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Belkacemi Y, Moran MS, Ozden BC, Masannat Y, Geara F, Albashir M, To NH, Debbi K, El Tamer M. Post-mastectomy radiation therapy after breast reconstruction: from historic dogmas to practical expert agreements based on a large literature review of surgical and radiation therapy considerations. Crit Rev Oncol Hematol 2024; 200:104421. [PMID: 38876160 DOI: 10.1016/j.critrevonc.2024.104421] [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: 12/10/2023] [Revised: 06/08/2024] [Accepted: 06/10/2024] [Indexed: 06/16/2024] Open
Abstract
Breast reconstruction (BR) after mastectomy is important to consider for a woman's body image enhancement and psychological well-being. Although post-mastectomy radiation (PMRT) significantly improves the outcome of patients with high-risk breast cancer (BC), PMRT after BR may affect cosmetic outcomes and may compromise the original goal of improving quality of life (QoL). With the lack of practical guidelines, it seems essential to work on a consensus and provide some "expert agreements" to offer patients the best option for PMRT after BR. We report a global "expert agreement" that results from a critical review of the literature on BR and PMRT during the 6th international multidisciplinary breast conference in March 2023.
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Affiliation(s)
- Yazid Belkacemi
- AP-HP, Department of Radiation Oncology and Henri Mondor Breast Center, Henri Mondor University Hospital. University of Paris Est Creteil (UPEC), France; Institut Mondor de Recherche Biomédicale (IMRB), INSERM U955, i-Biot, UPEC, Créteil, France.
| | - Meena S Moran
- Smilow Cancer Center, Yale University School of Medicine. Department of Therapeutic Radiology, New Haven, CT, USA
| | | | - Yazan Masannat
- Broomfield Hospital, Mid and South Essex NHS Trust, England, UK
| | - Fady Geara
- Department of Radiation Oncology, Oncology Institute, Cleveland Clinic Abu Dhabi, United Arab Emirates
| | - Mohamed Albashir
- Levantine Medical Center, Ain Alkhaleej Hospital and Burjeel Royal Hospital, Alain, United Arab Emirates
| | - Nhu Hanh To
- AP-HP, Department of Radiation Oncology and Henri Mondor Breast Center, Henri Mondor University Hospital. University of Paris Est Creteil (UPEC), France; Institut Mondor de Recherche Biomédicale (IMRB), INSERM U955, i-Biot, UPEC, Créteil, France
| | - Kamel Debbi
- AP-HP, Department of Radiation Oncology and Henri Mondor Breast Center, Henri Mondor University Hospital. University of Paris Est Creteil (UPEC), France; Institut Mondor de Recherche Biomédicale (IMRB), INSERM U955, i-Biot, UPEC, Créteil, France
| | - Mahmoud El Tamer
- Memorial Sloan Kettering Cancer Center and Weill Medical College at Cornell University, New York, USA
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Recht A. Internal Mammary Node Irradiation Debate: Case Closed? Not Yet, and Maybe Never. J Clin Oncol 2024; 42:1871-1874. [PMID: 38498804 DOI: 10.1200/jco.23.02480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 01/03/2024] [Accepted: 02/05/2024] [Indexed: 03/20/2024] Open
Abstract
The IMN debate is still open and may never be closed for reasons outlined in this Comments and Controversies piece.
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Affiliation(s)
- Abram Recht
- Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA
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3
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Kaidar-Person O, Meattini I, Boersma LJ, Becherini C, Cortes J, Curigliano G, de Azambuja E, Harbeck N, Rugo HS, Del Mastro L, Gennari A, Isacke CM, Vestmø Maraldo M, Marangoni E, Nader Marta G, Mjaaland I, Salvestrini V, Spanic T, Visani L, Morandi A, Lambertini M, Livi L, Coles CE, Poortmans P, Offersen BV. Essential requirements for reporting radiation therapy in breast cancer clinical trials: An international multi-disciplinary consensus endorsed by the European Society for Radiotherapy and Oncology (ESTRO). Radiother Oncol 2024; 195:110060. [PMID: 38122852 DOI: 10.1016/j.radonc.2023.110060] [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: 10/07/2023] [Revised: 12/12/2023] [Accepted: 12/14/2023] [Indexed: 12/23/2023]
Abstract
The European Society for Radiotherapy and Oncology (ESTRO) has advocated the establishment of guidelines to optimise precision radiotherapy (RT) in conjunction with contemporary therapeutics for cancer care. Quality assurance in RT (QART) plays a pivotal role in influencing treatment outcomes. Clinical trials incorporating QART protocols have demonstrated improved survival rates with minimal associated toxicity. Nonetheless, in routine clinical practice, there can be variability in the indications for RT, dosage, fractionation, and treatment planning, leading to uncertainty. In pivotal trials reporting outcomes of systemic therapy for breast cancer, there is limited information available regarding RT, and the potential interaction between modern systemic therapy and RT remains largely uncharted. This article is grounded in a consensus recommendation endorsed by ESTRO, formulated by international breast cancer experts. The consensus was reached through a modified Delphi process and was presented at an international meeting convened in Florence, Italy, in June 2023. These recommendations are regarded as both optimal and essential standards, with the latter aiming to define the minimum requirements. A template for a case report form (CRF) has been devised, which can be utilised by all clinical breast cancer trials involving RT. Optimal requirements include adherence to predefined RT planning protocols and centralised QART. Essential requirements aim to reduce variations and deviations from the guidelines in RT, even when RT is not the primary focus of the trial. These recommendations underscore the significance of implementing these practices in both clinical trials and daily clinical routines to generate high-quality data.
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Affiliation(s)
- Orit Kaidar-Person
- Breast Cancer Radiation Therapy Unit, Sheba Medical Center, Ramat Gan, Israel; The School of Medicine, Tel-Aviv University, Tel-Aviv, Israel; GROW-School for Oncology and Reproduction (Maastro), Maastricht University, Maastricht, the Netherlands
| | - Icro Meattini
- Department of Experimental and Clinical Biomedical Sciences "M. Serio", University of Florence, Florence, Italy; Radiation Oncology Unit, Oncology Department, Azienda Ospedaliero Universitaria Careggi, Florence, Italy.
| | - Liesbeth J Boersma
- GROW-School for Oncology and Reproduction (Maastro), Maastricht University, Maastricht, the Netherlands
| | - Carlotta Becherini
- Radiation Oncology Unit, Oncology Department, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Javier Cortes
- International Breast Cancer Center (IBCC), Pangaea Oncology, Quironsalud Group & Medical Scientia Innovation Research (MedSIR), Barcelona, Spain; Faculty of Biomedical and Health Sciences, Department of Medicine, Universidad Europea de Madrid, Madrid, Spain
| | - Giuseppe Curigliano
- Division of New Drugs and Early Drug Development for Innovative Therapies, European Institute of Oncology, IRCCS, Milan, Italy; Department of Oncology and Hemato - Oncology (DIPO), University of Milan, Milan, Italy
| | - Evandro de Azambuja
- Institut Jules Bordet and l'Université Libre de Bruxelles (U.L.B), Brussels, Belgium
| | - Nadia Harbeck
- Department of Gynecology and Obstetrics and CCCMunich, Breast Center, LMU University Hospital, Munich, Germany
| | - Hope S Rugo
- Medicine and Winterhof Family Professor of Breast Oncology, University of California San Francisco Comprehensive Cancer Center, San Francisco, CA, USA
| | - Lucia Del Mastro
- Department of Internal Medicine and Medical Specialties (DiMI), School of Medicine, University of Genova, Genova, Italy; Department of Medical Oncology, UOC Clinica di Oncologia Medica, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Alessandra Gennari
- Department of Translational Medicine, University Piemonte Orientale, Novara, Italy
| | - Clare M Isacke
- Breast Cancer Now Research Centre, The Institute of Cancer Research, London, UK
| | - Maja Vestmø Maraldo
- Department of Clinical Oncology, Center of Cancer and Organ Diseases, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Elisabetta Marangoni
- Laboratory of Preclinical Investigation, Translational Research Department, Institut Curie, Paris, France
| | - Gustavo Nader Marta
- Department of Radiation Oncology, Hospital Sírio-Libanês, Sao Paulo, Brazil; Latin American Cooperative Oncology Group, Porto Alegre, Brazil
| | - Ingvil Mjaaland
- Department of Oncology and Hematology, Stavanger University Hospital, Stavanger, Norway
| | - Viola Salvestrini
- Radiation Oncology Unit, Oncology Department, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Tanja Spanic
- Europa Donna - The European Breast Cancer Coalition, Milan, Italy; Europa Donna Slovenia, Ljubljana, Slovenia
| | - Luca Visani
- Radiation Oncology Unit, Oncology Department, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Andrea Morandi
- Department of Experimental and Clinical Biomedical Sciences "M. Serio", University of Florence, Florence, Italy
| | - Matteo Lambertini
- Department of Internal Medicine and Medical Specialties (DiMI), School of Medicine, University of Genova, Genova, Italy; Department of Medical Oncology, UOC Clinica di Oncologia Medica, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Lorenzo Livi
- Department of Experimental and Clinical Biomedical Sciences "M. Serio", University of Florence, Florence, Italy; Radiation Oncology Unit, Oncology Department, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | | | - Philip Poortmans
- Department of radiation oncology, Iridium Netwerk, Wilrijk-Antwerp, Belgium; Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk-Antwerp, Belgium
| | - Birgitte V Offersen
- Department of Experimental Clinical Oncology, Danish Centre for Particle Therapy, Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
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Shaikh PM, Mulherkar R, Khasawneh MT, Clump D, Hazard-Jenkins H, Hafez M, Vargo JA. Treatment of Internal Mammary Nodes is Associated With Improved Overall Survival in Breast Cancer: A Meta-Analysis. Am J Clin Oncol 2024; 47:81-87. [PMID: 37916961 DOI: 10.1097/coc.0000000000001060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2023]
Abstract
INTRODUCTION The role of internal mammary nodal irradiation (IMNI) as a component of regional nodal radiotherapy is a controversial issue in breast radiation oncology with conflicting results presented in recent landmark trials. We thus created a meta-analysis of available data to better ascertain the potential benefit of IMNI. We hypothesize that with the increased power available within a meta-analysis, IMNI will prove to improve overall survival (OS) in breast cancer. METHODS Literature search was conducted for prospective studies comparing IMNI to no IMNI. Primary endpoint was OS and secondary endpoints included local recurrence, regional recurrence, disease-free survival (DFS), breast cancer mortality (BCM), distant metastasis-free survival (DMFS), grade 2+ skin toxicity, cardiac events, and pneumonitis events. Subgroup analyses were performed for tumor location (medial/central vs. lateral), and nodal status (pN+ vs. pN0). Fixed-effect model was used if there was no heterogeneity, random-effects model otherwise. RESULTS Four studies with a total of 5258 patients (IMNI: n=2592; control: n=2666) were included in the study. Pooled results showed IMNI significantly improved OS for all-comers (hazard ratio [HR]=0.89; 95% CI 0.81-0.97; P =0.008), as well as subgroups of pN+ with medial/central tumor location (HR=0.84; 95% CI 0.73-0.96; P =0.01) and pN+ with lateral tumor location (HR=0.87; 95% CI 0.77-0.99; P =0.04). There was no significant difference in OS for subgroups of pN0 and medial/central tumor location. There was no difference in local recurrence, but regional recurrence was significantly improved ( P =0.04). Endpoints of DFS (HR 0.91, 95% CI 0.84-0.99 P =0.03), BCM (HR 0.87, 95% CI 0.77-0.98, P =0.03), and DMFS (HR=0.87; 95% CI, 0.78-0.98; P =0.02) were all improved with IMNI. Grade 2+ skin toxicity, cardiac events and pneumonitis events were not significantly different between patient in the IMNI and no IMNI groups. CONCLUSION Inclusion of IMN irradiation improves OS, DFS, BCM, and DMFS in breast cancer. Largest effect on OS was noted in the subgroup of patients with pN+ and medial/central tumor location.
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Affiliation(s)
| | - Ria Mulherkar
- Department of Radiation Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Mohammad T Khasawneh
- Department of Systems Science and Industrial Engineering at Binghamton University, Binghamton, NY
| | | | | | - Maria Hafez
- Department of Medicine, Division of Hematology/Oncology, West Virginia University, Morgantown, WV
| | - John A Vargo
- Department of Radiation Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA
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5
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Taylor C, Dodwell D, McGale P, Hills RK, Berry R, Bradley R, Braybrooke J, Clarke M, Gray R, Holt F, Liu Z, Pan H, Peto R, Straiton E, Coles C, Duane F, Hennequin C, Jones G, Kühn T, Oliveros S, Overgaard J, Pritchard KI, Suh CO, Beake G, Boddington C, Davies C, Davies L, Evans V, Gay J, Gettins L, Godwin J, James S, Kerr A, Liu H, MacKinnon E, Mannu G, McHugh T, Morris P, Nakahara M, Read S, Taylor H, Ferguson J, Scheurlen H, Zurrida S, Galimberti V, Ingle J, Valagussa P, Veronesi U, Anderson S, Tang G, Fisher B, Fossa S, Valborg Reinertsen K, Host H, Muss H, Holli K, Albain K, Arriagada R, Bartlett J, Bergsten-Nordström E, Bliss J, Brain E, Carey L, Coleman R, Cuzick J, Davidson N, Del Mastro L, Di Leo A, Dignam J, Dowsett M, Ejlertsen B, Francis P, García-Sáenz JA, Gelber R, Gnant M, Goetz M, Goodwin P, Halpin-Murphy P, Hayes D, Hill C, Jagsi R, Janni W, Loibl S, Mamounas E, Martín M, McIntosh S, Mukai H, Nekljudova V, Norton L, Ohashi Y, Piccart M, Pierce L, Raina V, Rea D, Regan M, Robertson J, Rutgers E, Salgado R, Slamon D, Spanic T, Sparano J, Steger G, Toi M, Tutt A, Viale G, Wang X, Wilcken N, Wolmark N, Yu KD, Cameron D, Bergh J, Swain S, Whelan T, Poortmans P. Radiotherapy to regional nodes in early breast cancer: an individual patient data meta-analysis of 14 324 women in 16 trials. Lancet 2023; 402:1991-2003. [PMID: 37931633 DOI: 10.1016/s0140-6736(23)01082-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 03/22/2023] [Accepted: 05/24/2023] [Indexed: 11/08/2023]
Abstract
BACKGROUND Radiotherapy has become much better targeted since the 1980s, improving both safety and efficacy. In breast cancer, radiotherapy to regional lymph nodes aims to reduce risks of recurrence and death. Its effects have been studied in randomised trials, some before the 1980s and some after. We aimed to assess the effects of regional node radiotherapy in these two eras. METHODS In this meta-analysis of individual patient data, we sought data from all randomised trials of regional lymph node radiotherapy versus no regional lymph node radiotherapy in women with early breast cancer (including one study that irradiated lymph nodes only if the cancer was right-sided). Trials were identified through the EBCTCG's regular systematic searches of databases including MEDLINE, Embase, the Cochrane Library, and meeting abstracts. Trials were eligible if they began before Jan 1, 2009. The only systematic difference between treatment groups was in regional node radiotherapy (to the internal mammary chain, supraclavicular fossa, or axilla, or any combinations of these). Primary outcomes were recurrence at any site, breast cancer mortality, non-breast-cancer mortality, and all-cause mortality. Data were supplied by trialists and standardised into a format suitable for analysis. A summary of the formatted data was returned to trialists for verification. Log-rank analyses yielded first-event rate ratios (RRs) and confidence intervals. FINDINGS We found 17 eligible trials, 16 of which had available data (for 14 324 participants), and one of which (henceforth excluded), had unavailable data (for 165 participants). In the eight newer trials (12 167 patients), which started during 1989-2008, regional node radiotherapy significantly reduced recurrence (rate ratio 0·88, 95% CI 0·81-0·95; p=0·0008). The main effect was on distant recurrence as few regional node recurrences were reported. Radiotherapy significantly reduced breast cancer mortality (RR 0·87, 95% CI 0·80-0·94; p=0·0010), with no significant effect on non-breast-cancer mortality (0·97, 0·84-1·11; p=0·63), leading to significantly reduced all-cause mortality (0·90, 0·84-0·96; p=0·0022). In an illustrative calculation, estimated absolute reductions in 15-year breast cancer mortality were 1·6% for women with no positive axillary nodes, 2·7% for those with one to three positive axillary nodes, and 4·5% for those with four or more positive axillary nodes. In the eight older trials (2157 patients), which started during 1961-78, regional node radiotherapy had little effect on breast cancer mortality (RR 1·04, 95% CI 0·91-1·20; p=0·55), but significantly increased non-breast-cancer mortality (1·42, 1·18-1·71; p=0·00023), with risk mainly after year 20, and all-cause mortality (1·17, 1·04-1·31; p=0·0067). INTERPRETATION Regional node radiotherapy significantly reduced breast cancer mortality and all-cause mortality in trials done after the 1980s, but not in older trials. These contrasting findings could reflect radiotherapy improvements since the 1980s. FUNDING Cancer Research UK, Medical Research Council.
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6
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Rodin D, Bazan JG. The Internal Mammary Node Irradiation Debate in Node-Positive Breast Cancer: Case Closed. Int J Radiat Oncol Biol Phys 2023; 117:779-782. [PMID: 37838444 DOI: 10.1016/j.ijrobp.2023.07.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 07/16/2023] [Indexed: 10/16/2023]
Affiliation(s)
- Danielle Rodin
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada.
| | - Jose G Bazan
- Department of Radiation Oncology, City of Hope Comprehensive Cancer Center, Duarte, California
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7
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Kaidar-Person O, Giasafaki P, Boersma L, De Brouwer P, Weltens C, Kirkove C, Peignaux-Casasnovas K, Budach V, van der Leij F, Vonk E, Weidner N, Rivera S, van Tienhoven G, Fourquet A, Noel G, Valli M, Guckenberger M, Koiter E, Racadot S, Abdah-Bortnyak R, Bartelink H, Struikmans H, Fortpied C, Poortmans PM. Mapping the location of local and regional recurrences according to breast cancer surgery and radiation therapy: Results from EORTC 22922/10925. Radiother Oncol 2023; 185:109698. [PMID: 37211281 DOI: 10.1016/j.radonc.2023.109698] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 05/01/2023] [Accepted: 05/03/2023] [Indexed: 05/23/2023]
Abstract
The purpose of this study is to evaluate the influence of the extent of surgery and radiation therapy (RT) on the rates and sites of local (LR) and regional recurrences (RR) in the EORTC 22922/10925 trial. PATIENTS AND METHODS All data were extracted from the trial's individual patients' case report forms (CRF) and analysed with a median follow-up of 15.7 years. Cumulative incidence curves were produced for LR and RR accounting for competing risks: an exploratory analysis of the effect of the extent of surgical and radiation treatments on LR rate was conducted using the Fine & Gray model accounting for competing risks and adjusted for baseline patient and disease characteristics. The significance level was set at 5%, 2-sided. Frequency tables were used to describe the spatial location of LR and RR. RESULTS Out of 4004 patients included in the trial, 282 (7%) patients experienced LR and 165 (4.1%) RR, respectively. Cumulative incidence rate of LR at 15 years was lower after mastectomy (3.1%) compared to BCS + RT (7.3%) (F&G: HR (Hazard Ratio) = 0.421, 95%CI = 0.282-0.628, p-value < 0.0001). LR were similar up to 3 years for both mastectomy and BCS but continued to occur at a steady rate for BCS + RT, only. The spatial location of the recurrence was related to the locoregional therapy applied and the absolute gain of RT correlated to stage of disease and extent of surgery. CONCLUSIONS The extent of locoregional therapies impacts significantly on LR and RR rates and spatial location.
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Affiliation(s)
- Orit Kaidar-Person
- Breast Cancer Radiation Therapy Unit, Sheba Medical Center, Ramat Gan, Israel; The Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel; Dept. Radiation Oncology (Maastro), GROW-School for Oncology and Reproduction, Maastricht University Medical Centre+, Maastricht, The Netherlands.
| | | | - Liesbeth Boersma
- Dept. Radiation Oncology (Maastro), GROW-School for Oncology and Reproduction, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Peter De Brouwer
- Department of Radiation Oncology, Institute Verbeeten, Tilburg, The Netherlands
| | - Caroline Weltens
- Department of Radiation Oncology, University Hospital Leuven, KU Leuven faculty of medicine, Leuven, Belgium
| | - Carine Kirkove
- Department of Radiation Oncology, University Hospital Saint Luc, Université Catholique de Louvain, Brussels, Belgium
| | | | - Volker Budach
- Department of Radiation Oncology and Radiotherapy, Comprehensive Cancer Center, Charite University Medicine, Berlin, Germany
| | - Femke van der Leij
- Department of Radiation Oncology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Ernest Vonk
- Institute for Radiation Oncology RISO, Deventer, The Netherlands
| | - Nicola Weidner
- Department of Radiation Oncology, University Hospital, Tübingen, Germany
| | - Sofia Rivera
- Department of Radiation Oncology, Gustave Roussy Cancer Centre, Villejuif, France
| | - Geertjan van Tienhoven
- Department of Radiation Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, The Netherlands
| | - Alain Fourquet
- Department of Radiation Oncology, Institut Curie, Paris, France
| | - Georges Noel
- Department of Radiation Oncology, Centre Paul Strauss, Strasbourg, France
| | - Mariacarla Valli
- Department of Radiation Oncology, Sant Anna Hospital, Como, Italy
| | - Matthias Guckenberger
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Switzerland
| | - Eveline Koiter
- Department of Radiation Oncology, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Severine Racadot
- Department of Radiation Oncology, Centre Léon Bérard, Lyon, France
| | | | - Harry Bartelink
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Henk Struikmans
- Department of Radiation Oncology, Leiden University Medical Centre, Leiden, The Netherlands
| | | | - Philip M Poortmans
- Department of Radiation Oncology, Iridium Netwerk, Wilrijk-Antwerp, Belgium; University of Antwerp, Faculty of Medicine and Health Sciences, Wilrijk-Antwerp, Belgium
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8
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Schad MD, Richman AH, Diego EJ, McAuliffe PF, Johnson RR, Steiman J, Vargo JA, Beriwal S. Dosimetry and Toxicity Outcomes in Patients Treated with Hypofractionated Regional Nodal Irradiation for Breast Cancer: What is the Best Dose-Volume Limit to Minimize Risks of Radiation Pneumonitis? Pract Radiat Oncol 2023; 13:291-300. [PMID: 36332799 PMCID: PMC11189663 DOI: 10.1016/j.prro.2022.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 10/10/2022] [Accepted: 10/12/2022] [Indexed: 11/07/2022]
Abstract
PURPOSE Although published data have supported the use of hypofractionated regional nodal irradiation (HF-RNI) for breast cancer, limited dosimetric data exist to evaluate predictors of lung toxicity. The ongoing RT CHARM trial limits the percentage of ipsilateral lung volume that receives ≥18 Gy to 35 to 40%. We assessed dosimetry, toxicity, and disease outcomes in patients with breast cancer treated with HF-RNI with a particular focus on pneumonitis. METHODS AND MATERIALS We retrospectively reviewed all patients with breast cancer treated with HF-RNI (40-43 Gy in 15-16 fractions) after either lumpectomy or mastectomy at The University of Pittsburgh Medical Center from September 2018 to December 2021 to collect dosimetric and outcomes data. All post-radiation therapy chest computed tomography (CT) scans were manually reviewed for evidence of acute (≤6 months postradiation) or chronic (>6 months postradiation) pneumonitis. RESULTS One-hundred-ninety-one patients qualified with a median follow-up of 20.3 months (range, 5.1-42.2). Acute grade 1 (G1) pneumonitis was observed in 6.8% of the overall cohort (13 of 191 patients) and 39.4% of the patients (13 of 33) who received a chest CT ≤6 months postradiation therapy. Only 1 patient developed acute G2 pneumonitis. Chronic G1 pneumonitis was observed in 29.8% of the overall cohort (57 of 191 patients) and 77% of patients (57 of 74 patients) who received a chest CT >6 months postradiation therapy. No patients developed acute G3+ or chronic G2+ pneumonitis. CONCLUSIONS Rates of symptomatic pneumonitis were low in this cohort of patients treated with HF-RNI, even with integration of HER2/neu-directed therapy, chemotherapy, hormone therapy, and internal mammary nodal irradiation. Lung V20Gy <26% appeared safe in this cohort to limit symptomatic pneumonitis, though this is not meant to represent the safe upper limit. Given the low event rate of symptomatic pneumonitis, data from larger cohorts will be needed to assess dosimetric predictors and the safe upper limit of lung dose.
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Affiliation(s)
- Michael D Schad
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Adam H Richman
- Department of Radiation Oncology, UPMC Hillman Cancer Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Emilia J Diego
- Department of Breast Surgical Oncology, UPMC Hillman Cancer Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Priscilla F McAuliffe
- Department of Breast Surgical Oncology, UPMC Hillman Cancer Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Ronald R Johnson
- Department of Breast Surgical Oncology, UPMC Hillman Cancer Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Jennifer Steiman
- Department of Breast Surgical Oncology, UPMC Hillman Cancer Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - John A Vargo
- Department of Radiation Oncology, UPMC Hillman Cancer Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Sushil Beriwal
- Department of Radiation Oncology, Allegheny Health Network, Pittsburgh, Pennsylvania; Varian Medical Systems, Palo Alto, California.
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9
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Kaidar-Person O, Pfob A, Gentilini OD, Borisch B, Bosch A, Cardoso MJ, Curigliano G, De Boniface J, Denkert C, Hauser N, Heil J, Knauer M, Kühn T, Lee HB, Loibl S, Mannhart M, Meattini I, Montagna G, Pinker K, Poulakaki F, Rubio IT, Sager P, Steyerova P, Tausch C, Tramm T, Vrancken Peeters MJ, Wyld L, Yu JH, Weber WP, Poortmans P, Dubsky P. The Lucerne Toolbox 2 to optimise axillary management for early breast cancer: a multidisciplinary expert consensus. EClinicalMedicine 2023; 61:102085. [PMID: 37528842 PMCID: PMC10388578 DOI: 10.1016/j.eclinm.2023.102085] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 06/20/2023] [Accepted: 06/20/2023] [Indexed: 08/03/2023] Open
Abstract
Clinical axillary lymph node management in early breast cancer has evolved from being merely an aspect of surgical management and now includes the entire multidisciplinary team. The second edition of the "Lucerne Toolbox", a multidisciplinary consortium of European cancer societies and patient representatives, addresses the challenges of clinical axillary lymph node management, from diagnosis to local therapy of the axilla. Five working packages were developed, following the patients' journey and addressing specific clinical scenarios. Panellists voted on 72 statements, reaching consensus (agreement of 75% or more) in 52.8%, majority (51%-74% agreement) in 43.1%, and no decision in 4.2%. Based on the votes, targeted imaging and standardized pathology of lymph nodes should be a prerequisite to planning local and systemic therapy, axillary lymph node dissection can be replaced by sentinel lymph node biopsy ( ± targeted approaches) in a majority of scenarios; and positive patient outcomes should be driven by both low recurrence risks and low rates of lymphoedema.
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Affiliation(s)
- Orit Kaidar-Person
- Breast Cancer Radiation Therapy Unit, Sheba Medical Center, Ramat Gan, Israel
- Department of Radiation Oncology (Maastro), GROW School for Oncology and Developmental Biology, Maastricht University Medical Centre+, Maastricht, the Netherlands
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - André Pfob
- Department of Obstetrics & Gynecology, Heidelberg University Hospital, Germany
- National Center for Tumor Diseases (NCT) and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | | | - Bettina Borisch
- Department of Histopathology, University of Geneva, 1202 Geneva, Switzerland
| | - Ana Bosch
- Division of Oncology, Department of Clinical Sciences, Lund University, Lund, Sweden
- Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Lasarettsgatan 23A, 22241, Lund, Sweden
| | - Maria João Cardoso
- Breast Unit, Champalimaud Foundation and University of Lisbon Faculty of Medicine, Lisbon, Portugal
| | - Giuseppe Curigliano
- Division of New Drugs and Early Drug Development, European Institute of Oncology IRCCS, Via Giuseppe Ripamonti, 435, 20141 Milano MI, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Jana De Boniface
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Surgery, Breast Centre, Capio St Göran's Hospital, Stockholm, Sweden
| | - Carsten Denkert
- Institute of Pathology, Philipps-University Marburg and University Hospital Marburg, Marburg, Germany
| | - Nik Hauser
- Breast Center, Hirslanden Clinic Aarau, Frauenarztzentrum Aargau AG, Baden, Switzerland
| | - Jörg Heil
- Department of Obstetrics & Gynecology, Heidelberg University Hospital, Germany
- Breast Center Heidelberg, Klinik St. Elisabeth, Heidelberg, Germany
| | - Michael Knauer
- Breast Center Eastern Switzerland, St. Gallen, Switzerland
| | - Thorsten Kühn
- Department of Gynecology and Obstetrics, University of Ulm, Germany
| | - Han-Byoel Lee
- Department of Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
- Cancer Research Institute, Seoul National University, Seoul, Republic of Korea
| | - Sibylle Loibl
- German Breast Group (GBG), C/o GBG Forschungs GmbH 63263 - Neu-Isenberg/, Germany
- Centre for Haematology and Oncology Bethanien, Frankfurt, Germany
| | | | - Icro Meattini
- Radiation Oncology Unit, Azienda Ospedaliero Universitaria Careggi, University of Florence, Florence, Italy
- Department of Experimental and Clinical Biomedical Sciences “M. Serio”, University of Florence, Florence, Italy
| | - Giacomo Montagna
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Katja Pinker
- Breast Imaging Service, Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Isabel T. Rubio
- Breast Surgical Oncology, Clinica Universidad de Navarra, Madrid, Spain
| | - Patrizia Sager
- Breast Center Bern-Biel, Hirslanden Clinic Salem, Bern, Switzerland
| | - Petra Steyerova
- Breast Cancer Screening and Diagnostic Center, Clinic of Radiology, General University Hospital in Prague, Prague, Czech Republic
| | | | - Trine Tramm
- Department of Pathology, Aarhus University Hospital, Aarhus, Denmark
| | - Marie-Jeanne Vrancken Peeters
- Department of Surgical Oncology Netherlands Cancer Institute, Antoni van Leeuwenhoek & Amsterdam University Medical Center, Netherlands
| | - Lynda Wyld
- Department of Oncology and Metabolism, The University of Sheffield, The Medical School, Sheffield, UK
| | - Jong Han Yu
- Division of Breast Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea
| | - Walter Paul Weber
- Breast Center, University Hospital Basel, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Philip Poortmans
- Department of Radiation Oncology, Iridium Netwerk, Antwerp 2610, Belgium
- University of Antwerp, Faculty of Medicine and Health Sciences, Antwerp, Belgium
| | - Peter Dubsky
- Breast Center, Hirslanden Clinic St Anna, 6006, Lucerne, Switzerland
- University of Lucerne, Faculty of Health Sciences and Medicine, Lucerne, Switzerland
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10
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Aristei C, Kaidar-Person O, Boersma L, Leonardi MC, Offersen B, Franco P, Arenas M, Bourgier C, Pfeffer R, Kouloulias V, Bölükbaşı Y, Meattini I, Coles C, Luis AM, Masiello V, Palumbo I, Morganti AG, Perrucci E, Tombolini V, Krengli M, Marazzi F, Trigo L, Borghesi S, Ciabattoni A, Ratoša I, Valentini V, Poortmans P. The 2022 Assisi Think Tank Meeting: White paper on optimising radiation therapy for breast cancer. Crit Rev Oncol Hematol 2023:104035. [PMID: 37244324 DOI: 10.1016/j.critrevonc.2023.104035] [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: 02/23/2023] [Revised: 05/11/2023] [Accepted: 05/23/2023] [Indexed: 05/29/2023] Open
Abstract
The present white paper, referring to the 4th Assisi Think Tank Meeting on breast cancer, reviews state-of-the-art data, on-going studies and research proposals. < 70% agreement in an online questionnaire identified the following clinical challenges: 1: Nodal RT in patients who have a) 1-2 positive sentinel nodes without ALND (axillary lymph node dissection); b) cN1 disease transformed into ypN0 by primary systemic therapy and c) 1-3 positive nodes after mastectomy and ALND. 2. The optimal combination of RT and immunotherapy (IT), patient selection, IT-RT timing, and RT optimal dose, fractionation and target volume. Most experts agreed that RT- IT combination does not enhance toxicity. 3: Re-irradiation for local relapse converged on the use of partial breast irradiation after second breast conserving surgery. Hyperthermia aroused support but is not widely available. Further studies are required to finetune best practice, especially given the increasing use of re-irradiation.
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Affiliation(s)
- C Aristei
- Radiation Oncology Section, Department of Medicine and Surgery, University of Perugia and Perugia General Hospital, Perugia, Italy.
| | - O Kaidar-Person
- Breast Radiation Unit, Radiation Oncology, Sheba Medical Center, Ramat Gan, Israel
| | - L Boersma
- Radiation Oncology (Maastro), GROW School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - M C Leonardi
- Division of Radiation Oncology, IEO European Institute of Oncology, IRCCS, Milan, Italy
| | - B Offersen
- Department of Experimental Clinical Oncology, Department of Oncology, Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
| | - P Franco
- Depatment of Translational Medicine, University of Eastern Piedmont and Department of Radiation Oncology, 'Maggiore della Carita`' University Hospital, Novara, Italy
| | - M Arenas
- Universitat Rovira I Virgili, Radiation Oncology Department, Hospital Universitari Sant Hoan de Reus, IISPV, Spain
| | - C Bourgier
- Radiation Oncology, ICM-Val d' Aurelle, Univ Montpellier, Montpellier, France
| | - R Pfeffer
- Oncology Institute, Assuta Medical Center, Tel Aviv and Ben Gurion University Medical School, Israel
| | - V Kouloulias
- 2nd Department of Radiology, Radiotherapy Unit, Medical School, National and Kapodistrian University of Athens, Greece
| | - Y Bölükbaşı
- Koc University, Faculty of Medicine, Department of Radiation Oncology, Istanbul, Turkey
| | - I Meattini
- Department of Experimental and Clinical Biomedical Sciences "M. Serio", University of Florence & Radiation Oncology Unit - Oncology Department, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - C Coles
- Department of Oncology, University of Cambridge, UK
| | - A Montero Luis
- Department of Radiation Oncology, University Hospital HM Sanchinarro, HM Hospitales, Madrid, Spain
| | - V Masiello
- Unità Operativa di Radioterapia Oncologica, Dipartimento di Diagnostica per Immagine, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Gemelli IRCSS Roma, Italy
| | - I Palumbo
- Radiation Oncology Section, Department of Medicine and Surgery, University of Perugia and Perugia General Hospital, Perugia, Italy
| | - A G Morganti
- DIMES, Alma Mater Studiorum Bologna University, Bologna, Italy; Radiation Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Alma Mater Studiorum Bologna University; Bologna, Italy
| | - E Perrucci
- Radiation Oncology Section, Perugia General Hospital, Perugia, Italy
| | - V Tombolini
- Radiation Oncology, Department of Radiological, Oncological and Pathological Science, University "La Sapienza", Roma, Italy
| | - M Krengli
- DISCOG, Università di Padova e Istituto Oncologico Veneto - IRCCS
| | - F Marazzi
- Unità Operativa di Radioterapia Oncologica, Dipartimento di Diagnostica per Immagine, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Gemelli IRCSS Roma, Italy
| | - L Trigo
- Service of Brachytherapy, Department of Image and Radioncology, Instituto Português Oncologia Porto Francisco Gentil E.P.E., Portugal
| | - S Borghesi
- Radiation Oncology Unit of Arezzo-Valdarno, Azienda USL Toscana Sud Est, Italy
| | - A Ciabattoni
- Department of Radiation Oncology, San Filippo Neri Hospital, ASL Rome 1, Rome, Italy
| | - I Ratoša
- Division of Radiation Oncology, Institute of Oncology Ljubljana, Ljubljana, Slovenia; Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - V Valentini
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Università Cattolica del Sacro Cuore e Fondazione Policlinico Gemelli IRCSS Roma, Italy
| | - P Poortmans
- Department of Radiation Oncology, Iridium Kankernetwerk, Antwerp, Belgium; University of Antwerp, Faculty of Medicine and Health Sciences, Antwerp, Belgium
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11
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Tramm T, Kaidar-Person O. Optimising post-operative radiation therapy after oncoplastic and reconstructive procedures. Breast 2023; 69:366-374. [PMID: 37023565 PMCID: PMC10119683 DOI: 10.1016/j.breast.2023.03.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 02/16/2023] [Accepted: 03/25/2023] [Indexed: 03/30/2023] Open
Abstract
Surgical techniques for breast cancer have been refined over the past decades to deliver an aesthetic outcome as close as possible to the contralateral intact breast. Current surgery further allows excellent aesthetic outcome even in case of mastectomy, by performing skin sparing or nipple sparing mastectomy in combination with breast reconstruction. In this review we discuss how to optimise post-operative radiation therapy after oncoplastic and breast reconstructive procedures, including dose, fractionation, volumes, surgical margins, and boost application.
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12
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Offersen BV, Overgaard M, Overgaard J. Breast cancer radiotherapy: Is it time to rethink the indication? Radiother Oncol 2022; 177:238-239. [PMID: 36265681 DOI: 10.1016/j.radonc.2022.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 10/10/2022] [Indexed: 11/07/2022]
Affiliation(s)
| | - Marie Overgaard
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Denmark
| | - Jens Overgaard
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Denmark.
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13
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Kaidar-Person O, Gentilini O, Poortmans P. Not only volumes matter for breast radiation therapy. Radiother Oncol 2022; 177:236-237. [PMID: 36334693 DOI: 10.1016/j.radonc.2022.10.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 10/17/2022] [Accepted: 10/18/2022] [Indexed: 11/13/2022]
Affiliation(s)
- Orit Kaidar-Person
- Breast Cancer Radiation Therapy Unit, Sheba Medical Center, Ramat Gan, Israel; Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel1; Department of Radiation Oncology (Maastro), GROW School for Oncology and Developmental Biology, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Oreste Gentilini
- Breast Surgery, San Raffaele University and Research Hospital, Milan, Italy
| | - Philip Poortmans
- Department of Radiation Oncology, Iridium Netwerk, Antwerp 2610, Belgium; University of Antwerp, Faculty of Medicine and Health Sciences, Antwerp, Belgium.
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14
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Simões R, Jayaprakash K. OncoFlash – Research Updates in a Flash! (August 2022). Clin Oncol (R Coll Radiol) 2022. [DOI: 10.1016/j.clon.2022.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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