respectively. The composite rigid and non-rigid errors are 2.3 ± 0.5 mm and 1.3 ± 0.8 mm, respectively. The rigid margins in the left-right, anterior-posterior, and superior-inferior directions are estimated as 2.1, 2.4, and 2.3 mm, respectively. The estimated non-rigid margin, assumed to be isotropic, is 1.7 mm. The outer breast quadrants are more susceptible to composite errors occurrence than the inner breast quadrants. The target to chest wall distance is the clinical factor correlated with target geometric errors. Conclusions This is the first comprehensive analysis of breast target geometric rigid and non-rigid errors in S-PBI. Upon the estimation, the non-rigid margin is comparable to rigid margin, and therefore should be included in planning target volume as it cannot be accounted for by the Cyberknife system. Treatment margins selection also need to consider the impact of relevant clinical factor. Electronic supplementary material The online version of this article (10.1186/s13014-017-0889-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Xin Zhen
- Department of Radiation Oncology, The University of Texas Southwestern Medical Center, Dallas, TX, 75390, USA.,Department of Biomedical Engineering, Southern Medical University, Guangzhou, Guangdong, 510515, China
| | - Bo Zhao
- Department of Radiation Oncology, The University of Texas Southwestern Medical Center, Dallas, TX, 75390, USA
| | - Zhuoyu Wang
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, 805 Sherbrooke Street West, Montreal, Quebec, H3A 0G4, Canada
| | - Robert Timmerman
- Department of Radiation Oncology, The University of Texas Southwestern Medical Center, Dallas, TX, 75390, USA
| | - Ann Spangler
- Department of Radiation Oncology, The University of Texas Southwestern Medical Center, Dallas, TX, 75390, USA
| | - Nathan Kim
- Department of Radiation Oncology, The University of Texas Southwestern Medical Center, Dallas, TX, 75390, USA
| | - Asal Rahimi
- Department of Radiation Oncology, The University of Texas Southwestern Medical Center, Dallas, TX, 75390, USA
| | - Xuejun Gu
- Department of Radiation Oncology, The University of Texas Southwestern Medical Center, Dallas, TX, 75390, USA.
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Coles CE, Griffin CL, Kirby AM, Titley J, Agrawal RK, Alhasso A, Bhattacharya IS, Brunt AM, Ciurlionis L, Chan C, Donovan EM, Emson MA, Harnett AN, Haviland JS, Hopwood P, Jefford ML, Kaggwa R, Sawyer EJ, Syndikus I, Tsang YM, Wheatley DA, Wilcox M, Yarnold JR, Bliss JM. Partial-breast radiotherapy after breast conservation surgery for patients with early breast cancer (UK IMPORT LOW trial): 5-year results from a multicentre, randomised, controlled, phase 3, non-inferiority trial. Lancet 2017; 390:1048-1060. [PMID: 28779963 PMCID: PMC5594247 DOI: 10.1016/s0140-6736(17)31145-5] [Citation(s) in RCA: 386] [Impact Index Per Article: 55.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Revised: 03/08/2017] [Accepted: 04/13/2017] [Indexed: 12/16/2022]
Abstract
BACKGROUND Local cancer relapse risk after breast conservation surgery followed by radiotherapy has fallen sharply in many countries, and is influenced by patient age and clinicopathological factors. We hypothesise that partial-breast radiotherapy restricted to the vicinity of the original tumour in women at lower than average risk of local relapse will improve the balance of beneficial versus adverse effects compared with whole-breast radiotherapy. METHODS IMPORT LOW is a multicentre, randomised, controlled, phase 3, non-inferiority trial done in 30 radiotherapy centres in the UK. Women aged 50 years or older who had undergone breast-conserving surgery for unifocal invasive ductal adenocarcinoma of grade 1-3, with a tumour size of 3 cm or less (pT1-2), none to three positive axillary nodes (pN0-1), and minimum microscopic margins of non-cancerous tissue of 2 mm or more, were recruited. Patients were randomly assigned (1:1:1) to receive 40 Gy whole-breast radiotherapy (control), 36 Gy whole-breast radiotherapy and 40 Gy to the partial breast (reduced-dose group), or 40 Gy to the partial breast only (partial-breast group) in 15 daily treatment fractions. Computer-generated random permuted blocks (mixed sizes of six and nine) were used to assign patients to groups, stratifying patients by radiotherapy treatment centre. Patients and clinicians were not masked to treatment allocation. Field-in-field intensity-modulated radiotherapy was delivered using standard tangential beams that were simply reduced in length for the partial-breast group. The primary endpoint was ipsilateral local relapse (80% power to exclude a 2·5% increase [non-inferiority margin] at 5 years for each experimental group; non-inferiority was shown if the upper limit of the two-sided 95% CI for the local relapse hazard ratio [HR] was less than 2·03), analysed by intention to treat. Safety analyses were done in all patients for whom data was available (ie, a modified intention-to-treat population). This study is registered in the ISRCTN registry, number ISRCTN12852634. FINDINGS Between May 3, 2007, and Oct 5, 2010, 2018 women were recruited. Two women withdrew consent for use of their data in the analysis. 674 patients were analysed in the whole-breast radiotherapy (control) group, 673 in the reduced-dose group, and 669 in the partial-breast group. Median follow-up was 72·2 months (IQR 61·7-83·2), and 5-year estimates of local relapse cumulative incidence were 1·1% (95% CI 0·5-2·3) of patients in the control group, 0·2% (0·02-1·2) in the reduced-dose group, and 0·5% (0·2-1·4) in the partial-breast group. Estimated 5-year absolute differences in local relapse compared with the control group were -0·73% (-0·99 to 0·22) for the reduced-dose and -0·38% (-0·84 to 0·90) for the partial-breast groups. Non-inferiority can be claimed for both reduced-dose and partial-breast radiotherapy, and was confirmed by the test against the critical HR being more than 2·03 (p=0·003 for the reduced-dose group and p=0·016 for the partial-breast group, compared with the whole-breast radiotherapy group). Photographic, patient, and clinical assessments recorded similar adverse effects after reduced-dose or partial-breast radiotherapy, including two patient domains achieving statistically significantly lower adverse effects (change in breast appearance [p=0·007 for partial-breast] and breast harder or firmer [p=0·002 for reduced-dose and p<0·0001 for partial-breast]) compared with whole-breast radiotherapy. INTERPRETATION We showed non-inferiority of partial-breast and reduced-dose radiotherapy compared with the standard whole-breast radiotherapy in terms of local relapse in a cohort of patients with early breast cancer, and equivalent or fewer late normal-tissue adverse effects were seen. This simple radiotherapy technique is implementable in radiotherapy centres worldwide. FUNDING Cancer Research UK.
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Affiliation(s)
| | - Clare L Griffin
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, UK
| | - Anna M Kirby
- Department of Radiotherapy and Imaging, Royal Marsden NHS Foundation Trust and Institute of Cancer Research, London, UK
| | - Jenny Titley
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, UK
| | - Rajiv K Agrawal
- Department of Oncology, Shrewsbury and Telford Hospital NHS Trust, Shrewsbury, UK
| | - Abdulla Alhasso
- Department of Clinical Oncology, Beatson West of Scotland Cancer Centre, Glasgow, UK
| | | | - Adrian M Brunt
- Cancer Centre, University Hospitals of North Midlands and Keele University, Stoke-on-Trent, UK
| | - Laura Ciurlionis
- Department of Radiation Oncology, Auckland City Hospital, Auckland, New Zealand
| | - Charlie Chan
- Department of Breast Surgery, Nuffield Health Cheltenham Hospital, Cheltenham, UK
| | - Ellen M Donovan
- Department of Health and Medical Sciences, University of Surrey, Guildford, UK
| | - Marie A Emson
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, UK
| | - Adrian N Harnett
- Department of Oncology, Norfolk and Norwich University Hospital NHS Foundation Trust, Norwich, UK
| | - Joanne S Haviland
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, UK
| | - Penelope Hopwood
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, UK
| | | | - Ronald Kaggwa
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, UK
| | - Elinor J Sawyer
- Department of Research Oncology, King's College London, London, UK
| | - Isabel Syndikus
- Cancer Centre, The Clatterbridge Cancer Centre NHS Foundation Trust, Bebington, UK
| | - Yat M Tsang
- Department of Radiotherapy, Mount Vernon Cancer Centre Northwood, Northwood, UK
| | - Duncan A Wheatley
- Department of Oncology, Royal Cornwall Hospitals NHS Trust, Truro, UK
| | | | - John R Yarnold
- Department of Radiotherapy and Imaging, The Institute of Cancer Research, London, UK
| | - Judith M Bliss
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, UK
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Efficacy and safety of accelerated partial breast irradiation: a meta-analysis of published randomized studies. Oncotarget 2017; 8:59581-59591. [PMID: 28938661 PMCID: PMC5601757 DOI: 10.18632/oncotarget.19225] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Accepted: 06/29/2017] [Indexed: 01/12/2023] Open
Abstract
Background and purpose Accelerated partial breast irradiation (APBI) technology has theoretical advantages in comparison with traditional adjuvant radiation therapy (whole-breast irradiation; WBI) after breast-conserving surgery. However, published randomized controlled trials have shown inconsistent outcomes. Therefore, a comprehensive assessment of the effectiveness and safety of APBI technology is needed. Results A total of 7 studies of 7452 patients were included in this analysis. All 7 studies reported local recurrence as an outcome. Meta-analysis of 5 trials that included 6486 patients showed significantly different 5-year local recurrence rates for APBI and WBI groups (hazard ratio = 4.54, 95% confidence interval: 1.78–11.61, p = 0.002). Further analysis showed that this difference may be related to the choice of treatment methods. Benefit was conferred to the APBI group for the outcome of non-breast cancer deaths. There was no significant difference between the two groups in terms of nodal recurrence, systemic recurrence, overall survival, or mortality rates. Toxicity side effects and cosmetic effects were similar in both groups, but intraoperative radiotherapy seemed to have a greater acute response. Material and methods Searches for relevant randomized controlled trials of APBI versus WBI were performed using the following sources: PubMed, EMBASE, Cochrane Library, Web of Science. Two independent observers evaluated the identified studies. The meta-analysis was conducted using RevMan 5.2 software. Conclusions Although the analysis showed that patients receiving APBI had a higher local recurrence rate, subgroup analyses suggested that this might be related to treatment options. Patients who receive accurate radiotherapy may have greater benefits. APBI is a promising treatment technology and more phase III clinical trials are expected based on new treatments.
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Breast cancer electron intraoperative radiotherapy: assessment of preoperative selection factors from a retrospective analysis of 758 patients and review of literature. Breast Cancer Res Treat 2017; 165:261-271. [DOI: 10.1007/s10549-017-4321-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Accepted: 05/29/2017] [Indexed: 11/25/2022]
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Trial sponsorship and self-reported conflicts of interest in breast cancer radiation therapy: An analysis of prospective clinical trials. Breast 2017; 33:29-33. [DOI: 10.1016/j.breast.2017.02.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Revised: 02/01/2017] [Accepted: 02/26/2017] [Indexed: 11/23/2022] Open
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Meattini I, Saieva C, Miccinesi G, Desideri I, Francolini G, Scotti V, Marrazzo L, Pallotta S, Meacci F, Muntoni C, Bendinelli B, Sanchez LJ, Bernini M, Orzalesi L, Nori J, Bianchi S, Livi L. Accelerated partial breast irradiation using intensity modulated radiotherapy versus whole breast irradiation: Health-related quality of life final analysis from the Florence phase 3 trial. Eur J Cancer 2017; 76:17-26. [DOI: 10.1016/j.ejca.2017.01.023] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Revised: 12/07/2016] [Accepted: 01/24/2017] [Indexed: 11/24/2022]
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High-dose-rate interstitial brachytherapy for accelerated partial breast irradiation - trial results of Azerbaijan National Center of Oncology. J Contemp Brachytherapy 2017; 9:106-111. [PMID: 28533797 PMCID: PMC5437082 DOI: 10.5114/jcb.2017.67145] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Accepted: 03/11/2017] [Indexed: 01/30/2023] Open
Abstract
Purpose To describe early results of two cohorts of patients with low and intermediate risk of early breast cancer treated with accelerated partial breast irradiation (APBI) using different schedules of multicatheter brachytherapy. Material and methods Patients with early stage breast cancer after breast conserving surgery were enrolled for a prospective analysis. The APBI, using multicatheter brachytherapy, was delivered either eight times 4 Gy in five days with a planned total dose of 32 Gy, or seven times 5 Gy in four days with a planned total dose of 35 Gy. Primary endpoints were side effects. Results Forty-eight patients were enrolled between 2012 and 2014. Patients characteristics were as follow: median age of patients was 55 years, early breast cancer was defined according GEC-ESTRO recommendations. With a median follow-up period of 37 months, no significant differences regarding late side effects and cosmesis between two cohorts of patients were documented. In total, cosmesis was excellent in 13/48 (27.1%) patients, good in 34/48 (70.8%) patients, and moderate in 1/48 patient (2.1%). Conclusions Accelerated partial breast irradiation using multicatheter brachytherapy with 32 Gy/8 fractions and 35 Gy/7 fractions for early breast cancer seems to be similar in terms of late side effects. According to our findings, APBI was also feasible for intermediate-risk of early breast cancer patients.
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Tamoxifen with radiotherapy compared with Tamoxifen alone in elderly women with early-stage breast cancer treated with breast conserving surgery: A systematic review and meta-analysis. Radiother Oncol 2017; 123:1-9. [DOI: 10.1016/j.radonc.2017.02.019] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Revised: 02/13/2017] [Accepted: 02/23/2017] [Indexed: 12/23/2022]
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Abstract
Breast cancer is one of the three most common cancers worldwide. Early breast cancer is considered potentially curable. Therapy has progressed substantially over the past years with a reduction in therapy intensity, both for locoregional and systemic therapy; avoiding overtreatment but also undertreatment has become a major focus. Therapy concepts follow a curative intent and need to be decided in a multidisciplinary setting, taking molecular subtype and locoregional tumour load into account. Primary conventional surgery is not the optimal choice for all patients any more. In triple-negative and HER2-positive early breast cancer, neoadjuvant therapy has become a commonly used option. Depending on clinical tumour subtype, therapeutic backbones include endocrine therapy, anti-HER2 targeting, and chemotherapy. In metastatic breast cancer, therapy goals are prolongation of survival and maintaining quality of life. Advances in endocrine therapies and combinations, as well as targeting of HER2, and the promise of newer targeted therapies make the prospect of long-term disease control in metastatic breast cancer an increasing reality.
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Affiliation(s)
- Nadia Harbeck
- Breast Center, Department of Gynecology and Obstetrics, Comprehensive Cancer Center of the Ludwig-Maximilians-University, Munich, Germany.
| | - Michael Gnant
- Department of Surgery and Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
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Reimer T, Stachs A, Nekljudova V, Loibl S, Hartmann S, Wolter K, Hildebrandt G, Gerber B. Restricted Axillary Staging in Clinically and Sonographically Node-Negative Early Invasive Breast Cancer (c/iT1-2) in the Context of Breast Conserving Therapy: First Results Following Commencement of the Intergroup-Sentinel-Mamma (INSEMA) Trial. Geburtshilfe Frauenheilkd 2017; 77:149-157. [PMID: 28331237 DOI: 10.1055/s-0042-122853] [Citation(s) in RCA: 88] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Axillary lymph node status remains an important prognostic factor in early breast cancer. It is regarded as an indicator for (neo)adjuvant systemic treatment and postoperative radiotherapy of the regional lymphatics. Commenced in September 2015, the INSEMA trial is investigating whether operative determination of nodal status as part of breast conserving therapy (BCT) for early stage breast cancer (c/iT1-2 c/iN0) can be avoided without reducing oncological safety. After inclusion of 1001 patients there was general acceptance of the complex study design by patients and study doctors so that recruitment for the first randomisation (axillary sentinel lymph node biopsy [SLNB]: yes or no) achieved predicted case numbers. The second randomisation however (SLNB alone versus complete axillary dissection when one or two macrometastases are present at SLNB) recruited fewer cases than expected for the following three reasons: a) the 13 % rate of one or two macrometastases after SLNB in the INSEMA trial collective was lower than expected; b) around 20 % of patients refused the second randomisation; c) there was delayed inclusion of the Austrian study centres, which only recruited for the second randomisation. Lack of knowledge of nodal status when SLNB is avoided represents a new challenge for the postoperative tumour board. In particular decisions on chemotherapy for luminal-like tumours and irradiation of the lymphatics (excluding axilla) must be guided by tumour biological parameters. The INSEMA trial does not provide answers to some important questions, e.g. it remains unclear whether patients without SLNB can be offered partial breast irradiation alone in low-risk situations and whether SLNB can also be avoided in patients with stage T1-2 tumours who have a mastectomy indication.
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Affiliation(s)
- T Reimer
- Department of Obstetrics and Gynecology, University of Rostock, Rostock, Germany
| | - A Stachs
- Department of Obstetrics and Gynecology, University of Rostock, Rostock, Germany
| | | | - S Loibl
- German Breast Group, Neu-Isenburg, Germany
| | - S Hartmann
- Department of Obstetrics and Gynecology, University of Rostock, Rostock, Germany
| | - K Wolter
- Department of Radiotherapy, University of Rostock, Rostock, Germany
| | - G Hildebrandt
- Department of Radiotherapy, University of Rostock, Rostock, Germany
| | - B Gerber
- Department of Obstetrics and Gynecology, University of Rostock, Rostock, Germany
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Charaghvandi RK, van Asselen B, Philippens MEP, Verkooijen HM, van Gils CH, van Diest PJ, Pijnappel RM, Hobbelink MGG, Witkamp AJ, van Dalen T, van der Wall E, van Heijst TC, Koelemij R, van Vulpen M, van den Bongard HJGD. Redefining radiotherapy for early-stage breast cancer with single dose ablative treatment: a study protocol. BMC Cancer 2017; 17:181. [PMID: 28274211 PMCID: PMC5343419 DOI: 10.1186/s12885-017-3144-5] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Accepted: 02/15/2017] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND A shift towards less burdening and more patient friendly treatments for breast cancer is currently ongoing. In low-risk patients with early-stage disease, accelerated partial breast irradiation (APBI) is an alternative for whole breast irradiation following breast-conserving surgery. MRI-guided single dose ablative APBI has the potential to offer a minimally burdening, non-invasive treatment that could replace current breast-conserving therapy. METHODS The ABLATIVE study is a prospective, single arm, multicenter study evaluating preoperative, single dose, ablative radiation treatment in patients with early-stage breast cancer. Patients with core biopsy proven non-lobular invasive breast cancer, (estrogen receptor positive, Her2 negative, maximum tumor size 3.0 cm on diagnostic MRI) and a negative sentinel node biopsy are eligible. Radiotherapy (RT) planning will be performed using a contrast enhanced (CE) planning CT-scan, co-registered with a CE-MRI, both in supine RT position. A total of twenty-five consecutive patients will be treated with a single ablative RT dose of 20 Gy to the tumor and 15 Gy to the tumorbed. Follow-up MRIs are scheduled within 1 week, 2, 4 and 6 months after single-dose RT. Breast-conserving surgery is scheduled at six months following RT. Primary study endpoint is pathological complete response. Secondary study endpoints are the radiological response and toxicity. Furthermore, patients will fill out questionnaires on quality of life and functional status. Cosmetic outcome will be evaluated by the treating radiation oncologist, patient and 'Breast Cancer Conservation Treatment cosmetic results' software. Recurrence and survival rates will be assessed. The patients will be followed up to 10 years after diagnosis. If patients give additional informed consent, a biopsy and a part of the irradiated specimen will be stored at the local Biobank and used for future research on radiotherapy response associated genotyping. DISCUSSION The ABLATIVE study evaluates MRI-guided single dose ablative RT in patients with early-stage breast cancer, aiming at a less burdening and non-invasive alternative for current breast-conserving treatment. TRIAL REGISTRATION ClinicalTrials.gov registration number NCT02316561 . The trial was registrated prospectively on October 10th 2014.
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Affiliation(s)
- R K Charaghvandi
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - B van Asselen
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - M E P Philippens
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - H M Verkooijen
- Imaging Division, University Medical Center Utrecht, Utrecht, The Netherlands
| | - C H van Gils
- Julius Center, University Medical Center Utrecht, Utrecht, The Netherlands
| | - P J van Diest
- Department of Pathology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - R M Pijnappel
- Imaging Division, University Medical Center Utrecht, Utrecht, The Netherlands
| | - M G G Hobbelink
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - A J Witkamp
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - T van Dalen
- Department of Surgery, Diakonessenhuis, Utrecht, The Netherlands
| | - E van der Wall
- Department of Medical Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - T C van Heijst
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - R Koelemij
- Department of Surgery, St. Antonius, Nieuwegein, The Netherlands
| | - M van Vulpen
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - H J G D van den Bongard
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
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Rakhra S, Bethke K, Strauss J, Hayes JP, Hansen N, Khan SA, Helenowski I, Donnelly ED. Risk Factors Leading to Complications in Early-Stage Breast Cancer Following Breast-Conserving Surgery and Intraoperative Radiotherapy. Ann Surg Oncol 2016; 24:1258-1261. [PMID: 27853900 DOI: 10.1245/s10434-016-5679-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2016] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate outcomes after breast-conserving surgery (BCS) and intraoperative radiotherapy (IORT), and to identify risk factors associated with complications. MATERIALS/METHODS We evaluated patients with early-stage breast cancer treated from January 1, 2011 to January 31, 2014 with BCS and IORT at a single institution. The presence of breast cancer recurrences, complications, or fat necrosis were assessed at subsequent follow-up visits using physical examination and breast imaging. RESULTS Overall, 113 patients, of whom three were undergoing bilateral treatments, were identified. The median length of time for IORT was 29 min and 36 s (range 15:50-59:00). Fifteen patients received additional external beam radiotherapy (EBRT), and the median follow-up was 40.3 months (range 1.6-58.3) for all patients. To date, one biopsy-proven ipsilateral recurrence has been noted (0.9%), for which the patient elected to undergo a mastectomy. Nine patients were found to have wound complications (7.7%) and two had fat necrosis (1.7%) on follow-up. Of all the evaluated risk factors, only applicator size (p < 0.01) had a statistically significant association with an increase in complications. CONCLUSIONS With a short follow-up, IORT appears to be a safe treatment modality for a select group of patients, leading to a reasonable increase in operating room time and complication rates following BCS. The utilization of larger applicators at the time of IORT was associated with an increase in wound complications and fat necrosis.
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Affiliation(s)
- Sunpreet Rakhra
- Department of Radiation Oncology, The Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, IL, USA
| | - Kevin Bethke
- Department of Surgery, The Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, IL, USA
| | - Jonathan Strauss
- Department of Radiation Oncology, The Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, IL, USA
| | - John P Hayes
- Department of Radiation Oncology, The Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, IL, USA
| | - Nora Hansen
- Department of Surgery, The Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, IL, USA
| | - Seema A Khan
- Department of Surgery, The Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, IL, USA
| | - Irene Helenowski
- Northwestern University Cancer Biostatistics Core, Chicago, IL, USA
| | - Eric D Donnelly
- Department of Radiation Oncology, The Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, IL, USA.
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De Rose F, Fogliata A, Franceschini D, Navarria P, Villa E, Iftode C, D'Agostino G, Cozzi L, Lobefalo F, Mancosu P, Tomatis S, Scorsetti M. Phase II trial of hypofractionated VMAT-based treatment for early stage breast cancer: 2-year toxicity and clinical results. Radiat Oncol 2016; 11:120. [PMID: 27639373 PMCID: PMC5027088 DOI: 10.1186/s13014-016-0701-z] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Accepted: 09/13/2016] [Indexed: 01/28/2023] Open
Abstract
Background To report toxicity and early clinical outcomes of hypofractionated simultaneous integrated boost (SIB) approach with Volumetric Modulated Arc Therapy (VMAT) as adjuvant treatment after breast-conserving surgery. Methods Patients presenting early-stage breast cancer were enrolled in a phase II trial. Eligibility criteria: age > 18 years old, invasive cancer or ductal carcinoma in situ (DCIS), Stage I-II (T < 3 cm and N ≤ 3), breast-conserving surgery without oncoplastic reconstruction. Any systemic therapy was allowed in neoadjuvant or adjuvant setting. All patients underwent VMAT-SIB technique to irradiate the whole breast and the tumor bed. Doses to whole breast and surgical bed were 40.5 Gy and 48 Gy, respectively, delivered in 15 fractions over 3 weeks. Acute and late skin toxicities were recorded. Cosmetic outcome was assessed as excellent/good or fair/poor. Results The present study focused on results of a cohort of 144 patients with a minimum follow-up of 24 months (median 37, range 24–55 months). Median age was 62 years old (range 30–88). All patients had an invasive carcinoma (no patients with DCIS were present in this subset). At one year, the highest reported skin toxicity was G1, in 14 % of the patients; this data dropped to 4 % at the last follow-up, after more than 2 years. Breast pain was recorded in 21.6 % of the patients 6 months after treatment, while it was present in 3.5 % of the patients at the last follow-up, showing a significant improvement with time. Correlation between liponecrosis and boost target volume was found not significant. Breast pain was correlated with breast volume. No pulmonary or cardiological toxicities were recorded. After an early evaluation of clinical outcomes, only one case presented disease relapse, as liver metastases. Conclusions The 3-week VMAT-SIB course as adjuvant treatment after breast-conserving surgery showed to be well tolerated and was associated with optimal local control. Long-term follow-up data are needed to assess late toxicity and clinical outcomes.
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Affiliation(s)
- Fiorenza De Rose
- Radiotherapy and Radiosurgery Department, Humanitas Research Hospital and Cancer Center, Milan-Rozzano, Italy
| | - Antonella Fogliata
- Radiotherapy and Radiosurgery Department, Humanitas Research Hospital and Cancer Center, Milan-Rozzano, Italy.
| | - Davide Franceschini
- Radiotherapy and Radiosurgery Department, Humanitas Research Hospital and Cancer Center, Milan-Rozzano, Italy
| | - Piera Navarria
- Radiotherapy and Radiosurgery Department, Humanitas Research Hospital and Cancer Center, Milan-Rozzano, Italy
| | - Elisa Villa
- Radiotherapy and Radiosurgery Department, Humanitas Research Hospital and Cancer Center, Milan-Rozzano, Italy
| | - Cristina Iftode
- Radiotherapy and Radiosurgery Department, Humanitas Research Hospital and Cancer Center, Milan-Rozzano, Italy
| | - Giuseppe D'Agostino
- Radiotherapy and Radiosurgery Department, Humanitas Research Hospital and Cancer Center, Milan-Rozzano, Italy
| | - Luca Cozzi
- Radiotherapy and Radiosurgery Department, Humanitas Research Hospital and Cancer Center, Milan-Rozzano, Italy.,Department of Biomedical Sciences, Humanitas University, Milan-Rozzano, Italy
| | - Francesca Lobefalo
- Radiotherapy and Radiosurgery Department, Humanitas Research Hospital and Cancer Center, Milan-Rozzano, Italy
| | - Pietro Mancosu
- Radiotherapy and Radiosurgery Department, Humanitas Research Hospital and Cancer Center, Milan-Rozzano, Italy
| | - Stefano Tomatis
- Radiotherapy and Radiosurgery Department, Humanitas Research Hospital and Cancer Center, Milan-Rozzano, Italy
| | - Marta Scorsetti
- Radiotherapy and Radiosurgery Department, Humanitas Research Hospital and Cancer Center, Milan-Rozzano, Italy.,Department of Biomedical Sciences, Humanitas University, Milan-Rozzano, Italy
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[Not Available]. Bull Cancer 2016; 103:S90-1. [PMID: 27494979 DOI: 10.1016/s0007-4551(16)30150-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Abstract
BACKGROUND Breast-conserving therapy for women with breast cancer consists of local excision of the tumour (achieving clear margins) followed by radiotherapy (RT). RT is given to sterilize tumour cells that may remain after surgery to decrease the risk of local tumour recurrence. Most true recurrences occur in the same quadrant as the original tumour. Whole breast radiotherapy (WBRT) may not protect against the development of a new primary cancer developing in other quadrants of the breast. In this Cochrane review, we investigated the delivery of radiation to a limited volume of the breast around the tumour bed (partial breast irradiation (PBI)) sometimes with a shortened treatment duration (accelerated partial breast irradiation (APBI)). OBJECTIVES To determine whether PBI/APBI is equivalent to or better than conventional or hypo-fractionated WBRT after breast-conserving therapy for early-stage breast cancer. SEARCH METHODS We searched the Cochrane Breast Cancer Group Specialized Register (4 May 2015), the Cochrane Central Register of Controlled Trials (CENTRAL) (2015, Issue 5), MEDLINE (January 1966 to 4 May 2015), EMBASE (1980 to 4 May 2015), CINAHL (4 May 2015) and Current Contents (4 May 2015). We searched the International Standard Randomised Controlled Trial Number Register (5 May 2015), the World Health Organization's International Clinical Trials Registry Platform (4 May 2015) and ClinicalTrials.gov (17 June 2015). We searched for grey literature: OpenGrey (17 June 2015), reference lists of articles, several conference proceedings and published abstracts, and applied no language restrictions. SELECTION CRITERIA Randomized controlled trials (RCTs) without confounding, that evaluated conservative surgery plus PBI/APBI versus conservative surgery plus WBRT. Published and unpublished trials were eligible. DATA COLLECTION AND ANALYSIS Two review authors (BH and ML) performed data extraction and used Cochrane's 'Risk of bias' tool, and resolved any disagreements through discussion. We entered data into Review Manager 5 for analysis. MAIN RESULTS We included seven RCTs and studied 7586 women of the 8955 enrolled.Local recurrence-free survival appeared worse for women receiving PBI/APBI compared to WBRT (hazard ratio (HR) 1.62, 95% confidence interval (CI) 1.11 to 2.35; six studies, 6820 participants, low-quality evidence). Cosmesis (physician-reported) appeared worse with PBI/APBI (odds ratio (OR) 1.51, 95% CI 1.17 to 1.95, five studies, 1720 participants, low-quality evidence). Overall survival did not differ with PBI/APBI (HR 0.90, 95% CI 0.74 to 1.09, five studies, 6718 participants, high-quality evidence).Late radiation toxicity (subcutaneous fibrosis) appeared worse with PBI/APBI (OR 6.58, 95% CI 3.08 to 14.06, one study, 766 participants, moderate-quality evidence). Acute skin toxicity appeared reduced with PBI/APBI (OR 0.04, 95% CI 0.02 to 0.09, two studies, 608 participants). Telangiectasia (OR 26.56, 95% CI 3.59 to 196.51, 1 study, 766 participants) and radiological fat necrosis (OR 1.58, 95% CI 1.02 to 2.43, three studies, 1319 participants) appeared worse with PBI/APBI. Late skin toxicity (OR 0.21, 95% CI 0.01 to 4.39, two studies, 608 participants) and breast pain (OR 2.17, 95% CI 0.56 to 8.44, one study, 766 participants) appeared not to differ with PBI/APBI.'Elsewhere primaries' (new primaries in the ipsilateral breast) appeared more frequent with PBI/APBI (OR 3.97, 95% CI 1.51 to 10.41, three studies, 3009 participants).We found no clear evidence of a difference for the comparison of PBI/APBI with WBRT for the outcomes of: cause-specific survival (HR 1.08, 95% CI 0.73 to 1.58, five studies, 6718 participants, moderate-quality evidence), distant metastasis-free survival (HR 0.94, 95% CI 0.65 to 1.37, four studies, 3267 participants, moderate-quality evidence), relapse-free survival (HR 1.36, 95% CI 0.88 to 2.09, three studies, 3811 participants), loco-regional recurrence-free survival (HR 1.80, 95% CI 1.00 to 3.25, two studies, 3553 participants) or mastectomy rates (OR 1.20, 95% CI 0.77 to 1.87, three studies, 4817 participants, low-quality evidence). Compliance was met: more than 90% of the women in all studies received the RT they were assigned to receive. We found no data for the outcomes of costs, quality of life or consumer preference. AUTHORS' CONCLUSIONS It appeared that local recurrence and 'elsewhere primaries' (new primaries in the ipsilateral breast) are increased with PBI/APBI (the difference was small), but we found no evidence of detriment to other oncological outcomes. It appeared that cosmetic outcomes and some late effects were worse with PBI/APBI but its use was associated with less acute skin toxicity. The limitations of the data currently available mean that we cannot make definitive conclusions about the efficacy and safety or ways to deliver of PBI/APBI. We await completion of ongoing trials.
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Affiliation(s)
- Brigid E Hickey
- Princess Alexandra HospitalRadiation Oncology Mater Service31 Raymond TerraceBrisbaneQueenslandAustralia4101
- The University of QueenslandSchool of MedicineBrisbaneAustralia
| | - Margot Lehman
- The University of QueenslandSchool of MedicineBrisbaneAustralia
- Princess Alexandra HospitalRadiation Oncology UnitGround Floor, Outpatients FIpswich Road, WoollangabbaBrisbaneQueenslandAustralia4102
| | - Daniel P Francis
- Queensland University of TechnologySchool of Public Health and Social WorkVictoria Park RoadBrisbaneQueenslandAustralia4059
| | - Adrienne M See
- Princess Alexandra HospitalRadiation Oncology Mater Service31 Raymond TerraceBrisbaneQueenslandAustralia4101
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Vaidya JS, Bulsara M, Wenz F, Coombs N, Singer J, Ebbs S, Massarut S, Saunders C, Douek M, Williams NR, Joseph D, Tobias JS, Baum M. Reduced Mortality With Partial-Breast Irradiation for Early Breast Cancer: A Meta-Analysis of Randomized Trials. Int J Radiat Oncol Biol Phys 2016; 96:259-265. [PMID: 27478165 DOI: 10.1016/j.ijrobp.2016.05.008] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Revised: 03/18/2016] [Accepted: 05/05/2016] [Indexed: 11/28/2022]
Abstract
PURPOSE With earlier detection and more effective treatment, mortality from breast cancer continues to fall and it has become increasingly important to reduce the toxicity of treatments. Partial-breast radiation therapy, which focuses radiation to the tumor bed, may achieve this aim. We analyzed mortality differences in randomized trials of partial-breast irradiation (PBI). METHODS AND MATERIALS We included data from published randomized trials of PBI (alone or as part of a risk-adapted approach) versus whole-breast irradiation (WBI) for invasive breast cancer suitable for breast-conserving therapy. We identified trials using PubMed and Google searches with the terms "partial breast irradiation" OR "intraoperative radiotherapy" OR "IMRT" OR ("accelerated" AND "radiation") AND "randomised/randomized," as well as through discussion with colleagues in the field. We calculated the proportion of patients who had events in each randomized arm at 5 years' follow-up and created a forest plot using Stata, version 14.1. RESULTS We identified 9 randomized trials of PBI versus WBI in invasive breast cancer; 5-year outcomes were available for non-breast cancer mortality in 5 trials (n=4489) and for breast cancer mortality in 4 trials (n=4231). The overall mortality was 4.9%. There was no detectable heterogeneity between the trials for any of the outcomes. There was no difference in the proportion of patients dying of breast cancer (difference, 0.000% [95% confidence interval (CI), -0.7 to +0.7]; P=.999). Non-breast cancer mortality with PBI was lower than with WBI (difference, 1.1% [95% CI, -2.1% to -0.2%]; P=.023). Total mortality with PBI was also lower than with WBI (difference, 1.3% [95% CI, -2.5% to 0.0%]; P=.05). CONCLUSIONS Use of PBI instead of WBI in selected patients results in a lower 5-year non-breast cancer and overall mortality, amounting to a 25% reduction in relative terms. This information should be included when breast-conserving therapy is proposed to a patient.
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Affiliation(s)
- Jayant S Vaidya
- Division of Surgery and Interventional Science, University College London, London, UK; Department of Surgery, Royal Free Hospital, London, UK; Department of Surgery, Whittington Health, London, UK.
| | - Max Bulsara
- Department of Biostatistics, University of Notre Dame, Fremantle, WA, Australia
| | - Frederik Wenz
- Department of Radiation Oncology, University Medical Centre Mannheim, University of Heidelberg, Mannheim, Germany
| | - Nathan Coombs
- Department of Surgery, Great Western Hospital, Swindon, UK
| | - Julian Singer
- Department of Clinical Oncology, The Princess Alexandra Hospital, Harlow, UK
| | | | - Samuele Massarut
- National Cancer Institute, Centro di Riferimento Oncologico, Aviano, Italy
| | | | - Michael Douek
- Department of Surgery, Kings College London, London, UK
| | - Norman R Williams
- Division of Surgery and Interventional Science, University College London, London, UK
| | - David Joseph
- Departments of Radiation Oncology, and Surgery, Sir Charles Gairdner Hospital, Perth, WA, Australia
| | - Jeffrey S Tobias
- Department of Clinical Oncology, University College London Hospitals, London, UK
| | - Michael Baum
- Division of Surgery and Interventional Science, University College London, London, UK
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Affiliation(s)
- C E Coles
- Oncology Centre, Cambridge University NHS Foundation Trust, Cambridge CB2 0QQ, UK.
| | - J R Yarnold
- Institute of Cancer Research and Royal Marsden Hospital NHS Foundation Trust, London, UK
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