1
|
Wang A, Quint E, Kukeev I, Agassi R, Belochitski O, Barski G, Vaynshtein J. Application of Intraoperative Radiotherapy in Early-Stage Breast Cancer Patients in a Clinical Setting. Int J Breast Cancer 2024; 2024:5551907. [PMID: 38919804 PMCID: PMC11199062 DOI: 10.1155/2024/5551907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 05/25/2024] [Accepted: 05/31/2024] [Indexed: 06/27/2024] Open
Abstract
Background: Intraoperative radiation therapy (IORT) has gained popularity in recent years as an alternative to external beam whole breast radiation therapy (WBRT) for early-stage breast cancer. Here, we report 43-month recurrence and survival outcomes in a multiethnic cohort treated with IORT in a clinical context. Method: Two hundred and eleven patients with low-risk features were treated with IORT for early-stage breast cancer from 2014 to 2021. Selection criteria were based on Group Europeen de Curietherapie-European Society for Therapeutic Radiology and Oncology (GEC-ESTRO) guidelines: preferably unifocal intraductal carcinoma (IDC), aged > 50, tumor size ≤ 2.0 cm, and without lymph node involvement. All patients received 20 Gy of radiation dose during the lumpectomy. Information on patient and tumor characteristics was collected. Results: The mean age of this cohort was 67.5 years; 95.2% of patients are Jewish, and the rest are Bedouins (4.7%). Most tumors were intraductal carcinoma (97.2%) and stage 1 (94.8%). The mean follow-up time was 43.4 months. Bedouins had larger tumor sizes (mean 1.21 vs. 1.13 cm) and were younger at diagnosis than Jewish patients (mean 65.4 vs. 67.6 years), although the differences are not significant. The overall recurrence rate was 1.4%. One case of local recurrence (0.5%) and two cases of metastasis (0.9%) were observed during the study period. One patient died from metastasis. Conclusion: Our findings suggest that IORT in selected low-risk patients can achieve an excellent prognosis with low rates of recurrence and metastasis.
Collapse
Affiliation(s)
- Ao Wang
- Medical School for International HealthBen-Gurion University of the Negev, Be'er Sheva 8410501, Israel
| | - Elchanan Quint
- Department of General Surgery BSoroka University Medical Center, Be'er Sheva 8410101, Israel
| | - Ivan Kukeev
- Department of General Surgery BSoroka University Medical Center, Be'er Sheva 8410101, Israel
| | - Ravit Agassi
- Center Surgical Oncology of BreastSoroka University Medical Center, Be'er Sheva 8410101, Israel
| | - Olga Belochitski
- Radiation Oncology UnitSoroka University Medical Center, Be'er Sheva, Israel
| | - Gay Barski
- Department of General Surgery BSoroka University Medical Center, Be'er Sheva 8410101, Israel
| | - Julie Vaynshtein
- Department of General Surgery BSoroka University Medical Center, Be'er Sheva 8410101, Israel
| |
Collapse
|
2
|
Aristei C, Camilli F, Epifani V, Borghesi S, Palumbo I, Bini V, Poortmans P. A systematic review and meta-analysis of intraoperative electron radiation therapy delivered with a dedicated mobile linac for partial breast irradiation in early breast cancer. Breast 2024; 76:103759. [PMID: 38851057 PMCID: PMC11219955 DOI: 10.1016/j.breast.2024.103759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2024] [Revised: 05/28/2024] [Accepted: 06/03/2024] [Indexed: 06/10/2024] Open
Abstract
•PBI is valid alternative to WBI in patients at low-risk of local relapse. •PBI is delivered by means of various techniques, one of which is IOeRT. •After IOeRT, an unexpectedly high LR rate was observed in the only phase III RCT. •Patient selection impacts on LR rates after IOeRT. •With appropriate patient selection IOeRT outcomes overlap with other RT techniques.
Collapse
Affiliation(s)
- Cynthia Aristei
- Radiation Oncology Section, Department of Medicine and Surgery, University of Perugia, Perugia, Italy; Radiation Oncology Section, Perugia General Hospital, Perugia, Italy.
| | - Federico Camilli
- Radiation Oncology Section, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - Valeria Epifani
- Radiation Oncology Section, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - Simona Borghesi
- Radiation Oncology Unit of Arezzo-Valdarno, Azienda USL Toscana Sud Est, Arezzo, Italy
| | - Isabella Palumbo
- Radiation Oncology Section, Department of Medicine and Surgery, University of Perugia, Perugia, Italy; Radiation Oncology Section, Perugia General Hospital, Perugia, Italy
| | - Vittorio Bini
- Internal Medicine, Endocrine and Metabolic Science Section, University of Perugia, Perugia, Italy
| | - Philip Poortmans
- University of Antwerp, Faculty of Medicine and Health Sciences, Antwerp, Belgium; Iridium Netwerk, Department of Radiation Oncology, Antwerp, Belgium
| |
Collapse
|
3
|
Gimeno-Morales M, Martínez-Monge R, Martinez-Lage A, Jablonska PA, Blanco J, Martínez-Regueira F, Rodriguez-Spiteri N, Olartecoechea B, Ramos L, Insausti LP, Elizalde A, Abengozar M, Cambeiro M. Long-term results of intraoperative multicatheter breast implant (IOMBI) for accelerated partial breast irradiation (APBI) on early breast cancer patients. Radiother Oncol 2024; 194:110193. [PMID: 38432310 DOI: 10.1016/j.radonc.2024.110193] [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: 06/30/2023] [Revised: 02/12/2024] [Accepted: 02/24/2024] [Indexed: 03/05/2024]
Abstract
BACKGROUND AND PURPOSE Multicatheter breast brachytherapy is a standard technique for accelerated partial breast irradiation (APBI) in early breast cancer patients. Intraoperative multicatheter breast implant (IOMBI) followed by perioperative high-dose-rate brachytherapy (PHDRBT) offers a novel and advantageous approach. We present long-term oncological, toxicity, and cosmesis outcomes for a well-experienced single institution. MATERIALS AND METHODS Eligible women aged ≥ 40 years with clinically and radiologically confirmed unifocal invasive or in situ ≤ 3 cm breast tumors underwent IOMBI during breast-conserving surgery. Patients meeting APBI criteria by definitive pathologic results received 3.4 Gy × 10fx with PHDRBT. Patients not suitable for APBI received PHDRBT-boost followed by WBRT. RESULTS A total of 171 patients underwent IOMBI during BCS, 120 patients (70.1 %) were suitable for APBI and 51 (29.8 %) for anticipated PHDRBT-boost. The median age was 61 years (range: 40-78), the median tumor size was 1.1 cm (range: 0.2-3.5), with a histological diagnosis of invasive ductal carcinoma in 78.9 % and ductal in situ in 21.1 %. A median of 9 catheters (range: 4-14) were used. For APBI, the median CTV and V100 were 40.8 cc (range: 8.6-99) and 35.4 cc (range: 7.2-94). The median of healthy breast tissue irradiated represents 7.2 % (range: 2.3-28 %) and the median local treatment duration was 10 days (range: 7-16). With a median follow-up of 8.8 years (range: 0.3-16.25), the 8-year local, locoregional, and distant control rates were 99 %, 98.1 %, and 100 %. G1-G2 late-toxicity rate was 53.4 %. Long-term cosmetic evaluation was excellent-good in 90.8 %. CONCLUSION IOMBI&PHDRBT program reports excellent long-term oncological outcomes, with a reduction from unnecessary irradiation exposure which translates into low long-term toxicity and good cosmesis outcomes, especially on well-selected APBI patients.
Collapse
Affiliation(s)
- Marta Gimeno-Morales
- Departments of Radiation Oncology, Cancer Center Clinica Universidad de Navarra. University of Navarre. Pamplona-Madrid, Spain.
| | - Rafael Martínez-Monge
- Departments of Radiation Oncology, Cancer Center Clinica Universidad de Navarra. University of Navarre. Pamplona-Madrid, Spain
| | - Adriana Martinez-Lage
- Departments of Radiation Oncology, Cancer Center Clinica Universidad de Navarra. University of Navarre. Pamplona-Madrid, Spain
| | - Paola Anna Jablonska
- Departments of Radiation Oncology, Cancer Center Clinica Universidad de Navarra. University of Navarre. Pamplona-Madrid, Spain
| | - Javier Blanco
- Medical Oncology, Cancer Center Clinica Universidad de Navarra. University of Navarre. Pamplona-Madrid, Spain
| | - Fernando Martínez-Regueira
- Breast Surgical Oncology Cancer Center Clinica Universidad de Navarra. University of Navarre. Pamplona-Madrid, Spain
| | - Natalia Rodriguez-Spiteri
- Breast Surgical Oncology Cancer Center Clinica Universidad de Navarra. University of Navarre. Pamplona-Madrid, Spain
| | - Begoña Olartecoechea
- Breast Surgical Oncology Cancer Center Clinica Universidad de Navarra. University of Navarre. Pamplona-Madrid, Spain
| | - Luis Ramos
- Departament of Medical Physic, Hospital Arnau de Villanova, Lleida, Spain
| | - Luis Pina Insausti
- Radiology Cancer Center Clinica Universidad de Navarra. University of Navarre. Pamplona-Madrid, Spain
| | - Arlette Elizalde
- Radiology Cancer Center Clinica Universidad de Navarra. University of Navarre. Pamplona-Madrid, Spain
| | - Marta Abengozar
- Pathology Cancer Center Clinica Universidad de Navarra. University of Navarre. Pamplona-Madrid, Spain
| | - Mauricio Cambeiro
- Departments of Radiation Oncology, Cancer Center Clinica Universidad de Navarra. University of Navarre. Pamplona-Madrid, Spain
| |
Collapse
|
4
|
Orozco JIJ, Valdez BJ, Matsuba C, Simanonok MP, Ensenyat-Mendez M, Ramiscal JAB, Salomon MP, Takasumi Y, Grumley JG. Biological effects of intraoperative radiation therapy: histopathological changes and immunomodulation in breast cancer patients. Front Immunol 2024; 15:1373497. [PMID: 38720889 PMCID: PMC11076837 DOI: 10.3389/fimmu.2024.1373497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Accepted: 04/08/2024] [Indexed: 05/12/2024] Open
Abstract
Introduction Intraoperative radiation therapy (IORT) delivers a single accelerated radiation dose to the breast tumor bed during breast-conserving surgery (BCS). The synergistic biologic effects of simultaneous surgery and radiation remain unclear. This study explores the cellular and molecular changes induced by IORT in the tumor microenvironment and its impact on the immune response modulation. Methods Patients with hormone receptor (HR)-positive/HER2-negative, ductal carcinoma in situ (DCIS), or early-stage invasive breast carcinoma undergoing BCS with margin re-excision were included. Histopathological evaluation and RNA-sequencing in the re-excision tissue were compared between patients with IORT (n=11) vs. non-IORT (n=11). Results Squamous metaplasia with atypia was exclusively identified in IORT specimens (63.6%, p=0.004), mimicking DCIS. We then identified 1,662 differentially expressed genes (875 upregulated and 787 downregulated) between IORT and non-IORT samples. Gene ontology analyses showed that IORT was associated with the enrichment of several immune response pathways, such as inflammatory response, granulocyte activation, and T-cell activation (p<0.001). When only considering normal tissue from both cohorts, IORT was associated with intrinsic apoptotic signaling, response to gamma radiation, and positive regulation of programmed cell death (p<0.001). Using the xCell algorithm, we inferred a higher abundance of γδ T-cells, dendritic cells, and monocytes in the IORT samples. Conclusion IORT induces histological changes, including squamous metaplasia with atypia, and elicits molecular alterations associated with immune response and intrinsic apoptotic pathways. The increased abundance of immune-related components in breast tissue exposed to IORT suggests a potential shift towards active immunogenicity, particularly immune-desert tumors like HR-positive/HER2-negative breast cancer.
Collapse
Affiliation(s)
- Javier I. J. Orozco
- Saint John’s Cancer Institute, Providence Saint John’s Health Center, Santa Monica, CA, United States
| | - Betsy J. Valdez
- Saint John’s Cancer Institute, Providence Saint John’s Health Center, Santa Monica, CA, United States
| | - Chikako Matsuba
- Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Michael P. Simanonok
- Center for Cardiovascular Analytics, Research and Data Science, Providence Research Network, Portland, OR, United States
| | - Miquel Ensenyat-Mendez
- Cancer Epigenetics Laboratory at the Cancer Cell Biology Group, Institut d’Investigació Sanitària Illes Balears (IdISBa), Palma, Spain
| | - Judi Anne B. Ramiscal
- Department of Surgical Oncology, Arrowhead Regional Medical Center & California University of Science and Medicine, Colton, CA, United States
| | - Matthew P. Salomon
- Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Yuki Takasumi
- Department of Pathology, Providence Saint John’s Health Center, Santa Monica, CA, United States
| | - Janie G. Grumley
- Saint John’s Cancer Institute, Providence Saint John’s Health Center, Santa Monica, CA, United States
| |
Collapse
|
5
|
Sfarad HK, Allweis TM. Postoperative Complications Following Lumpectomy With Intraoperative X-Ray Radiation Therapy: A Retrospective Comparative Study. Clin Breast Cancer 2024; 24:237-242. [PMID: 38233254 DOI: 10.1016/j.clbc.2023.12.005] [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: 07/25/2023] [Revised: 10/28/2023] [Accepted: 12/16/2023] [Indexed: 01/19/2024]
Abstract
BACKGROUND Lumpectomy with intraoperative radiation (IORT) is a relatively new modality for the treatment of early breast cancer. IORT delivers targeted radiation to the tumor bed and obviates the need for external beam radiation (EBRT) in 85% of the cases. IORT is being used increasingly around the world, however information regarding early and late postoperative complications associated with the procedure is limited. AIM To describe and compare complication rates after lumpectomy and IORT with those seen after lumpectomy and EBRT or lumpectomy alone. METHODS Clinical, demographic, and histopathological data were collected from electronic medical records and a retrospectively maintained database. Postoperative complications were compared for patients undergoing lumpectomy with IORT, lumpectomy with EBRT, and lumpectomy alone over the same period. RESULTS A total of 445 patients were included in the study: 113 underwent lumpectomy with IORT, 253 had lumpectomy followed by EBRT, and 79 had Lumpectomy alone. Postoperative seroma was documented in 74 patients (65%) after IORT,87 (34%) after EBRT, and 9 (11%) after lumpectomy alone (P = .000). Surgical site infection requiring antibiotic treatment was diagnosed in 26 patients (23%) after IORT, 38 (15%) after EBRT, and 5 (6%) after lumpectomy alone (P = .013). Postoperative erythema was documented in 39 patients (34%) after IORT, 40 (16%) after EBRT, and 5 (6%) after lumpectomy alone (P = .000). Postoperative minor complications such as scar and breast deformity, edema, Mondor's syndrome, and chronic tenderness, were documented in 62 patients (55%) after IORT, 119 (47%) after EBRT, and 13 (17%) after lumpectomy alone (P = .000). The average follow-up was 14 months. CONCLUSIONS IORT is associated with an increased rate of postoperative complications compared to EBRT or lumpectomy alone. Most complications are minor and transient. We hypothesize that the increased occurrence of complications may also be attributed to overreporting, which is associated with the introduction of a new technology. Educating physicians and patients about potential complications and their course may help establish expectations and improve the management of postoperative complications.
Collapse
Affiliation(s)
| | - Tanir M Allweis
- Department of Breast Surgery, Hadassah Medical Center, Jerusalem, Israel; Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| |
Collapse
|
6
|
Grimm A, Wollmann E, Sperk E, Weiß C, Sütterlin M, Berlit S, Tuschy B. Intraoperative radiotherapy (IORT) of early breast cancer with low-energy x-rays in breast-conserving surgery : Prospective identification of pre- and intraoperative factors influencing the feasibility of IORT. Strahlenther Onkol 2024; 200:296-305. [PMID: 37792017 DOI: 10.1007/s00066-023-02149-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 08/21/2023] [Indexed: 10/05/2023]
Abstract
PURPOSE The aim of this study is to identify pre- and intraoperative factors indicating the feasibility of intraoperative radiotherapy (IORT) during breast-conserving surgery (BCS). MATERIALS AND METHODS From January 2018 to December 2019, a total of 128 women undergoing BCS due to early breast cancer were included in this prospective observational study, independent of whether IORT was planned or not. Patient and tumor characteristics as well as surgical parameters that could potentially influence the feasibility of IORT were recorded for the entire collective. In addition, a preoperative senological assessment was performed and analyzed to assess the feasibility of IORT. Logistic regression was then used to identify relevant preoperative parameters and to generate a formula predicting the feasibility of IORT. RESULTS Of the 128 included women undergoing BCS, 46 were preoperatively rated to be feasible, 20 to be questionably feasible for IORT. Ultimately, IORT was realized in 30 patients. The most frequent reasons for omission of IORT were insufficient tumor-to-skin distance and/or an excessively large tumor cavity. Small clinical tumor size and large tumor-to-skin distance according to preoperative ultrasound were significantly related to accomplishment of IORT. CONCLUSION We observed that preoperative ultrasound-based tumor-skin distance is a significant factor in addition to already known parameters to predict feasibility of IORT. Based on our findings we developed a formula to optimize IORT planning which might serve as an additional tool to improve patient selection for IORT in early breast cancer.
Collapse
Affiliation(s)
- Anja Grimm
- Department of Obstetrics and Gynecology, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany.
- Department of Obstetrics and Gynecology, University Medical Center Mannheim, Theodor-Kutzer Ufer 1-3, Mannheim, Germany.
| | - Eva Wollmann
- Department of Obstetrics and Gynecology, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany
| | - Elena Sperk
- Department of Radiation Oncology, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany
- Mannheim Cancer Center, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany
| | - Christel Weiß
- Department of Medical Statistics and Biomathematics, Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany
| | - Marc Sütterlin
- Department of Obstetrics and Gynecology, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany
| | - Sebastian Berlit
- Department of Obstetrics and Gynecology, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany
| | - Benjamin Tuschy
- Department of Obstetrics and Gynecology, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany
| |
Collapse
|
7
|
Grendarova P, Roumeliotis M, Quirk S, Phan T, Liu HW, Craighead P, Lesiuk M, Pinilla J, Long K, Olivotto IA. Accelerated Partial Breast Irradiation Using 5 Daily Fractions: A Prospective, Phase 2, Multicenter Trial of Cosmetic Outcomes and Toxicity-ACCEL Final Results. Int J Radiat Oncol Biol Phys 2024; 118:1041-1048. [PMID: 37871884 DOI: 10.1016/j.ijrobp.2023.10.016] [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: 06/30/2023] [Revised: 09/15/2023] [Accepted: 10/12/2023] [Indexed: 10/25/2023]
Abstract
PURPOSE This study investigated the cosmetic degradation and toxicity for an accelerated partial breast irradiation (APBI) prescription delivered in 5 fractions over 1 week and compared the outcomes with those of whole breast irradiation (WBI). METHODS AND MATERIALS The trial was a multicenter, single-arm, phase 2 prospective cohort study. Eligible women 50 years of age or older with estrogen receptor-positive and human epidermal growth factor receptor 2-negative invasive ductal carcinoma or ductal carcinoma in situ after breast-conserving surgery received 27 Gy in 5 daily fractions of APBI. The primary endpoint was noninferiority of 2-year cosmesis using the RAPID trial's WBI arm as the control arm. A global consensus cosmetic score using a European Organisation for Research and Treatment of Cancer rating scale score of excellent, good, fair, or poor for each patient at baseline and 2 years was generated by a panel of 5 radiation oncologists using photographs of treated and untreated breasts. RESULTS From 2016 to 2019, 298 eligible women were enrolled. By the 2-year follow-up, 76 patients had been lost or withdrawn and 3 had died, resulting in 219 patients available for complete, 2-year photographic cosmetic evaluation. The median follow-up for all participants was 4.7 years (IQR, 3.8-5.5 years). No patient had a fair or poor cosmetic score at the 2-year evaluation. Cosmesis was better or unchanged for 97% of patients and worse for 3% (excellent to good), and no cosmetic failures occurred. The confidence intervals were 0.88 (0.86-0.90) and 1.00 (0.99-1.00) for the RAPID and ACCEL trials, respectively. CONCLUSIONS Cosmetic degradation with 5 daily treatments of the ACCEL trial's APBI intervention is noninferior to the WBI arm of the RAPID trial.
Collapse
Affiliation(s)
- Petra Grendarova
- Department of Radiation Oncology, British Columbia Cancer Agency, Victoria, British Columbia, Canada.
| | - Michael Roumeliotis
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, Maryland.
| | - Sarah Quirk
- Department of Radiation Oncology, Brigham and Women's Hospital, Dana-Farber Cancer Institute and Harvard Medical School, Boston, Massachusetts.
| | - Tien Phan
- Department of Oncology, University of Calgary, Calgary, Alberta, Canada; Tom Baker Cancer Centre, Calgary, Alberta, Canada
| | - Hong-Wei Liu
- Department of Oncology, University of Calgary, Calgary, Alberta, Canada; Central Alberta Cancer Centre, Red Deer, Alberta, Canada
| | - Peter Craighead
- Department of Oncology, University of Calgary, Calgary, Alberta, Canada; Tom Baker Cancer Centre, Calgary, Alberta, Canada
| | - Mark Lesiuk
- Tom Baker Cancer Centre, Calgary, Alberta, Canada
| | | | - Karen Long
- Tom Baker Cancer Centre, Calgary, Alberta, Canada
| | - Ivo A Olivotto
- Department of Oncology, University of Calgary, Calgary, Alberta, Canada; Tom Baker Cancer Centre, Calgary, Alberta, Canada
| |
Collapse
|
8
|
Shaitelman SF, Anderson BM, Arthur DW, Bazan JG, Bellon JR, Bradfield L, Coles CE, Gerber NK, Kathpal M, Kim L, Laronga C, Meattini I, Nichols EM, Pierce LJ, Poppe MM, Spears PA, Vinayak S, Whelan T, Lyons JA. Partial Breast Irradiation for Patients With Early-Stage Invasive Breast Cancer or Ductal Carcinoma In Situ: An ASTRO Clinical Practice Guideline. Pract Radiat Oncol 2024; 14:112-132. [PMID: 37977261 DOI: 10.1016/j.prro.2023.11.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 11/06/2023] [Accepted: 11/07/2023] [Indexed: 11/19/2023]
Abstract
PURPOSE This guideline provides evidence-based recommendations on appropriate indications and techniques for partial breast irradiation (PBI) for patients with early-stage invasive breast cancer and ductal carcinoma in situ. METHODS ASTRO convened a task force to address 4 key questions focused on the appropriate indications and techniques for PBI as an alternative to whole breast irradiation (WBI) to result in similar rates of ipsilateral breast recurrence (IBR) and toxicity outcomes. Also addressed were aspects related to the technical delivery of PBI, including dose-fractionation regimens, target volumes, and treatment parameters for different PBI techniques. The guideline is based on a systematic review provided by the Agency for Healthcare Research and Quality. Recommendations were created using a predefined consensus-building methodology and system for grading evidence quality and recommendation strength. RESULTS PBI delivered using 3-dimensional conformal radiation therapy, intensity modulated radiation therapy, multicatheter brachytherapy, and single-entry brachytherapy results in similar IBR as WBI with long-term follow-up. Some patient characteristics and tumor features were underrepresented in the randomized controlled trials, making it difficult to fully define IBR risks for patients with these features. Appropriate dose-fractionation regimens, target volume delineation, and treatment planning parameters for delivery of PBI are outlined. Intraoperative radiation therapy alone is associated with a higher IBR rate compared with WBI. A daily or every-other-day external beam PBI regimen is preferred over twice-daily regimens due to late toxicity concerns. CONCLUSIONS Based on published data, the ASTRO task force has proposed recommendations to inform best clinical practices on the use of PBI.
Collapse
Affiliation(s)
- Simona F Shaitelman
- Department of Breast Radiation Oncology, University of Texas MD - Anderson Cancer Center, Houston, Texas.
| | - Bethany M Anderson
- Department of Radiation Oncology, University of Wisconsin, Madison, Wisconsin
| | - Douglas W Arthur
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, Virginia
| | - Jose G Bazan
- Department of Radiation Oncology, City of Hope Comprehensive Cancer Center, Duarte, California
| | - Jennifer R Bellon
- Department of Radiation Oncology, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Boston, Massachusetts
| | - Lisa Bradfield
- American Society for Radiation Oncology, Arlington, Virginia
| | - Charlotte E Coles
- Department of Oncology, University of Cambridge, Cambridge, United Kingdom
| | - Naamit K Gerber
- Department of Radiation Oncology, New York University Grossman School of Medicine, New York, New York
| | - Madeera Kathpal
- Department of Radiation Oncology, Duke University Wake County Campus, Raleigh, North Carolina
| | - Leonard Kim
- Department of Radiation Oncology, MD - Anderson Cancer Center at Cooper, Camden, New Jersey
| | - Christine Laronga
- Department of Breast Oncology, Moffitt Cancer Center, Tampa, Florida
| | - Icro Meattini
- Department of Radiation Oncology, University of Florence, Florence, Italy
| | - Elizabeth M Nichols
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Lori J Pierce
- Department of Radiation Oncology, University of Michigan School of Medicine, Ann Arbor, Michigan
| | - Matthew M Poppe
- Department of Radiation Oncology, Huntsman Cancer Institute, Salt Lake City, Utah
| | - Patricia A Spears
- Patient Representative, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Shaveta Vinayak
- Department of Medical Oncology, University of Washington, Seattle, Washington
| | - Timothy Whelan
- Department of Oncology, McMaster University, Hamilton, Ontario, Canada
| | - Janice A Lyons
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Cleveland, Ohio
| |
Collapse
|
9
|
Halima A, Fane L, Parker S, Obi E, Fleming-Hall E, Gentle C, Cherian S, Valente S, Al-Hilli Z, Tendulkar R, Shah C. Intraoperative Radiation Therapy for Early-Stage Breast Cancer: Updated Outcomes from a Single-Institution Experience. Ann Surg Oncol 2024; 31:931-935. [PMID: 37857985 DOI: 10.1245/s10434-023-14448-6] [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: 04/26/2023] [Accepted: 10/02/2023] [Indexed: 10/21/2023]
Abstract
BACKGROUND Increasingly, data have supported the use of partial-breast irradiation (PBI) for low-risk patients after breast-conserving surgery, with techniques allowing for completion of treatment in 1-3 weeks. Intraoperative radiation therapy (IORT) is an alternative to PBI. Our institution had used low-energy photon IORT (TARGIT) for more than a decade. The initial results demonstrated a 2% local recurrence rate with a short follow-up period of 2 years. This report presents updated outcomes during with 5-year follow-up. METHODS A review of an institutional review board (IRB)-approved institutional registry was performed. The review identified 215 patients with early-stage breast cancer (stages 0-IIA) who received IORT. At the time of surgery, IORT was delivered with 20 Gy in a single fraction, with 5.1% (n = 11) of patients receiving additional whole-breast irradiation (WBI). RESULTS The mean age at diagnosis was 71 years (range, 49-98 years), and the median follow-up was 5.7 years (interquartile range [IQR], 4.2-7.0 years). Of the 215 patients, 2.8% (n = 6) had ductal carcinoma in situ (DCIS), 90.7% (n = 195) had T1 disease, and 6.5% (n = 14) had T2 disease. Endocrine therapy was prescribed for 79% and chemotherapy for 1.4% of the patients. The 5-year rates were 5.3% for local recurrence, 6.4% for locoregional recurrence, and 2.7% for distant metastases. At 5 years, 93% of the patients were alive. CONCLUSIONS The 5-year outcomes with TARGIT IORT demonstrated high rates of local recurrence, exceeding those seen with alternative modern approaches. The local recurrence outcomes with IORT are more consistent with studies omitting radiation following breast-conserving surgery, using endocrine therapy alone. Consistent with current guidelines and previous data, TARGIT IORT should not be used as monotherapy outside prospective clinical trials.
Collapse
Affiliation(s)
- Ahmed Halima
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Lauren Fane
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Sean Parker
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Elizabeth Obi
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Erica Fleming-Hall
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Corey Gentle
- Department of Breast Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Sheen Cherian
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Stephanie Valente
- Department of Breast Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Zahraa Al-Hilli
- Department of Breast Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Rahul Tendulkar
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Chirag Shah
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA.
| |
Collapse
|
10
|
King CA, Shaposhnik G, Sayyed AA, Shoucair S, Farha MJ. Intraoperative Radiation Therapy as a Safe Alternative to Whole Breast Radiation for Treatment of Minimally Invasive Breast Cancers: A Retrospective Cohort Study. Am Surg 2024; 90:190-198. [PMID: 37522359 DOI: 10.1177/00031348231192067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/01/2023]
Abstract
BACKGROUND Intraoperative radiation therapy (IORT) in select populations is a viable alternative to whole breast radiation therapy (WBRT) in the treatment of biopsy-proven localized invasive and non-invasive breast cancer. We aim to assess recurrence and complication rates following IORT in lumpectomy patients at a community hospital in Baltimore City. METHODS An IRB-approved retrospective cohort study was conducted on consecutive cases of lumpectomy with IORT from 2013 through 2020 by a single surgeon. Patient demographics, tumor and operative characteristics, and complications were retrieved from electronic medical records. Primary outcomes were postoperative complications and local recurrence rates. RESULTS The final cohort included 117 patients with mean follow-up time of 2.60 + 1.78 years. Mean age was 69.84 + 8.77 years. Thirty-three (28.21%) of patients developed a seroma. Odds of seroma formation were mildly significant for skin spacing [OR: 1.18, 95% CI: (1.02-1.37)] and balloon fill volume [1.04 (1.00-1.08)], but not for age, BMI, diabetes, former or current smoking status, history of WBRT, tumor size, or balloon size. Three (2.6%) patients had local recurrence. Odds of local recurrence were mildly significant for increased tumor size [1.14 (1.04-1.24)] and not significant for any other covariates. CONCLUSIONS IORT exposure did not confer higher rates of complications and the local recurrence rate mirrored that of the general population undergoing lumpectomy and WBRT. This study demonstrates the need for equitable treatment options based on individual needs: IORT is a safe alternative to WBRT in certain subpopulations, especially those with physical, social, or personal limitations preventing participation in a 3- to 7-week time commitment of WBRT.
Collapse
Affiliation(s)
- Caroline A King
- Georgetown University School of Medicine, Washington, DC, USA
| | - Guy Shaposhnik
- Georgetown University School of Medicine, Washington, DC, USA
| | - Adaah A Sayyed
- Georgetown University School of Medicine, Washington, DC, USA
| | - Sami Shoucair
- Department of Surgery, MedStar Good Samaritan Hospital, Baltimore, MD, USA
| | - Maen J Farha
- Department of Surgery, MedStar Good Samaritan Hospital, Baltimore, MD, USA
| |
Collapse
|
11
|
Zangouri V, Roshanshad A, Ranjbar A, Izadi M, Rajaeifar S, Goodarzi A, Nasrollahi H. Outcomes and complications of intraoperative radiotherapy versus external beam radiotherapy for early breast cancer. Cancer Rep (Hoboken) 2024; 7:e1950. [PMID: 38205671 PMCID: PMC10849931 DOI: 10.1002/cnr2.1950] [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: 06/07/2023] [Revised: 09/19/2023] [Accepted: 11/12/2023] [Indexed: 01/12/2024] Open
Abstract
BACKGROUND Intraoperative radiotherapy (IORT) is an alternative for external beam radiotherapy (EBRT) for early stage breast cancer (BC). Herein, we compared outcomes, postoperative and post-radiation complications of IORT and EBRT. METHODS We conducted a cohort study to compare complications of IORT and EBRT in patients. A checklist of the complications of IORT and EBRT, was used to assess and post-radiation complications and outcomes. RESULTS Overall, 264 women (121 in IORT and 143 in EBRT group) with a mean (SD) age of 55 ± 8.6 years analyzed in this study. The IORT group (quadrantectomy + SLNB + IORT) had more severe post-operative pain compared to the EBRT group (quadrantectomy + SLNB) (OR = 1.929, 95% CI: 1.116-3.332). Other postoperative complications, including edema, erythema, seroma, hematoma, and wound complications were not significantly different between the IORT and EBRT groups. EBRT was associated with higher rates post-radiation complications, including erythema (95.8% vs. 21.5%), skin dryness (30.8% vs. 12.4%), pruritus (26.6% vs. 17.4%), hyperpigmentation (48.3% vs. 9.9%), and telangiectasia (1.4% vs. 0.8%). Multivariate analysis showed that erythema, skin dryness and pruritus, and hyperpigmentation were more severe in the EBRT group, while breast induration was higher in the IORT group (OR = 4.109, 95% CI: 2.242-7.531). Excellent, good, and fair cosmetic outcome was seen in 11.2%, 72%, and 16.8% of the patients in the EBRT group and 29.8%, 63.6%, and 6.6% in the IORT group, respectively, suggesting that the cosmetic outcome was significantly better in the IORT group (P < .001). There wasn't statistically significant difference in recurrence-free survival and overall survival rates between two groups of patients who received either IORT or EBRT (P = .953, P = .56). CONCLUSION IORT is considered to have lower post-radiation complications and better cosmetic outcomes in breast cancer patients. Therefore, IORT might be used as the treatment of choice in eligible patients.
Collapse
Affiliation(s)
- Vahid Zangouri
- Surgical Oncology Division, General Surgery DepartmentShiraz University of Medical SciencesShirazIran
- Breast Diseases Research CenterShiraz University of Medical SciencesShirazIran
| | - Amirhossein Roshanshad
- Student Research CommitteeShiraz University of Medical SciencesShirazIran
- Poostchi Ophthalmology Research CenterShiraz University of Medical SciencesShirazIran
| | - Aliyeh Ranjbar
- Breast Diseases Research CenterShiraz University of Medical SciencesShirazIran
- Student Research CommitteeShiraz University of Medical SciencesShirazIran
| | - Mahsa Izadi
- Student Research CommitteeShiraz University of Medical SciencesShirazIran
| | - Sara Rajaeifar
- Student Research CommitteeShiraz University of Medical SciencesShirazIran
| | - Ali Goodarzi
- Student Research CommitteeShiraz University of Medical SciencesShirazIran
| | - Hamid Nasrollahi
- Radiation Oncology, Radio‐Oncology Department, School of MedicineShiraz University of Medical SciencesShirazIran
| |
Collapse
|
12
|
Salari K, Glaza A, Lee JS, Sarvepalli N, Dekhne N, Kiran SH, Chen PY, Dilworth JT. Clinical Outcomes of Breast-Conserving Surgery with Synchronous 50-kV X-ray Intraoperative Partial Breast Irradiation in Patients Aged 64 Years or Older with Low-Risk Breast Cancer. Breast Cancer (Auckl) 2024; 18:11782234231224267. [PMID: 38192516 PMCID: PMC10771749 DOI: 10.1177/11782234231224267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 12/15/2023] [Indexed: 01/10/2024] Open
Abstract
Background Breast-conserving surgery with synchronous 50-kV X-ray intraoperative radiation therapy (TARGIT-IORT) is a convenient form of partial breast irradiation; however, the existing literature supports a wide range of local control rates. Objectives We investigated the treatment effectiveness and toxic effects of TARGIT-IORT in a patient cohort aged 64 years or older with low-risk breast cancer. Design Retrospective analysis. Methods Patients who received breast-conserving surgery with synchronous TARGIT-IORT at a single institution from 2016 to 2019 were reviewed. Additional whole breast irradiation was recommended at the discretion of the treating radiation oncologist. Baseline patient demographics and treatment details were recorded. Acute and chronic toxicities, measured using the Common Terminology Criteria for Adverse Events version 3.0 or 4.0 and breast cosmetic outcomes, using the Harvard Cosmesis score, were recorded. Locoregional recurrence, distant metastasis, and overall survival were recorded, and 5-year rates were estimated using the Kaplan-Meier method. Results 61 patients were included with a median follow-up of 3.5 years and median age of 72 years. Eight (13%) patients received additional whole breast irradiation, and fifty-four (89%) received adjuvant hormone therapy. There were no local, regional, or distance recurrences. One patient died of complications from COVID-19 infection. Grade 2 + acute and chronic toxicities were observed in 6 (12%) and 7 (14%) patients, respectively. One patient experienced a grade 3 acute toxicity. Cosmetic outcome was "excellent" or "good" in 45 (92%) patients. Conclusions Breast TARGIT-IORT was well tolerated and conferred excellent disease control in this cohort of patients with low-risk breast cancer. While continued follow-up is required, TARGIT-IORT may be an appropriate treatment option for this population.
Collapse
Affiliation(s)
- Kamran Salari
- Department of Radiation Oncology, Corewell Health East William Beaumont University Hospital, Royal Oak, MI, USA
| | - Andrew Glaza
- Department of Radiation Oncology Oakland University William Beaumont School of Medicine, Rochester, MI, USA
| | - Joseph S Lee
- Department of Radiation Oncology, Corewell Health East William Beaumont University Hospital, Royal Oak, MI, USA
| | - Neha Sarvepalli
- Department of Breast Surgery, Premier Surgical Oncology at Miami Valley Hospital North Campus, Englewood, OH, USA
| | - Nayana Dekhne
- Department of Breast Surgery, Corewell Health East William Beaumont University Hospital, Royal Oak, MI, USA
| | - Sayee H Kiran
- Department of Breast Surgery, Corewell Health East William Beaumont University Hospital, Royal Oak, MI, USA
| | - Peter Y Chen
- Department of Radiation Oncology, Corewell Health East William Beaumont University Hospital, Royal Oak, MI, USA
| | - Joshua T Dilworth
- Department of Radiation Oncology, Corewell Health East William Beaumont University Hospital, Royal Oak, MI, USA
| |
Collapse
|
13
|
Turkheimer LM, Petroni GR, Berger AC, Schroen AT, Brenin DR, Lazar M, Libby B, Janowski EM, Showalter TN, Showalter SL. Novel Form of Breast Intraoperative Radiation Therapy with CT-Guided High-Dose-Rate Brachytherapy: Interim Results of a Prospective Phase-II Clinical Trial. J Am Coll Surg 2024; 238:10-20. [PMID: 37870228 DOI: 10.1097/xcs.0000000000000869] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2023]
Abstract
BACKGROUND Precision breast intraoperative radiation therapy (PB-IORT) is a novel method of IORT that uses customized CT-based treatment plans and high-dose-rate (HDR) brachytherapy. We conducted a phase-II multi-institution trial to evaluate the efficacy of PB-IORT. STUDY DESIGN Between 2015 and 2022, 3 centers enrolled women aged 45 years and older with invasive or in situ carcinoma measuring 3 cm or smaller and N0 status (n = 358). Breast-conserving surgery was performed, and a multilumen balloon catheter was placed in the lumpectomy bed. CT images were used to create customized HDR brachytherapy plans that delivered 12.5 Gy to the tumor bed. The primary outcome assessed was the 5-year rate of index quadrant tumor recurrence. An interim analysis was conducted after one-third of eligible participants completed 5 years of follow-up. This trial is registered with clinicaltrials.gov (NCT02400658). RESULTS The cohort comprised 153 participants with a median age of 64 years and median follow-up time of 5.9 years. The estimated 5-year index quadrant tumor recurrence rate and overall survival were 5.08% (95% CI 2.23 to 9.68) and 95.1%, respectively. Locoregional (ipsilateral breast and axilla) and distant recurrence rates were each 1.96%. Seven deaths occurred during the first 5 years of follow-up, with only 1 attributable to breast cancer. Overall, 68.6% of patients experienced any adverse effects, and 4 cases of breast-related severe toxicities were observed. CONCLUSIONS This study presents the results of a planned interim analysis of a phase-II trial investigating PB-IORT and demonstrates the efficacy and safety of single-fraction, CT-based, HDR brachytherapy after breast-conserving surgery. These findings provide valuable insights into the use of PB-IORT as a treatment modality.
Collapse
Affiliation(s)
- Lena M Turkheimer
- From the Departments of Surgery (Turkheimer, Schroen, Brenin, SL Showalter), University of Virginia School of Medicine, Charlottesville, VA
| | - Gina R Petroni
- Division of Translational Research and Applied Statistics, Department of Public Health Sciences, University of Virginia Health System, Charlottesville, VA (Petroni)
| | - Adam C Berger
- Department of Surgery, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ (Berger)
| | - Anneke T Schroen
- From the Departments of Surgery (Turkheimer, Schroen, Brenin, SL Showalter), University of Virginia School of Medicine, Charlottesville, VA
| | - David R Brenin
- From the Departments of Surgery (Turkheimer, Schroen, Brenin, SL Showalter), University of Virginia School of Medicine, Charlottesville, VA
| | - Melissa Lazar
- Department of Surgery, Sidney Kimmel Cancer Center at Thomas Jefferson University, Philadelphia, PA (Lazar)
| | - Bruce Libby
- Radiation Oncology, Moffitt Cancer Center, Tampa, FL (Libby)
| | - Einsley M Janowski
- Radiation Oncology (Janowski, TN Showalter), University of Virginia School of Medicine, Charlottesville, VA
| | - Timothy N Showalter
- Radiation Oncology (Janowski, TN Showalter), University of Virginia School of Medicine, Charlottesville, VA
| | - Shayna L Showalter
- From the Departments of Surgery (Turkheimer, Schroen, Brenin, SL Showalter), University of Virginia School of Medicine, Charlottesville, VA
| |
Collapse
|
14
|
Haussmann J, Budach W, Corradini S, Krug D, Jazmati D, Tamaskovics B, Bölke E, Pedotoa A, Kammers K, Matuschek C. Comparison of adverse events in partial- or whole breast radiotherapy: investigation of cosmesis, toxicities and quality of life in a meta-analysis of randomized trials. Radiat Oncol 2023; 18:181. [PMID: 37919752 PMCID: PMC10623828 DOI: 10.1186/s13014-023-02365-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 10/17/2023] [Indexed: 11/04/2023] Open
Abstract
PURPOSE/OBJECTIVE Adjuvant whole breast radiotherapy and systemic therapy are part of the current evidence-based treatment protocols for early breast cancer, after breast-conserving surgery. Numerous randomized trials have investigated the therapeutic effects of partial breast irradiation (PBI) compared to whole breast irradiation (WBI), limiting the treated breast tissue. These trials were designed to achieve equal control of the disease with possible reduction in adverse events, improvements in cosmesis and quality of life (QoL). In this meta-analysis, we aimed to investigate the differences between PBI and WBI in side effects and QoL. MATERIAL/METHODS We performed a systematic literature review searching for randomized trials comparing WBI and PBI in early-stage breast cancer with publication dates after 2009. The meta-analysis was performed using the published event rates and the effect-sizes for available acute and late adverse events. Additionally, we evaluated cosmetic outcomes as well as general and breast-specific QoL using the EORTC QLQ-C30 and QLQ-BR23 questionnaires. RESULTS Sixteen studies were identified (n = 19,085 patients). PBI was associated with a lower prevalence in any grade 1 + acute toxicity and grade 2 + skin toxicity (OR = 0.12; 95% CI 0.09-0.18; p < 0.001); (OR = 0.16; 95% CI 0.07-0.41; p < 0.001). There was neither a significant difference in late adverse events between the two treatments, nor in any unfavorable cosmetic outcomes, rated by either medical professionals or patients. PBI-technique using EBRT with twice-daily fractionation schedules resulted in worse cosmesis rated by patients (n = 3215; OR = 2.08; 95% CI 1.22-3.54; p = 0.007) compared to WBI. Maximum once-daily EBRT schedules (n = 2071; OR = 0.60; 95% CI 0.45-0.79; p < 0.001) and IORT (p = 0.042) resulted in better cosmetic results grade by medical professionals. Functional- and symptom-based QoL in the C30-scale was not different between PBI and WBI. Breast-specific QoL was superior after PBI in the subdomains of "systemic therapy side effects" as well as "breast-" and "arm symptoms". CONCLUSION The analysis of multiple randomized trials demonstrate a superiority of PBI in acute toxicity as well breast-specific quality of life, when compared with WBI. Overall, late toxicities and cosmetic results were similar. PBI-technique with a fractionation of twice-daily schedules resulted in worse cosmesis rated by patients.
Collapse
Affiliation(s)
- Jan Haussmann
- Department of Radiation Oncology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Germany.
| | - Wilfried Budach
- Department of Radiation Oncology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Stefanie Corradini
- Department of Radiation Oncology, Ludwig Maximillian University, Munich, Germany
| | - David Krug
- Department of Radiation Oncology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Danny Jazmati
- Department of Radiation Oncology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Bálint Tamaskovics
- Department of Radiation Oncology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Edwin Bölke
- Department of Radiation Oncology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Alessia Pedotoa
- Department of Anesthesiology, Memorial Sloan Kettering Cancer Center, New York City, New York, USA
| | - Kai Kammers
- Department of Oncology, The Sidney Kimmel Comprehensive Cancer Center, The Johns Hopkins University School of Medicine, Baltimore, USA
| | - Christiane Matuschek
- Department of Radiation Oncology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Germany
| |
Collapse
|
15
|
Ayala Alvarez DS, Watson PGF, Popovic M, Heng VJ, Evans MDC, Panet-Raymond V, Seuntjens J. Evaluation of Dosimetry Formalisms in Intraoperative Radiation Therapy of Glioblastoma. Int J Radiat Oncol Biol Phys 2023; 117:763-773. [PMID: 37150259 DOI: 10.1016/j.ijrobp.2023.04.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 03/21/2023] [Accepted: 04/29/2023] [Indexed: 05/09/2023]
Abstract
PURPOSE The intraoperative radiotherapy in newly diagnosed glioblastoma multiforme (INTRAGO) clinical trial assesses survival in patients with glioblastoma treated with intraoperative radiation therapy (IORT) using the INTRABEAM. Treatment planning for INTRABEAM relies on vendor-provided in-water depth dose curves obtained according to the TARGeted Intraoperative radioTherapy (TARGIT) dosimetry protocol. However, recent studies have shown discrepancies between the estimated TARGIT and delivered doses. This work evaluates the effect of the choice of dosimetry formalism on organs at risk (OAR) doses. METHODS AND MATERIALS A treatment planning framework for INTRABEAM was developed to retrospectively calculate the IORT dose in 8 INTRAGO patients. These patients received an IORT prescription dose of 20 to 30 Gy in addition to external beam radiation therapy. The IORT dose was obtained using (1) the TARGIT method; (2) the manufacturer's V4.0 method; (3) the CQ method, which uses an ionization chamber Monte Carlo (MC) calculated factor; (4) MC dose-to-water; and (5) MC dose-to-tissue. The IORT dose was converted to 2 Gy fractions equivalent dose. RESULTS According to the TARGIT method, the OAR dose constraints were respected in all cases. However, the other formalisms estimated a higher mean dose to OARs and revealed 1 case where the constraint for the brain stem was exceeded. The addition of the external beam radiation therapy and TARGIT IORT doses resulted in 10 cases of OARs exceeding the dose constraints. The more accurate MC calculation of dose-to-tissue led to the highest dosimetric differences, with 3, 3, 2, and 2 cases (out of 8) exceeding the dose constraint to the brain stem, optic chiasm, optic nerves, and lenses, respectively. Moreover, the mean cumulative dose to brain stem exceeded its constraint of 66 Gy with the MC dose-to-tissue method, which was not evident with the current INTRAGO clinical practice. CONCLUSIONS The current clinical approach of calculating the IORT dose with the TARGIT method may considerably underestimate doses to nearby OARs. In practice, OAR dose constraints may have been exceeded, as revealed by more accurate methods.
Collapse
Affiliation(s)
| | | | | | - Veng Jean Heng
- Department of Physics and Medical Physics Unit, McGill University, Montreal, QC, Canada
| | | | - Valerie Panet-Raymond
- Department of Radiation Oncology, McGill University Health Centre, Montreal, QC, Canada
| | - Jan Seuntjens
- Medical Physics Unit and; Princess Margaret Cancer Centre, Radiation Medicine Program, University Health Network, Toronto, ON, Canada
| |
Collapse
|
16
|
Bhimani F, McEvoy M, Gupta A, Pastoriza J, Shihabi A, Basavatia A, Tomé WA, Fox J, Mehta K, Feldman S. Case Report: Bilateral targeted intraoperative radiotherapy: a safe and effective alternative for synchronous bilateral breast cancer. Front Oncol 2023; 13:1276766. [PMID: 37941541 PMCID: PMC10628514 DOI: 10.3389/fonc.2023.1276766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Accepted: 10/13/2023] [Indexed: 11/10/2023] Open
Abstract
Background The incidence of bilateral breast cancer (BBC) ranges from 1.4% to 11.8%. BBC irradiation is a challenge in current clinical practice due to the large target volume that must be irradiated while minimizing the dose to critical organs. Supine or prone breast techniques can be used, with the latter providing better organ sparing; both, however, result in lengthy treatment times. The use of Intra-operative radiotherapy (IORT) in breast cancer patients who choose breast conservation has been highlighted in previous studies, but there is a scarcity of literature analyzing the utility and applicability of IORT in BBC. This case series aims to highlight the applicability of administering bilateral IORT in patients with BBC. Case reports Five patients with bilateral early-stage breast cancer (or DCIS) were treated with breast-conserving surgery followed by bilateral IORT. Of the 10 breast cancers, 8 were diagnosed as either DCIS or IDC, while the other 2 were diagnosed as invasive lobular carcinoma and invasive carcinoma, respectively. During surgery, all patients received bilateral IORT. Furthermore, 1 patient received external beam radiation therapy after her final pathology revealed grade 3 DCIS. The IORT procedure was well tolerated by all five patients, and all patients received aromatase inhibitors as adjuvant therapy. Additionally, none of these patients showed evidence of disease after a 36-month median follow-up. Conclusion Our findings demonstrate the successful use of IORT for BCS in patients with BBC. Furthermore, none of the patients in our study experienced any complications, suggesting the feasibility of the use of IORT in BBC. Considering the benefits of improved patient compliance and a reduced number of multiple visits, IORT may serve as an excellent patient-centered alternative for BBC. Future studies are recommended to reinforce the applicability of IORT in patients with BBC.
Collapse
Affiliation(s)
- Fardeen Bhimani
- Breast Surgery Division, Department of Surgery, Montefiore Medical Center, Montefiore Einstein Center for Cancer Care, Bronx, NY, United States
| | - Maureen McEvoy
- Breast Surgery Division, Department of Surgery, Montefiore Medical Center, Montefiore Einstein Center for Cancer Care, Bronx, NY, United States
| | - Anjuli Gupta
- Breast Surgery Division, Department of Surgery, Montefiore Medical Center, Montefiore Einstein Center for Cancer Care, Bronx, NY, United States
| | - Jessica Pastoriza
- Breast Surgery Division, Department of Surgery, Montefiore Medical Center, Montefiore Einstein Center for Cancer Care, Bronx, NY, United States
| | - Areej Shihabi
- Breast Surgery Division, Department of Surgery, Montefiore Medical Center, Montefiore Einstein Center for Cancer Care, Bronx, NY, United States
| | - Amar Basavatia
- Department of Radiation Oncology, Montefiore Medical Center, Bronx, NY, United States
| | - Wolfgang A. Tomé
- Department of Radiation Oncology, Montefiore Medical Center, Bronx, NY, United States
| | - Jana Fox
- Department of Radiation Oncology, Montefiore Medical Center, Bronx, NY, United States
| | - Keyur Mehta
- Department of Radiation Oncology, Montefiore Medical Center, Bronx, NY, United States
| | - Sheldon Feldman
- Breast Surgery Division, Department of Surgery, Montefiore Medical Center, Montefiore Einstein Center for Cancer Care, Bronx, NY, United States
| |
Collapse
|
17
|
Silverstein MJ, Kim B, Lin K, Lloyd S, Snyder L, Khan S, Kramme K, Chen P. Risk-Adapted Intraoperative Radiation Therapy (IORT) for Breast Cancer: A Novel Analysis. Ann Surg Oncol 2023; 30:6079-6088. [PMID: 37464138 PMCID: PMC10495476 DOI: 10.1245/s10434-023-13897-3] [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: 04/04/2023] [Accepted: 06/27/2023] [Indexed: 07/20/2023]
Abstract
BACKGROUND Randomized trials have shown that risk-adapted intraoperative radiation therapy (IORT) after breast-conserving surgery for low-risk breast cancer patients is a safe alternative to whole-breast radiation therapy (WBRT). The risk-adapted strategy allows additional WBRT for predefined high-risk pathologic characteristics discovered on final histopathology. The greater the percentage of patients receiving WBRT, the lower the recurrence rate. The risk-adapted strategy, although important and necessary, can make IORT appear better than it actually is. METHODS Risk-adapted IORT was used to treat 1600 breast cancers. They were analyzed by the intention-to-treat method and per protocol to better understand the contribution of IORT with and without additional whole-breast treatment. Any ipsilateral breast tumor event was considered a local recurrence. RESULTS During a median follow-up period of 63 months, local recurrence differed significantly between the patients who received local treatment and those who received whole-breast treatment. For 1393 patients the treatment was local treatment alone. These patients experienced 79 local recurrences and a 5-year local recurrence probability of 5.95 %. For 207 patients with high-risk final histopathology, additional whole-breast treatment was administered. They experienced two local recurrences and a 5-year local recurrence probability of 0.5 % (p = 0.0009). CONCLUSIONS Whole-breast treatment works well at reducing local recurrence, and it is a totally acceptable and necessary addition to IORT as part of a risk-adapted program. However, the more whole-breast treatment that is given, the more it dilutes the original plan of simplifying local treatment and the less we understand exactly what IORT contributes to local control as a stand-alone treatment.
Collapse
Affiliation(s)
- Melvin J Silverstein
- Department of Surgery, Hoag Memorial Hospital Presbyterian, Newport Beach, CA, USA.
- Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
| | - Brian Kim
- Department of Radiation Oncology, Hoag Memorial Hospital Presbyterian, Newport Beach, CA, USA
| | - Kevin Lin
- Department of Radiation Oncology, Hoag Memorial Hospital Presbyterian, Newport Beach, CA, USA
| | - Shane Lloyd
- Department of Radiation Oncology, Hoag Memorial Hospital Presbyterian, Newport Beach, CA, USA
| | - Lincoln Snyder
- Department of Surgery, Hoag Memorial Hospital Presbyterian, Newport Beach, CA, USA
| | - Sadia Khan
- Department of Surgery, Hoag Memorial Hospital Presbyterian, Newport Beach, CA, USA
- Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Katherine Kramme
- Department of Surgery, Hoag Memorial Hospital Presbyterian, Newport Beach, CA, USA
- Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Peter Chen
- Department of Radiation Oncology, Hoag Memorial Hospital Presbyterian, Newport Beach, CA, USA
| |
Collapse
|
18
|
Shumway DA, Corbin KS, Farah MH, Viola KE, Nayfeh T, Saadi S, Shah V, Hasan B, Shah S, Mohammed K, Riaz IB, Prokop LJ, Murad MH, Wang Z. Partial breast irradiation compared with whole breast irradiation: a systematic review and meta-analysis. J Natl Cancer Inst 2023; 115:1011-1019. [PMID: 37289549 PMCID: PMC10483267 DOI: 10.1093/jnci/djad100] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 05/21/2023] [Accepted: 05/23/2023] [Indexed: 06/10/2023] Open
Abstract
BACKGROUND Early-stage breast cancer is among the most common cancer diagnoses. Adjuvant radiotherapy is an essential component of breast-conserving therapy, and several options exist for tailoring its extent and duration. This study assesses the comparative effectiveness of partial-breast irradiation (PBI) compared with whole-breast irradiation (WBI). METHODS A systematic review was completed to identify relevant randomized clinical trials and comparative observational studies. Independent reviewers working in pairs selected studies and extracted data. Randomized trial results were pooled using a random effects model. Prespecified main outcomes were ipsilateral breast recurrence (IBR), cosmesis, and adverse events (AEs). RESULTS Fourteen randomized clinical trials and 6 comparative observational studies with 17 234 patients evaluated the comparative effectiveness of PBI. PBI was not statistically significantly different from WBI for IBR at 5 years (RR = 1.34, 95% CI = 0.83 to 2.18; high strength of evidence [SOE]) and 10 years (RR = 1.29, 95% CI = 0.87 to 1.91; high SOE). Evidence for cosmetic outcomes was insufficient. Statistically significantly fewer acute AEs were reported with PBI compared with WBI, with no statistically significant difference in late AEs. Data from subgroups according to patient, tumor, and treatment characteristics were insufficient. Intraoperative radiotherapy was associated with higher IBR at 5, 10, and over than 10 years (high SOE) compared with WBI. CONCLUSIONS Ipsilateral breast recurrence was not statistically significantly different between PBI and WBI. Acute AEs were less frequent with PBI. This evidence supports the effectiveness of PBI among selected patients with early-stage, favorable-risk breast cancer who are similar to those represented in the included studies.
Collapse
Affiliation(s)
- Dean A Shumway
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN, USA
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | - Kimberly S Corbin
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN, USA
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | - Magdoleen H Farah
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN, USA
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Kelly E Viola
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN, USA
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Tarek Nayfeh
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN, USA
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Samer Saadi
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN, USA
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Vishal Shah
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN, USA
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Bashar Hasan
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN, USA
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Sahrish Shah
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN, USA
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Khaled Mohammed
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN, USA
| | - Irbaz Bin Riaz
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN, USA
| | - Larry J Prokop
- Library Public Services, Mayo Clinic, Rochester, MN, USA
| | - M Hassan Murad
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN, USA
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Zhen Wang
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN, USA
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
- Division of Health Care Delivery Research, Mayo Clinic, Rochester, MN, USA
| |
Collapse
|
19
|
Belkacemi Y, Biston MC, Benchekroun N, Benider A, Chargari C, Debbi K, Doré M, El Kacimi H, Flandin I, Lalya I, Samlali H, Sellal N, Supiot S. Limited applicability and implementation of the international oncology treatments guidelines in low- and middle-income countries, an example from the Mediterranean area borders. Cancer Radiother 2023; 27:666-675. [PMID: 37550156 DOI: 10.1016/j.canrad.2023.07.006] [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: 07/02/2023] [Revised: 07/09/2023] [Accepted: 07/10/2023] [Indexed: 08/09/2023]
Abstract
The quality of cancer care in the modern era is based on a precise diagnosis and personalized therapy according to patients and their disease based on validated guidelines with a high level of evidence. During cancer patients' management, the objective is first to make an accurate diagnosis and then offer the best treatment, validated beforehand in a multidisciplinary board meeting, with the best benefit/risk ratio. In the context of many low- and middle-income countries, the limited available means do not allow an adequate offer, resulting in non-optimal patients' care. In addition, in many low- and middle-income countries, priority can be given to other types of disease than cancer, which may considerably reduce allocation of specific resources to cancer care. Thus, the limited availability of systemic therapy, radiotherapy machines, brachytherapy and technological development may come up against another difficulty, that of geographical distribution of the means in the countries or a lack of expertise due to insufficient training programs. For all these reasons, the implementation of the guidelines established in Western countries could be impossible for many low- and middle-income countries which, moreover, have to face a completely different epidemiology of cancers compared to developed countries. In this work, we will discuss through a few examples of common cancers on both borders of the Mediterranean area, the applicability of the guidelines and the limits of their implementation for optimal cancer care.
Collapse
Affiliation(s)
- Y Belkacemi
- Department of Radiation Oncology and Henri-Mondor Breast Center, centre hospitalier universitaire Henri-Mondor, AP-HP, université Paris-Est Créteil, Créteil, France; Inserm U955, i-Biot Team, IMRB, university of Paris-Est Crétil, Créteil, France.
| | - M-C Biston
- Centre Léon-Bérard and Creatis, CNRS UMR 5225, Inserm U1044, Insa-Lyon, université Lyon 1, Villeurbanne, France
| | - N Benchekroun
- Department of Radiation Oncology, centre Mohamed-VI, université de Casablanca, Casablanca, Morocco
| | - A Benider
- Department of Radiation Oncology, centre Mohamed-VI, université de Casablanca, Casablanca, Morocco
| | - C Chargari
- Department of Radiation Oncology, groupe hospitalier Pitié-Salpêtrière, AP-HP, Sorbonne Université Paris VI, Paris, France
| | - K Debbi
- Department of Radiation Oncology and Henri-Mondor Breast Center, centre hospitalier universitaire Henri-Mondor, AP-HP, université Paris-Est Créteil, Créteil, France; Inserm U955, i-Biot Team, IMRB, university of Paris-Est Crétil, Créteil, France
| | - M Doré
- Department of Radiation Oncology, Institute de cancérologie de l'Ouest (ICO) centre René-Gauducheau, Saint-Herblain, France
| | - H El Kacimi
- Department of Radiation Oncology, Institut d'oncologie de Rabat, Rabat, Morocco
| | - I Flandin
- Department of Radiation Oncology, centre hospitalier universitaire de Grenoble, Grenoble, France
| | - I Lalya
- Department of Radiation Oncology, hôpital militaire Mohamed-V, Rabat, Morocco
| | - H Samlali
- Department of Radiation Oncology, clinique d'oncologie le Littoral, Casablanca, Morocco
| | - N Sellal
- Department of Radiation Oncology, hôpital universitaire Mohmed-VI, université Abdelmalek-Essadi, Tanger, Morocco
| | - S Supiot
- Department of Radiation Oncology, Institute de cancérologie de l'Ouest (ICO) centre René-Gauducheau, Saint-Herblain, France; Université de Nantes, Nantes, France
| |
Collapse
|
20
|
Martinez C, Meterissian S, Saidi A, Tremblay F, Meguerditchian AN, Fleiszer D, Lambert C, David M, Panet-Raymond V, Abdulkarim B, Hijal T. Targeted Intraoperative Radiation Therapy during Breast-Conserving Surgery for Patients with Early Stage Breast Cancer: A Phase II Single Center Prospective Trial. Adv Radiat Oncol 2023; 8:101236. [PMID: 37408681 PMCID: PMC10318266 DOI: 10.1016/j.adro.2023.101236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 03/26/2023] [Indexed: 07/07/2023] Open
Abstract
Purpose Patients with early stage breast cancer (ESBC) are conventionally treated with breast-conserving surgery (BCS) followed by whole-breast external beam radiation therapy (EBRT). The emergence of targeted intraoperative radiation therapy (TARGIT) with Intrabeam has been used as a therapeutic alternative for patients with risk-adapted ESBC. Here we present our radiation therapy toxicities (RTT), postoperative complications (PC), and short-term outcomes of the prospective phase II trial at the McGill University Health Center. Methods and Materials Patients aged ≥50 years with biopsy-proven hormone receptor-positive, grade 1 or 2, invasive ductal carcinoma of the breast, cT1N0, were eligible for the study. Enrolled patients underwent BCS followed by immediate TARGIT of 20 Gy in 1 fraction. Upon final pathology, patients with low-risk breast cancer (LRBC) received no further EBRT, and those with high-risk breast cancer (HRBC) received further 15 to 16 fractions of whole breast EBRT. HRBC criteria included pathologic tumor size >2 cm, grade 3, positive lympho-vascular invasion, multifocal disease, close margins (<2 mm), or positive nodal disease. Results A total of 61 patients with ESBC were enrolled in the study; upon final pathology, 40 (65.6%) had LRBC, and 21 (34.4%) had HRBC. The median follow-up was 3.9 years. The most common HRBC criteria were close margins in 66.6% (n = 14) and lymphovascular invasion in 28.6% (n = 6). No grade 4 RTT were observed in either group. The most common PC were seroma and cellulitis for both groups. The rate of locoregional recurrence was 0% in both groups. The overall survival in LRBC was 97.5% and in HRBC 95.2% with no significant differences. Deaths were nonbreast cancer related. Conclusions In patients with ESBC undergoing BCS, the use of TARGIT shows low rates of RTT and PC complications. Moreover, our short-term outcomes show no significant difference at 3.9 years median follow-up for locoregional recurrence or overall survival between groups of patients receiving TARGIT alone or TARGIT followed by EBRT. Of all patients, 34.4% required further EBRT, most commonly due to close margins.
Collapse
Affiliation(s)
- Constanza Martinez
- Division of Radiation Oncology, McGill University Health Centre, Quebec, Canada
| | - Sarkis Meterissian
- Department of Surgery, McGill University Health Centre, Montreal, Quebec, Canada
| | - Asma Saidi
- Division of Radiation Oncology, McGill University Health Centre, Quebec, Canada
| | - Francine Tremblay
- Department of Surgery, McGill University Health Centre, Montreal, Quebec, Canada
| | | | - David Fleiszer
- Department of Surgery, McGill University Health Centre, Montreal, Quebec, Canada
| | - Christine Lambert
- Division of Radiation Oncology, McGill University Health Centre, Quebec, Canada
| | - Marc David
- Division of Radiation Oncology, McGill University Health Centre, Quebec, Canada
| | | | - Bassam Abdulkarim
- Division of Radiation Oncology, McGill University Health Centre, Quebec, Canada
| | - Tarek Hijal
- Division of Radiation Oncology, McGill University Health Centre, Quebec, Canada
| |
Collapse
|
21
|
Colciago RR, La Rocca E, Giandini C, Rejas Mateo A, Bedini N, Capri G, Folli S, Lozza L, Meroni S, Emanuele P, Rancati T, Arcangeli S, De Santis MC. One-week external beam partial breast irradiation: survival and toxicity outcomes. J Cancer Res Clin Oncol 2023; 149:10965-10974. [PMID: 37329461 DOI: 10.1007/s00432-023-04973-y] [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: 05/04/2023] [Accepted: 06/04/2023] [Indexed: 06/19/2023]
Abstract
PURPOSE According to ASTRO and ESTRO guidelines, external beam Partial Breast Irradiation (PBI) is a valid option for early-stage breast cancer patients. Nevertheless, there is lack of consensus about the best treatment schedule. METHODS We retrospectively analysed data of female patients treated at our institution from 2013 to 2022 with adjuvant "one-week" partial breast irradiation. Clinical Target Volume (CTV) was an isotropic expansion of 15 mm from the tumour bed (identified as the breast tissue between surgical clips). The treatment schedule was 30 Gy delivered with Volumetric Modulated Arc Therapy in 5 daily fractions. The primary endpoint was Local Control (LC). Disease-Free Survival (DFS), Overall Survival (OS) and safety were secondary endpoints. RESULTS Three hundred and forty-four patients with a median age of 69 (33-87) years were included in the study. After a median follow-up of 34 (7-105) months, 7 patients (2.0%) developed a local recurrence. Three-year LC, DFS and OS actuarial rates were 97.5% (95% CI 96.2%-98.8%), 95.7% (95% CI 94.2%-97.2%), and 96.9% (95% CI 95.7%-98.1%), respectively. Ten (2.9%) patients experienced grade 2 late toxicities. Five (1.5%) patients reported late cardiac major events. Three (0.9%) late pulmonary toxicities were detected. One hundred and five (30.5%) patients reported fat necrosis. Good or excellent cosmetic evaluation following the Harvard Scale was reported in 252 (96.9%) cases by the physicians, while in 241 (89.2%) cases by the patients. CONCLUSION "One-week" PBI is effective and safe, and this schedule is a valid option for highly selected early breast cancer patients.
Collapse
Affiliation(s)
- Riccardo Ray Colciago
- School of Medicine and Surgery, University of Milan Bicocca, Milan, Italy
- Department of Radiation Oncology, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Eliana La Rocca
- Department of Radiation Oncology, Azienda Ospedaliero Universitaria Integrata, P.le A. Stefani 1, 37126, Verona, Italy.
| | - Carlotta Giandini
- Department of Radiation Oncology, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Alicia Rejas Mateo
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Nice Bedini
- Department of Radiation Oncology, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Giuseppe Capri
- Medical Oncology Department, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Secondo Folli
- Breast Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Laura Lozza
- Department of Radiation Oncology, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Silvia Meroni
- Medical Physics Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Pignoli Emanuele
- Medical Physics Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Tiziana Rancati
- Data Science Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Stefano Arcangeli
- School of Medicine and Surgery, University of Milan Bicocca, Milan, Italy
- Department of Radiation Oncology, Ospedale S. Gerardo, Monza, Italy
| | - Maria Carmen De Santis
- Department of Radiation Oncology, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| |
Collapse
|
22
|
Wang Y, Shen J, Gu P, Wang Z. Recent advances progress in radiotherapy for breast cancer after breast-conserving surgery: a review. Front Oncol 2023; 13:1195266. [PMID: 37671064 PMCID: PMC10475720 DOI: 10.3389/fonc.2023.1195266] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 08/07/2023] [Indexed: 09/07/2023] Open
Abstract
Adjuvant radiotherapy after breast-conserving surgery has become an integral part of the treatment of breast cancer. In recent years, the development of radiotherapy technology has made great progress in this field, including the comparison of the curative effects of various radiotherapy techniques and the performance of the segmentation times. The choice of radiotherapy technology needs to be co-determined by clinical evidence practice and evaluated for each individual patient to achieve precision radiotherapy. This article discusses the treatment effects of different radiotherapy, techniques, the risk of second cancers and short-range radiation therapy techniques after breast-conserving surgery such as hypo fractionated whole breast irradiation and accelerated partial breast irradiation. The choice of radiotherapy regimen needs to be based on the individual condition of the patient, and the general principle is to focus on the target area and reduce the irradiation of the normal tissues and organs. Short-range radiotherapy and hypofractionated are superior to conventional radiotherapy and are expected to become the mainstream treatment after breast-conserving surgery.
Collapse
Affiliation(s)
- Yun Wang
- Department of Radiation Oncology, Shidong Hospital, Shidong Hospital Affiliated to University of Shanghai for Science and Technology, Shanghai, China
| | - Jingjing Shen
- Department of Radiation Oncology, Shidong Hospital, Shidong Hospital Affiliated to University of Shanghai for Science and Technology, Shanghai, China
- School of Health Science and Engineering, University of Shanghai for Science and Technology, Shanghai, China
| | - Peihua Gu
- Department of Radiation Oncology, Shidong Hospital, Shidong Hospital Affiliated to University of Shanghai for Science and Technology, Shanghai, China
| | - Zhongming Wang
- Department of Radiation Oncology, Shidong Hospital, Shidong Hospital Affiliated to University of Shanghai for Science and Technology, Shanghai, China
- School of Health Science and Engineering, University of Shanghai for Science and Technology, Shanghai, China
| |
Collapse
|
23
|
Sanz J, Eraso A, Ibáñez R, Williams R, Algara M. Tumor Bed Boost Radiotherapy in the Conservative Treatment of Breast Cancer: A Review of Intra-Operative Techniques and Outcomes. Cancers (Basel) 2023; 15:4025. [PMID: 37627053 PMCID: PMC10452620 DOI: 10.3390/cancers15164025] [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: 07/03/2023] [Revised: 08/01/2023] [Accepted: 08/07/2023] [Indexed: 08/27/2023] Open
Abstract
Conservative surgery is the preferred treatment in the management of breast cancer followed by adjuvant whole-breast irradiation. Since the tumor bed is the main site of relapse, boost doses are conveniently administered according to risk factors for local relapse to increase the efficacy of the treatment. The benefit of a radiation boost is well established and it can be performed by several techniques like brachytherapy, external radiation or intraoperative radiotherapy. Greater precision in localizing the tumor cavity, immediacy and increased biological response are the main advantages of intraoperative boost irradiation. This modality of treatment can be performed by means of mobile electron accelerators or low-photon X-ray devices. There is a lot of research and some published series analyzing the results of the use of an intraoperative boost as an adjuvant treatment, after neoadjuvant systemic therapy and in combination with some reconstructive surgeries. This review discusses advantages of intraoperative radiotherapy and presents the main results of a boost in terms of local control, survival, tolerance and cosmesis.
Collapse
Affiliation(s)
- Javier Sanz
- Radiation Oncology Department, Hospital del Mar Barcelona, 08003 Barcelona, Spain
- Facultat de Medicina, Campus del Mar, Universitat Pompeu Fabra, 08002 Barcelona, Spain
| | - Arantxa Eraso
- Radiation Oncology Department, Institut Català d’Oncologia, Hospital Trueta, 17007 Girona, Spain;
- Facultat de Medicina, Campus Centre, Universitat de Girona, 17004 Girona, Spain
| | - Reyes Ibáñez
- Radiation Oncology Department, Hospital Universitario Miguel Servet, 50009 Zaragoza, Spain;
| | - Rachel Williams
- College of Liberal Arts, Texas A&M University, College Station, TX 77843, USA;
| | - Manuel Algara
- Radiation Oncology Department, Hospital del Mar Barcelona, 08003 Barcelona, Spain
- Facultat de Medicina, Campus del Mar, Universitat Pompeu Fabra, 08002 Barcelona, Spain
| |
Collapse
|
24
|
Hochhertz F, Hass P, Röllich B, Ochel HJ, Gawish A. A single-institution retrospective analysis of intraoperative radiation boost during breast-conservation treatment for breast cancer. J Cancer Res Clin Oncol 2023; 149:5743-5749. [PMID: 36566484 PMCID: PMC10356640 DOI: 10.1007/s00432-022-04534-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 12/16/2022] [Indexed: 12/26/2022]
Abstract
BACKGROUND As part of a breast-conservation strategy for breast cancer, there are presently no data from randomized controlled studies on the use of intraoperative radiation (IORT) as a tumor bed boost. The effectiveness and safety of IORT as a boost therapy at a tertiary cancer center were retrospectively reviewed in this study. METHODS Patients had breast-conserving surgery from 2012 to 2016 that included staging of the axillary lymph nodes, a single dose of 20 Gy IORT with 50-kV photons, whole-breast irradiation (WBI), and (neo-)adjuvant systemic treatment (if applicable). During the follow-up patients were monitored for the assessment of acute and late toxicities (using the Common Terminology Criteria for Adverse Events version 4.03). Results included ipsilateral (IBTR), contralateral (CBE), and distant metastasis-free (DMFS) breast progression-free survival, as well as overall survival (OS). RESULTS The 68 patients had a median follow-up of 91.5 months (with a range of 9-125). Most patients (n = 51) had T1 disease and were clinically node negative. Only a small number of individuals had triple negative or high-grade illness. The majority of patients had sentinel node biopsy, and three (4.4%) had to have their tumors removed again since their original margins were positive. Finally, there were no distinct tumor bed margins. Neoadjuvant chemotherapy was administered to ten (14.7%). The median duration from BCS to WBI was 54.5 days, and conventionally fractionated WBI was used to accomplish WBI most frequently (n = 57, 96.6%). IORT was administered in a single 20 Gy dosage. 50 Gy was the median WBI dosage (range 40.05-50.4 Gy). There were no grade 4 adverse events for any patients in. Toxicities following surgery were minimal. There were only one patient with grade 3 toxicity (radiation dermatitis) to observe. Five tumor bed recurrences and two contralateral breast incident each occurred. CONCLUSION This work adds to the preliminary evidence already in the literature and supports the use of IORT in boost settings. When randomized trials like TARGIT-B are eventually published, these hopeful findings should be prospectively evaluated.
Collapse
Affiliation(s)
- Franka Hochhertz
- Department of Radiation Oncology, University Hospital Magdeburg, Leipziger Str. 44, 39120, Magdeburg, Germany
| | - Peter Hass
- Department of Radiation Oncology, University Hospital Magdeburg, Leipziger Str. 44, 39120, Magdeburg, Germany
- Department of Radiation Oncology, Erfurt Helios Hospital, Erfurt, Germany
| | - Burkard Röllich
- Department of Radiation Oncology, University Hospital Magdeburg, Leipziger Str. 44, 39120, Magdeburg, Germany
| | - Hans-Joachim Ochel
- Department of Radiation Oncology, University Hospital Magdeburg, Leipziger Str. 44, 39120, Magdeburg, Germany
| | - Ahmed Gawish
- Department of Radiation Oncology, University Hospital Magdeburg, Leipziger Str. 44, 39120, Magdeburg, Germany.
| |
Collapse
|
25
|
Fan Y, Chen R, Lu Y, Lin Y, Zhang Y, Shao N, Wang S, Nie D, Shan Z. The Efficacy of Low-Kilovoltage X-Rays Intraoperative Radiation as Boost for Breast Cancer: A Systematic Review and Meta-Analysis. Breast J 2023; 2023:9035266. [PMID: 37435101 PMCID: PMC10332922 DOI: 10.1155/2023/9035266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Revised: 05/05/2023] [Accepted: 06/24/2023] [Indexed: 07/13/2023]
Abstract
Background Intraoperative radiotherapy (IORT) is a novel promising technology that may replace external beam radiation therapy (EBRT) as boost for patients receiving breast-conserving surgery. To better evaluate the efficacy of IORT using low-kilovoltage (low-kV) X-rays as boost, we presented this meta-analysis according to the PRISMA checklist. Methods Studies reported survival outcomes of intraoperative radiation using low-kilovoltage X-rays system (Intrabeam®, Carl Zeiss Meditec, Dublin, CA, USA) as boost were identified through electronic bibliographic database: PUBMED. The meta-analysis module in Stata (16.0) is used to pool the studies. A Poisson regression model is used to predict a 5-year local recurrence rate. Results Twelve studies including 3006 cases were included in the final analysis, with a median follow-up of 55 months weighted by sample size. The pooled local recurrence rate is 0.39% per person-year (95% CI: 0.15%-0.71%), with a low degree of heterogeneity (I2 = 0%). The predicted 5-year local recurrence rate was 3.45%. No difference in pooled local recurrence rate was found between non-neoadjuvant patients studies and neoadjuvant patients studies (0.41% per person-year vs. 0.58% per person-year, P = 0.580). Conclusions This study shows that low-kV IORT is an effective method as boost in breast cancer patients, with a low pooled local recurrence rate and low predicted 5-year local recurrence rate. Besides, no difference in the local recurrence rate was found between non-neoadjuvant patients studies and neoadjuvant patients studies. Low-kV IORT boost may be a promising alternative to EBRT boost in the future, which is being tested in the ongoing TARGIT-B trial.
Collapse
Affiliation(s)
- Yuanjian Fan
- Center of Vascular-Thyroid-Breast Surgery, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Ruiwan Chen
- Department of Radiology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Ying Lu
- Department of Ultrasound, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Ying Lin
- Center of Vascular-Thyroid-Breast Surgery, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Yunjian Zhang
- Center of Vascular-Thyroid-Breast Surgery, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Nan Shao
- Center of Vascular-Thyroid-Breast Surgery, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Shenming Wang
- Center of Vascular-Thyroid-Breast Surgery, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Dahong Nie
- Department of Radiology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Zhen Shan
- Center of Vascular-Thyroid-Breast Surgery, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| |
Collapse
|
26
|
Abstract
Breast cancer is the most prevalent cancer in women, and the second leading cause of cancer death in women in the United States. Radiation therapy is an important component in the multimodal management of breast cancer, including early stage and locally advanced breast cancers, as well as metastatic cases. Breast cancer radiation therapy has seen significant advancements over the past 20 years. This article discusses the latest advances in the radiotherapeutic management of breast cancer, especially focusing on the technological advances in radiation treatment planning and techniques that have exploited the understanding of radiation biology.
Collapse
Affiliation(s)
- Rituraj Upadhyay
- Department of Radiation Oncology, The Ohio State University Medical Center, The Arthur G. James Cancer Hospital D259, 460 W 10th Avenue, Columbus, OH 43210, USA
| | - Jose G Bazan
- Department of Radiation Oncology, The Ohio State University Medical Center, The Arthur G. James Cancer Hospital and Solove Research Institute, The Ohio State University Comprehensive Cancer Center, 1145 Olentangy River Road, Columbus, OH 43212, USA.
| |
Collapse
|
27
|
Stefanelli A, Farina E, Mastella E, Fabbri S, Turra A, Bonazza S, De Troia A, Radica MK, Carcoforo P. Full-Dose Intraoperative Electron Radiotherapy for Early Breast Cancer: Evidence from a Single Center's Experience. Cancers (Basel) 2023; 15:3239. [PMID: 37370849 DOI: 10.3390/cancers15123239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 06/12/2023] [Accepted: 06/16/2023] [Indexed: 06/29/2023] Open
Abstract
To evaluate the clinical response rate and cosmetic outcome after full-dose intraoperative electron radiotherapy (IOERT) in early breast cancer (BC) treated with conserving surgery. Inclusion criteria were: >60 years old, clinical tumor size ≤2 cm, luminal A carcinoma, patological negative lymph nodes, excluded lobular carcinoma histology. IOERT was delivered with a dose of 21 Gy at 90% isodose. Clinical, cosmetic and/or instrumental follow-up were performed 45 days after IOERT, 6 months after the first check, and every 12 months thereafter. Acute and late toxicities were assessed with the CTCAE v.4.03 and EORTC-RTOG scales, respectively. Cosmetic outcome was evaluated using the Harvard/NSABO/RTOG Breast Cosmesis Grading Scale. Overall, 162 consecutive patients were included in this analysis (median follow-up: 54 months, range: 1-98 months). The overall response rate was 97.5% (CI 95%: 0.93-0.99%). Locoragional relapse occurred in 2.5% of patients. No patient showed distant metastases. No patient showed radiation-related acute complications, with 3.7% showing late G2-3 toxicity. Only 3.7% of patients showed poor cosmetic results. Our data confirmed that IOERT is a feasible and valid therapeutic option in low-risk BC patients treated with lumpectomy. A low local recurrence rate combined with good cosmetic results validates the settings of our operative method in routinely clinical practice.
Collapse
Affiliation(s)
- Antonio Stefanelli
- Department of Radiation Oncology, University Hospital of Ferrara, 44121 Ferrara, Italy
| | - Eleonora Farina
- Department of Radiation Oncology, University Hospital of Ferrara, 44121 Ferrara, Italy
| | - Edoardo Mastella
- Department of Medical Physics, University Hospital of Ferrara, 44121 Ferrara, Italy
| | - Sara Fabbri
- Department of Medical Physics, University Hospital of Ferrara, 44121 Ferrara, Italy
| | - Alessandro Turra
- Department of Medical Physics, University Hospital of Ferrara, 44121 Ferrara, Italy
| | - Simona Bonazza
- Department of Surgery, University Hospital of Ferrara, 44121 Ferrara, Italy
| | | | | | - Paolo Carcoforo
- Department of Surgery, University Hospital of Ferrara, 44121 Ferrara, Italy
| |
Collapse
|
28
|
Torabinejad S, Soleymanifard S, Sayyah S, Behnam Rasouli F. High-dose Irradiation Stimulated Breast Tumor Microenvironment to Enhance Tumor Cell Growth and Decrease Tumor Cell Motility. J Biomed Phys Eng 2023; 13:209-216. [PMID: 37312890 PMCID: PMC10258208 DOI: 10.31661/jbpe.v0i0.2008-1167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 11/25/2020] [Indexed: 06/15/2023]
Abstract
Background Surgery and radiotherapy are two main modalities of breast cancer treatment. However, surgery affects the tumor microenvironment negatively and promotes the growth of possible malignant cells remaining in the tumor bed. Objective The present study aimed to investigate the effects of intraoperative radiotherapy (IORT) on the tumor microenvironment. Therefore, the effect of surgical wound fluid (WF), collected from operated and irradiated patients on the growth and motility of a breast cancer cell line (MCF-7) was assessed. Material and Methods In this experimental study, preoperative blood serum (PS) and secreted WF from 18 patients who underwent breast-conserving surgery (IORT-) and 19 patients who received IORT following surgery (IORT+) were collected. The samples were purified and added to MCF-7 cultures. Two groups of the cells were treated with and without fetal bovine serum (FBS) and used as positive and negative controls. Applying 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) and scratch wound healing assays, the growth and motility of MCF-7 cells were measured. Results Cell growth of the cells receiving WF from IORT+ patients (WF+) was statistically higher than the corresponding values of the cells received PS or WF from IORT- patients (WF-) (P<0.01). Both WF+ and WF- decreased the cells' migration ability compared to PS (P<0.02) and FBS (P<0.002), although WF+ caused a more significant reduction (P<0.02). Conclusion Wound fluid extracted from breast cancer patients who underwent both surgery and IORT increased the growth of breast tumor cells, but decreased their ability to migrate.
Collapse
Affiliation(s)
- Sepehr Torabinejad
- Department of Genetics, Tehran Medical Sciences Branch, Islamic Azad University, Tehran, Iran
| | | | - Sima Sayyah
- Department of Biophysics, Faculty of Sciences, Mashhad Branch, Islamic Azad University, Mashhad, Iran
| | - Fatemeh Behnam Rasouli
- Novel Diagnostics and Therapeutics Research Group, Institute of Biotechnology, Ferdowsi University of Mashhad, Mashhad, Iran
| |
Collapse
|
29
|
Yashar C, Khan AJ, Chen P, Einck J, Poppe M, Li L, Yehia ZA, Vicini FA, Moore D, Arthur D, Quinn TJ, Kowzun M, Simon L, Scanderbeg D, Shah C, Haffty BG, Kuske R. Three-Fraction Accelerated Partial Breast Irradiation (APBI) Delivered With Interstitial Brachytherapy Is Safe: First Results From the Tri-fraction Radiation Therapy Used to Minimize Patient Hospital Trips (TRIUMPH-T) Trial. Pract Radiat Oncol 2023:S1879-8500(23)00062-0. [PMID: 37140504 DOI: 10.1016/j.prro.2023.03.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 02/27/2023] [Accepted: 03/07/2023] [Indexed: 05/05/2023]
Abstract
PURPOSE Shorter courses of breast radiotherapy are offered as an alternative to 4 weeks of whole-breast irradiation after lumpectomy, including brachytherapy. A prospective phase 2multi-institution clinical trial to study 3-fraction accelerated partial breast irradiation delivered by brachytherapy was conducted. METHODS AND MATERIALS The trial treated selected breast cancers after breast-conserving surgery with brachytherapy applicators that delivered 22.5 Gy in 3 fractions of 7.5 Gy. The planning treatment volume was 1 to 2 cm beyond the surgical cavity. Eligible women were age ≥45 years with unicentric invasive or in situ tumors ≤3 cm excised with negative margins and with positive estrogen or progesterone receptors and no metastases to axillary nodes. Strict dosimetric parameters were required to be met and follow up information was collected from the participating sites. RESULTS Two hundred patients were prospectively enrolled; however, a total of 185 patients who were enrolled were followed for a median of 3.63 years. Three-fraction brachytherapy was associated with low chronic toxicity. There was excellent or good cosmesis in 94% of patients. There were no grade 4 toxicities. Grade 3 fibrosis at the treatment site was present in 1.7% and 32% percent had grades 1 or 2 fibrosis at the treatment site. There was 1 rib fracture. Other late toxicities included 7.4% grade 1 hyperpigmentation, 2% grade 1 telangiectasias, 1.7% symptomatic seromas, 1.7% abscessed cavities, and 1.1% symptomatic fat necrosis. There were 2 (1.1%) ipsilateral local recurrences, 2 (1.1%) nodal recurrences and no distant recurrences. Other incidents included one contralateral breast cancer and 2 second malignancies (lung). CONCLUSIONS Ultra-short breast brachytherapy is feasible and has excellent toxicity and could be an alternative to standard 5-day, 10 fraction accelerated partial breast irradiation in eligible patients. Patients from this prospective trial will continue to be followed to evaluate long-term outcomes.
Collapse
Affiliation(s)
- Catheryn Yashar
- UC San Diego/Moores Cancer Center, La Jolla, California; Bryn Mawr Hospital, Bryn Mawr, Pennsylvania.
| | - Atif J Khan
- Memorial Sloan Kettering Cancer Center, New York, New York
| | - Peter Chen
- William Beaumont Hospital/Rose Cancer Treatment Center, Royal Oak, Michigan
| | - John Einck
- Kansas University Medical Center, Kansas City, Kansas
| | - Matthew Poppe
- Hunstman Cancer Center, University of Utah, Salt Lake City, Utah
| | - Linna Li
- William Beaumont Hospital/Rose Cancer Treatment Center, Royal Oak, Michigan
| | | | - Frank A Vicini
- Michigan Health care Professional, 21st Century Oncology, Farmington Hills, Michigan
| | - Dirk Moore
- Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
| | - Doug Arthur
- Virginia Commonwealth University, Massey Cancer Center, Richmond, Virginia
| | - T J Quinn
- William Beaumont Hospital/Rose Cancer Treatment Center, Royal Oak, Michigan
| | - Maria Kowzun
- Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
| | - Laurie Simon
- UC San Diego/Moores Cancer Center, La Jolla, California
| | | | - Chirag Shah
- Cleveland Clinic Cancer Center, Cleveland, Ohio
| | - Bruce G Haffty
- Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
| | - Robert Kuske
- Arizona Breast Cancer Specialists, Scottsdale, Arizona
| |
Collapse
|
30
|
Meattini I, de Oliveira Franco R, Salvestrini V, Hijal T. Special issue. De-escalation of loco-regional treatment in breast cancer: Time to find the balance? Partial breast irradiation. Breast 2023; 69:401-409. [PMID: 37116401 PMCID: PMC10163674 DOI: 10.1016/j.breast.2023.04.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 04/15/2023] [Accepted: 04/23/2023] [Indexed: 04/30/2023] Open
Abstract
Breast cancer is the most common cancer in women worldwide. Over the past few decades, remarkable progress has been made in understanding the biology and pathology of breast cancer. A personalized conservative approach has been currently adopted addressing the patient's individual risk of relapse. After postoperative whole breast irradiation for early-stage breast cancer, a rate of recurrences outside the initial tumour bed lower than 4% was observed. Thus, the highest benefits of breast irradiation seem to result from the dose delivered to the tissue neighbouring the tumour bed. Nonetheless, reducing treatment morbidity while maintaining radiation therapy's ability to decrease local recurrences is an important challenge in treating patients with radiation therapy. In this regard, strategies such as partial-breast irradiation have been developed to reduce toxicity without compromising oncologic outcomes. According to the national and international published guidelines, clinical oncologists can refer to specific dose/fractionation schedules and eligible criteria. However, there are still some areas of open questions. Breast cancer represents a multidisciplinary paradigm; it should be considered a heterogeneous disease where a "one-treatment-fits-all" approach cannot be considered an appropriate option. This is a wide overview on the main partial breast irradiation advantages, risks, timings, techniques, and available recommendations. We aim to provide practical findings to support clinical decision-making, exploring future perspectives, towards a balance for optimisation of breast cancer.
Collapse
Affiliation(s)
- 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.
| | - Rejane de Oliveira Franco
- Department of Oncology, McGill University, Montreal, Canada; Division of Radiation Oncology, McGill University Health Centre, Montreal, Canada
| | - Viola Salvestrini
- 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
| | - Tarek Hijal
- Department of Oncology, McGill University, Montreal, Canada; Division of Radiation Oncology, McGill University Health Centre, Montreal, Canada
| |
Collapse
|
31
|
Vijayakumar S, Nittala MR, Buddala V, Mobit P, Duggar WN, Yang CC, Lirette ST, Mundra E, Ahmed HZ, Berry SM, Craft BS, Woods WC, Otts J, Rahimi A, Dobbs T. Real World and Public Health Perspectives of Intraoperative Radiotherapy in Early-Stage Breast Cancer: A Multidisciplinary Analysis Beyond the Statistical Facts. Cureus 2023; 15:e36432. [PMID: 37025715 PMCID: PMC10072193 DOI: 10.7759/cureus.36432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/20/2023] [Indexed: 04/08/2023] Open
Abstract
Breast conservation therapy (BCT) (usually a lumpectomy plus radiotherapy (RT)) has become a standard alternative to radical mastectomy in early-stage breast cancers with equal, if not higher, survival rates. The established standard of the RT component of the BCT had been about six weeks of Monday through Friday external beam RT to the whole breast (WBRT). Recent clinical trials have shown that partial breast radiation therapy (PBRT) to the region surrounding the lumpectomy cavity with shorter courses can result in equal local control, survival, and slightly improved cosmetic outcomes. Intraoperative RT (IORT) wherein RT is administered at the time of operation for BCT to the lumpectomy cavity as a single-fraction RT is also considered PBRT. The advantage of IORT is that weeks of RT are avoided. However, the role of IORT as part of BCT has been controversial. The extreme views go from "I will not recommend to anyone" to "I can recommend to all early-stage favorable patients." These divergent views are due to difficulty in interpreting the clinical trial results. There are two modalities of delivering IORT, namely, the use of low-energy 50 kV beams or electron beams. There are several retrospective, prospective, and two randomized clinical trials comparing IORT versus WBRT. Yet, the opinions are divided. In this paper, we try to bring clarity and consensus from a highly broad-based multidisciplinary team approach. The multidisciplinary team included breast surgeons, radiation oncologists, medical physicists, biostatisticians, public health experts, nurse practitioners, and medical oncologists. We show that there is a need to more carefully interpret and differentiate the data based on electron versus low-dose X-ray modalities; the randomized study results have to be extremely carefully dissected from biostatistical points of view; the importance of the involvement of patients and families in the decision making in a very transparent and informed manner needs to be emphasized; and the compromise some women may be willing to accept between 2-4% potential increase in local recurrence (as interpreted by some of the investigators in IORT randomized studies) versus mastectomy. We conclude that, ultimately, the choice should be that of women with detailed facts of the pros and cons of all options being presented to them from the angle of patient/family-focused care. Although the guidelines of various professional societies can be helpful, they are only guidelines. The participation of women in IORT clinical trials is still needed, and as genome-based and omics-based fine-tuning of prognostic fingerprints evolve, the current guidelines need to be revisited. Finally, the use of IORT can help rural, socioeconomically, and infrastructure-deprived populations and geographic regions as the convenience of single-fraction RT and the possibility of breast preservation are likely to encourage more women to choose BCT than mastectomy. This option can also likely lead to more women choosing to get screened for breast cancer, thus enabling the diagnosis of breast cancer at an earlier stage and improving the survival outcomes.
Collapse
Affiliation(s)
| | - Mary R Nittala
- Radiation Oncology, University of Mississippi Medical Center, Jackson, USA
| | - Vedanth Buddala
- Radiation Oncology, University of Mississippi Medical Center, Jackson, USA
| | - Paul Mobit
- Radiation Oncology, University of Mississippi Medical Center, Jackson, USA
| | - William N Duggar
- Radiation Oncology, University of Mississippi Medical Center, Jackson, USA
| | - Claus Chunli Yang
- Radiation Oncology, University of Mississippi Medical Center, Jackson, USA
| | | | - Eswar Mundra
- Radiation Oncology, University of Mississippi Medical Center, Jackson, USA
| | - Hiba Z Ahmed
- Radiation Oncology, University of Mississippi Medical Center, Jackson, USA
| | - Scott M Berry
- Surgery, University of Mississippi Medical Center, Jackson, USA
| | - Barbara S Craft
- Medicine, University of Mississippi Medical Center, Jackson, USA
| | - William C Woods
- Radiation Oncology, University of Mississippi Medical Center, Jackson, USA
| | - Jeremy Otts
- Radiation Oncology, University of Mississippi Medical Center, Jackson, USA
| | - Asal Rahimi
- Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, USA
| | - Thomas Dobbs
- Population Health, University of Mississippi Medical Center, Jackson, USA
| |
Collapse
|
32
|
Squeo GC, Meneveau MO, Varhegyi NE, Lattimore CM, Janowski E, Showalter TN, Showalter SL. Factors Associated With Cosmetic Outcomes After Treatment With a Novel Form of Breast Intraoperative Radiation Therapy. J Surg Res 2023; 283:514-522. [PMID: 36436288 DOI: 10.1016/j.jss.2022.10.077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 09/07/2022] [Accepted: 10/15/2022] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Precision breast intraoperative radiation therapy (PB-IORT) incorporates computed tomography-guided treatment planning and high dose rate brachytherapy to deliver a single dose of highly conformal radiational therapy. The purpose of this study is to determine factors associated with poor cosmetic outcomes after treatment with PB-IORT. METHODS The study included all consecutive participants enrolled in an ongoing phase II clinical trial that had completed a minimum of 12 mo of follow-up. A poor cosmetic outcome was defined as scoring "fair" or "poor" on the Harvard Cosmesis evaluation, or "some" or "very much" on any of the three general cosmesis categories. Statistical analysis was performed utilizing R. RESULTS The final cohort included 201 participants, of which 181 (90%) had an overall good/excellent cosmetic outcome. Group 1 consisted of 162 (81%) participants who reported only excellent/good cosmetic outcomes. Group 2 consisted of 39 (19%) participants who reported some aspect of a poor cosmetic outcome. On multivariable analysis, participants with ductal carcinoma in situ were significantly more likely to experience a poor cosmetic outcome (odds ratio 2.45, 95% confidence interval 1.03-5.82, P = 0.04), and those who received subsequent whole breast irradiation were also more likely to have a poor cosmetic outcome (odds ratio 10.20, 95% confidence interval CI 1.04-99.95, P = 0.04). CONCLUSIONS Patients with need for further radiation after PB-IORT are at increased risk for a poor cosmetic outcome. Larger balloon volume and distance between the skin do not have deleterious effects on cosmetic outcomes.
Collapse
Affiliation(s)
- Gabriella C Squeo
- University of Virginia School of Medicine, Department of Surgery, Charlottesville, Virginia
| | - Max O Meneveau
- University of Virginia School of Medicine, Department of Surgery, Charlottesville, Virginia
| | - Nikole E Varhegyi
- University of Virginia School of Medicine, Department of Public Health Sciences, Charlottesville, Virginia
| | - Courtney M Lattimore
- University of Virginia School of Medicine, Department of Surgery, Charlottesville, Virginia
| | - Einsley Janowski
- University of Virginia School of Medicine, Department of Radiation Oncology, Charlottesville, Virginia
| | - Timothy N Showalter
- University of Virginia School of Medicine, Department of Radiation Oncology, Charlottesville, Virginia
| | - Shayna L Showalter
- University of Virginia School of Medicine, Department of Surgery, Charlottesville, Virginia.
| |
Collapse
|
33
|
Recent Advances in Optimizing Radiation Therapy Decisions in Early Invasive Breast Cancer. Cancers (Basel) 2023; 15:cancers15041260. [PMID: 36831598 PMCID: PMC9954587 DOI: 10.3390/cancers15041260] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 02/07/2023] [Accepted: 02/10/2023] [Indexed: 02/18/2023] Open
Abstract
Adjuvant whole breast irradiation after breast-conserving surgery is a well-established treatment standard for early invasive breast cancer. Screening, early diagnosis, refinement in surgical techniques, the knowledge of new and specific molecular prognostic factors, and now the standard use of more effective neo/adjuvant systemic therapies have proven instrumental in reducing the rates of locoregional relapses. This underscores the need for reliably identifying women with such low-risk disease burdens in whom elimination of radiation from the treatment plan would not compromise oncological safety. This review summarizes the current evidence for radiation de-intensification strategies and details ongoing prospective clinical trials investigating the omission of adjuvant whole breast irradiation in molecularly defined low-risk breast cancers and related evidence supporting the potential for radiation de-escalation in HER2+ and triple-negative clinical subtypes. Furthermore, we discuss the current evidence for the de-escalation of regional nodal irradiation after neoadjuvant chemotherapy. Finally, we also detail the current knowledge of the clinical value of stromal tumor-infiltrating lymphocytes and liquid-based biomarkers as prognostic factors for locoregional relapse.
Collapse
|
34
|
Merten R, Fischer M, Kopytsia G, Wichmann J, Lange T, Knöchelmann AC, Becker JN, Klapdor R, Hinrichs J, Bremer M. Linac-Based Ultrahypofractionated Partial Breast Irradiation (APBI) in Low-Risk Breast Cancer: First Results of a Monoinstitutional Observational Analysis. Cancers (Basel) 2023; 15:cancers15041138. [PMID: 36831481 PMCID: PMC9954287 DOI: 10.3390/cancers15041138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Revised: 01/15/2023] [Accepted: 02/08/2023] [Indexed: 02/12/2023] Open
Abstract
Purpose: For adjuvant radiotherapy of low-risk breast cancer after breast-conserving surgery, there have been many trials of hypofractionation and partial breast irradiation (PBI) over the years, with proven mild long-term toxicity. The aim of this study was to introduce a short-course dose-adapted concept, proven in whole breast irradiation (WBI) for use in accelerated partial breast irradiation (APBI), while monitoring dosimetric data and toxicity. Methods: From April 2020 to March 2022, 61 patients with low-risk breast cancer or ductal carcinoma in situ (DCIS) were treated at a single institution with percutaneous APBI of 26 Gy in five fractions every other day after breast-conserving surgery. Dosimetric data for target volume and organs at risk were determined retrospectively. Acute toxicity was evaluated. Results: The target volume of radiotherapy comprised an average of 19% of the ipsilateral mamma. The burden on the heart and lungs was very low. The mean cardiac dose during irradiation of the left breast was only 0.6 Gy. Two out of three patients remained without any acute side effects. Conclusions: Linac-based APBI is an attractive treatment option for patients with low-risk breast cancer in whom neither WBI nor complete omission of radiotherapy appears to be an adequate alternative.
Collapse
Affiliation(s)
- Roland Merten
- Clinic for Radiotherapy, Hannover Medical School, 30625 Hannover, Germany
- Correspondence:
| | - Mirko Fischer
- Clinic for Radiotherapy, Hannover Medical School, 30625 Hannover, Germany
| | - Gennadii Kopytsia
- Clinic for Radiotherapy, Hannover Medical School, 30625 Hannover, Germany
| | - Jörn Wichmann
- Clinic for Radiotherapy, Hannover Medical School, 30625 Hannover, Germany
| | - Tim Lange
- Clinic for Radiotherapy, Hannover Medical School, 30625 Hannover, Germany
| | | | - Jan-Niklas Becker
- Clinic for Radiotherapy, Hannover Medical School, 30625 Hannover, Germany
| | - Rüdiger Klapdor
- Clinic for Gynecology and Obstetrics, Hannover Medical School, 30625 Hannover, Germany
| | - Jan Hinrichs
- Institute for Radiology, Hannover Medical School, 30625 Hannover, Germany
| | - Michael Bremer
- Clinic for Radiotherapy, Hannover Medical School, 30625 Hannover, Germany
| |
Collapse
|
35
|
Ward KA, Muller DA, Dutta SW, Malhi J, Sanders JC, Luminais CK, Millard TA, Showalter TN, Showalter SL, Janowski EM. Long-Term Adherence to Adjuvant Endocrine Therapy Following Various Radiotherapy Modalities in Early Stage Hormone Receptor Positive Breast Cancer. Clin Breast Cancer 2023; 23:369-377. [PMID: 36868913 DOI: 10.1016/j.clbc.2023.01.012] [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: 07/28/2022] [Revised: 12/24/2022] [Accepted: 01/25/2023] [Indexed: 02/04/2023]
Abstract
INTRODUCTION We compared the rates of long-term adjuvant endocrine therapy (AET) adherence after various radiation therapy (RT) modalities among patients with early stage breast cancer. MATERIALS AND METHODS Medical records from patients with stage 0, I, or IIA (tumors ≤3 cm), hormone receptor (HR) positive breast cancer that received adjuvant radiation therapy (RT) from 2013 to 2015 at a single institution were retrospectively reviewed. All patients received breast conserving surgery (BCS) followed by adjuvant RT via one of the following modalities: whole breast radiotherapy (WBI), partial breast irradiation (PBI) with either external beam radiation therapy (EBRT) or fractionated intracavitary high-dose rate (HDR) brachytherapy, or single fraction HDR-brachytherapy intraoperative-radiation therapy (IORT). RESULTS One hundred fourteen patients were reviewed. Thirty patients received WBI, 41 PBI, and 43 IORT with a median follow up of 64.2, 72.0, and 58.6 months, respectively. For the entire cohort, AET adherence was approximately 64% at 2 years and 56% at 5 years. Among patients in the IORT clinical trial, adherence to AET was approximately 51% at 2 years and 40% at 5 years. After controlling for additional factors, DCIS histology (vs invasive disease) and IORT (compared to other radiation modalities) were associated with decreased endocrine therapy adherence (P < 0.05). CONCLUSION DCIS histology and receipt of IORT were associated with lower rates of adherence to AET at 5 years. Our findings suggest that examination of the efficacy of RT interventions such as PBI and IORT in patients who do not receive AET is warranted.
Collapse
Affiliation(s)
- Kristin A Ward
- Department of Radiation Oncology, University of Virginia, Charlottesville, VA.
| | - Donald A Muller
- Department of Radiation Oncology, University of Virginia, Charlottesville, VA
| | - Sunil W Dutta
- Department of Radiation Oncology, Emory University, Atlanta, GA
| | - Jasmine Malhi
- Department of Radiation Oncology, University of Virginia, Charlottesville, VA
| | - Jason C Sanders
- Department of Radiation Oncology, University of Virginia, Charlottesville, VA
| | | | - Trish A Millard
- Department of Hematology/Oncology, University of Virginia, Charlottesville, VA
| | - Timothy N Showalter
- Department of Radiation Oncology, University of Virginia, Charlottesville, VA
| | | | | |
Collapse
|
36
|
Yu CX. Radiotherapy of early‐stage breast cancer. PRECISION RADIATION ONCOLOGY 2023. [DOI: 10.1002/pro6.1183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Affiliation(s)
- Cedric X. Yu
- Radiation Oncology University of Maryland School of Medicine Baltimore Maryland USA
- Xcision Medical Systems Columbia Maryland USA
| |
Collapse
|
37
|
Goldberg M, Bridhikitti J, Khan AJ, McGale P, Whelan TJ. A Meta-Analysis of Trials of Partial Breast Irradiation. Int J Radiat Oncol Biol Phys 2023; 115:60-72. [PMID: 36155214 DOI: 10.1016/j.ijrobp.2022.09.062] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 08/31/2022] [Accepted: 09/05/2022] [Indexed: 02/09/2023]
Abstract
PURPOSE Partial breast irradiation (PBI) is the delivery of radiation therapy (RT) limited to the tumor bed after breast conserving surgery. The results of recent trials of PBI compared with whole breast irradiation (WBI) have suggested conflicting results with respect to local control and toxicity. The purpose of this meta-analysis was to assess effectiveness of PBI and to compare the different techniques. METHODS AND MATERIALS A meta-analysis of aggregate data from published randomized trials was performed to examine the effectiveness of PBI compared with WBI in patients with invasive breast cancer and ductal carcinoma in situ. Relevant data were extracted. The primary outcome was any ipsilateral breast event (invasive or noninvasive). Secondary outcomes included acute and late toxicity. The results of randomized trials were pooled using a fixed effects model and the inverse variance method. RESULTS Fifteen trials involving 16,474 patients were identified. The majority of enrolled patients were >60 years of age and had T1N0 grade 1 to 2 disease treated with hormone therapy. The percent of ipsilateral breast events was higher in patients treated with PBI compared with WBI (5.0% vs 2.8%; risk ratio [RR], 1.72; 95% confidence interval [CI], 1.47-2.02). Heterogeneity (P = .0002) was observed between the 4 PBI techniques: external beam RT without computed tomography (CT) planning (RR, 2.06; 95% CI, 1.36-3.12); brachytherapy (RR, 1.21; 95% CI, 0.65-2.25); intraoperative RT (RR, 2.79; 95% CI, 2.08-3.73); and external beam RT with CT planning (RR, 1.25; 95% CI, 0.99-1.58). When external beam RT without CT planning and intraoperative RT trials were excluded, the percent of ipsilateral breast events was 3.3% versus 2.6%, respectively (RR, 1.25; 95% CI, 1.00-1.55; P = .05), and no heterogeneity was observed (P = .92). Overall, acute toxicity was less with PBI, and the effect on late toxicity varied by technique. CONCLUSIONS Overall, WBI was more effective than PBI, but the effectiveness of PBI was technique related. PBI was less effective when given by external beam RT without CT planning or intraoperative therapy. Although PBI given by multicatheter brachytherapy or external beam RT with CT planning tended to be statistically less effective than WBI, the absolute difference between groups for ipsilateral breast events was very small (<1%), supporting these approaches for women considering PBI.
Collapse
Affiliation(s)
- Mira Goldberg
- Department of Oncology, McMaster University, Hamilton, Ontario, Canada; Division of Radiation Oncology, Juravinski Cancer Centre at Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Jidapa Bridhikitti
- Division of Radiation Oncology, Department of Radiology, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | - Atif J Khan
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Paul McGale
- Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Timothy J Whelan
- Department of Oncology, McMaster University, Hamilton, Ontario, Canada; Division of Radiation Oncology, Juravinski Cancer Centre at Hamilton Health Sciences, Hamilton, Ontario, Canada.
| |
Collapse
|
38
|
Meattini I, Kim K, Livi L. Accelerated Partial Breast Irradiation: Florence Phase 3 Trial Experience and Future Perspectives. Am J Clin Oncol 2023; 46:10-15. [PMID: 36472353 DOI: 10.1097/coc.0000000000000968] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Accelerated partial breast irradiation Florence phase 3 trial is a single-center study comparing intensity-modulated based accelerated partial breast irradiation (PBI, 30 Gy in 5 fractions) and whole breast irradiation (50 Gy in 25 fractions) followed by a tumor bed boost (10 Gy in 5 fractions). This easy-to-deliver PBI approach showed excellent long-term disease control with favorable safety and cosmetic outcome profiles. A plateau has been probably reached concerning the reduction of the number of fractions in the postoperative PBI setting. A 5-fraction schedule is the standard regimen and probably the appropriate compromise in terms of efficacy, safety, and quality of life, also considering the negative results of most intraoperative single-fraction PBI trials. A new frontier is now open on the potential benefit of preoperative PBI delivery, although concerns remain on the optimal dose, fractionation, and technique. Hereby we report the accelerated PBI Florence phase 3 trial experience and future perspectives.
Collapse
Affiliation(s)
- Icro Meattini
- Department of Experimental and Clinical Biomedical Sciences "M. Serio," University of Florence
- Radiation Oncology Unit, Oncology Department, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Kyubo Kim
- Radiation Oncology Unit, Oncology Department, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
- Department of Radiation Oncology, Ewha Womans University Mokdong Hospital, Ewha Womans University College of Medicine, Seoul, Republic of Korea
| | - Lorenzo Livi
- Department of Experimental and Clinical Biomedical Sciences "M. Serio," University of Florence
- Radiation Oncology Unit, Oncology Department, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| |
Collapse
|
39
|
Mosiun JA, See MH, Teoh LY, Danaee M, Lai LL, Ng CH, Yip CH, Teh MS, Taib NAM, Bustam A, Malik RA, Saad M, Jamaris S, Ung NM. Comparison of Clinical Outcomes Between Low- and High-Risk Groups of Early Breast Cancer Patients Treated with Intraoperative Radiotherapy in Addition to External Beam Radiation: A Multi-Centre Prospective Study. World J Surg 2023; 47:201-208. [PMID: 36305952 DOI: 10.1007/s00268-022-06753-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/16/2022] [Indexed: 01/28/2023]
Abstract
BACKGROUND There is a paucity of data on the use of intraoperative radiotherapy (IORT) with low-energy X-rays in Malaysian women with early breast cancer. The aim of this study is to evaluate the clinical, cosmetic, and patient-reported outcomes in low- and high-risk early breast cancer patients treated with breast conserving surgery (BCS) and IORT. METHODOLOGY Patients suitable for BCS who were treated with IORT between January 2016 and June 2019 from three centres were analysed. They were divided into low-risk and high-risk groups based on the risk of recurrence according to the TARGeted Intraoperative radioTherapy (TARGIT) A and B study criteria. Outcomes of interest included local recurrence, wound complications, and radiation toxicity, with a subset analysed for cosmetic and patient-reported outcomes. RESULTS Within a median follow-up of 31 months, there were 104 and 211 patients in the low- and high-risk groups, respectively. No significant difference was observed in local recurrence rates (low-risk, 1.0% vs. high-risk, 1.4%; p = 1.000). Both cohorts exhibited low frequencies of severe wound complications ranging between 1.4 and 1.9%. No major radiation toxicities were reported in either group. In the subgroup analysis, low-risk patients had significantly better mean scores in the subscales of inframammary fold and scar. Based on the BREAST-Q patient-reported outcomes questionnaire, seven out of nine parameters were scored similarly between both groups with no significant difference. CONCLUSION This study showed that the use of IORT in both low- and high-risk early breast cancers is efficacious and safe with low recurrence rates and an acceptable toxicity profile.
Collapse
Affiliation(s)
- J A Mosiun
- Breast Surgery Unit, Department of Surgery, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
| | - Mee-Hoong See
- Breast Surgery Unit, Department of Surgery, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia.
| | - Li-Ying Teoh
- Breast Surgery Unit, Department of Surgery, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
| | - Mahmoud Danaee
- Department of Social and Preventive Medicine, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
| | - Lee-Lee Lai
- Department of Nursing Science, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
| | - Char-Hong Ng
- Sunway Medical Centre, 5, Jalan Lagoon Selatan, Bandar Sunway, 47500, Petaling Jaya, Selangor, Malaysia
| | - Cheng-Har Yip
- Ramsay Sime Darby Health Care, Jalan SS 12/1A, Subang Jaya, Malaysia
| | - Mei-Sze Teh
- Breast Surgery Unit, Department of Surgery, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
| | - Nur Aishah Md Taib
- Breast Surgery Unit, Department of Surgery, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
- Universiti Malaya Cancer Research Institute, Universiti Malaya, Kuala Lumpur, Malaysia
| | - Anita Bustam
- Clinical Oncology Unit, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
| | - Rozita Abdul Malik
- Clinical Oncology Unit, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
| | - Marniza Saad
- Clinical Oncology Unit, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
| | - Suniza Jamaris
- Breast Surgery Unit, Department of Surgery, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
| | - Ngie-Min Ung
- Clinical Oncology Unit, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
| |
Collapse
|
40
|
Special Techniques of Adjuvant Breast Carcinoma Radiotherapy. Cancers (Basel) 2022; 15:cancers15010298. [PMID: 36612294 PMCID: PMC9818986 DOI: 10.3390/cancers15010298] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 12/23/2022] [Accepted: 12/28/2022] [Indexed: 01/03/2023] Open
Abstract
Modern radiotherapy techniques are designed to permit reduced irradiation of healthy tissue, resulting in a diminished risk of adverse effects and shortened recovery times. Several randomized studies have demonstrated the benefits of increased dosage to the tumor bed area in combination with whole breast irradiation (WBI). Conventional WBI treatment following breast-conserving procedures, which required 5-7 weeks of daily treatments, has been reduced to 3-4 weeks when using hyperfractionated regimens. The dosage administration improves local control, albeit with poorer cosmesis. The method of accelerated partial breast irradiation (APBI) shortens the treatment period whilst reducing the irradiated volume. APBI can be delivered using intraoperative radiation, brachytherapy, or external beam radiotherapy. Currently available data support the use of external beam partial breast irradiation in selected patients. Modern radiotherapy techniques make it possible to achieve favorable cosmesis in most patients undergoing immediate breast reconstruction surgery, and studies confirm that current methods of external beam radiation allow an acceptable coverage of target volumes both in the reconstructed breast and in the regional lymphatic nodes.
Collapse
|
41
|
McEvoy MP, Gomberawalla A, Smith M, Boccardo FM, Holmes D, Djohan R, Thiruchelvam P, Klimberg S, Dietz J, Feldman S. The prevention and treatment of breast cancer- related lymphedema: A review. Front Oncol 2022; 12:1062472. [PMID: 36561522 PMCID: PMC9763870 DOI: 10.3389/fonc.2022.1062472] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 11/07/2022] [Indexed: 12/12/2022] Open
Abstract
Background Breast cancer- related lymphedema (BCRL) affects about 3 to 5 million patients worldwide, with about 20,000 per year in the United States. As breast cancer mortality is declining due to improved diagnostics and treatments, the long-term effects of treatment for BCRL need to be addressed. Methods The American Society of Breast Surgeons Lymphatic Surgery Working Group conducted a large review of the literature in order to develop guidelines on BCRL prevention and treatment. This was a comprehensive but not systematic review of the literature. This was inclusive of recent randomized controlled trials, meta-analyses, and reviews evaluating the prevention and treatment of BCRL. There were 25 randomized clinical trials, 13 systemic reviews and meta-analyses, and 87 observational studies included. Results The findings of our review are detailed in the paper, with each guideline being analyzed with the most recent data that the group found evidence of to suggest these recommendations. Conclusions Prevention and treatment of BCRL involve a multidisciplinary team. Early detection, before clinically apparent, is crucial to prevent irreversible lymphedema. Awareness of risk factors and appropriate practice adjustments to reduce the risk aids are crucial to decrease the progression of lymphedema. The treatment can be costly, time- consuming, and not always effective, and therefore, the overall goal should be prevention.
Collapse
Affiliation(s)
- Maureen P. McEvoy
- Breast Surgery Division, Department of Surgery, Montefiore Medical Center, Montefiore Einstein Center for Cancer Care, Bronx, NY, United States,*Correspondence: Maureen P. McEvoy,
| | - Ameer Gomberawalla
- Department of Surgery, Advocate Medical Group, Oak Lawn, IL, United States
| | - Mark Smith
- Department of Plastic Surgery, Northwell Health System, New Hyde Park, NY, United States
| | | | - Dennis Holmes
- Department of Surgery, Los Angeles Center for Women’s Health, Los Angeles, CA, United States
| | - Risal Djohan
- Department of Plastic Surgery, Cleveland Clinic, Cleveland, OH, United States
| | - Paul Thiruchelvam
- Department of Breast Surgery, Imperial College, London, United Kingdom
| | - Suzanne Klimberg
- Department of Surgery, University of Texas Medical Branch(UTMB) Cancer Center, Galveston, TX, United States
| | - Jill Dietz
- Department of Surgery, University Hospital Cleveland Medical Center, Cleveland, OH, United States
| | - Sheldon Feldman
- Breast Surgery Division, Department of Surgery, Montefiore Medical Center, Montefiore Einstein Center for Cancer Care, Bronx, NY, United States
| |
Collapse
|
42
|
Franco P, De Felice F, Jagsi R, Nader Marta G, Kaidar-Person O, Gabrys D, Kim K, Ramiah D, Meattini I, Poortmans P. Breast cancer radiation therapy: A bibliometric analysis of the scientific literature. Clin Transl Radiat Oncol 2022; 39:100556. [PMID: 36545362 PMCID: PMC9761378 DOI: 10.1016/j.ctro.2022.11.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Accepted: 11/25/2022] [Indexed: 12/12/2022] Open
Abstract
Background and purpose Breast cancer is the most common malignancy in women and radiation therapy (RT) is crucial in its multimodality management. Since bibliometrics is a powerful tool to reveal the scientific literature, we decided to perform a bibliometric analysis of the literature on breast cancer radiotherapy. We explored emerging trends and common patterns in research, tracking collaboration and networks, and foreseeing future directions in this clinical setting. Material and methods The electronic Scopus database was searched using the keywords "breast cancer" and "radiotherapy" to include manuscripts published in English, between 2000 and 2021. Data analysis was performed using R-Studio 0.98.1091 software with a machine-learning bibliometric method, based on the bibliometrix R package. The most relevant authors were quantified per number and fractionalized number of authored documents. Author productivity was analysed through Lotka's law. Bradford's law was applied to identify the nucleus of journals focused on the addressed topic. Mainstream themes area included isolated topics (niche themes), new topics (emerging themes), hot topics (motor themes) and essential topics (basic themes). Results A total of 27 184 documents was found, mainly original articles (76 %). The annual growth rate was 6.98 %, with an increase in scientific production from 485 to 2000 documents between 2000 and 2021. Overall, 2 544 journals published ≥ 1 documents. The most relevant authors were affiliated in the United States. Surgical procedures, cancer type and treatment strategies represented basic themes, while primary systemic therapy and sentinel lymph node biopsy were emerging themes. Health-related quality of life was a niche theme, while RT techniques had high centrality. Conclusion The primary interests of breast cancer radiation oncologists have evolved over time, adding safety, health related quality of life, sustainability of treatments and combination to systemic therapies to radiotherapy efficacy and effectiveness and treatment outcomes.
Collapse
Affiliation(s)
- Pierfrancesco Franco
- Department of Translational Medicine, University of Eastern Piedmont, Novara, Italy,Department of Radiation Oncology, ‘Maggiore della Carità’ University Hospital, Novara, Italy,Corresponding author at: Radiation Oncology. Department of Translational Medicine (DIMET), University of Eastern Piedmont, Via Solaroli 17, 28100 Novara, Italy.
| | - Francesca De Felice
- Department of Radiological, Oncological, and Pathological Sciences, “Sapienza” University of Rome, Rome, Italy,Department of Radiation Oncology, Policlinico “Umberto I”, Rome, Italy
| | - Reshma Jagsi
- Department of Radiation Oncology, Center for Bioethics and Social Sciences, University of Michigan, Ann Arbor, MI, USA
| | - Gustavo Nader Marta
- Department of Radiation Oncology – Hospital Sírio-Libanês, São Paulo, Brazil
| | - Orit Kaidar-Person
- Sheba Medical Center, Ramat Gan and Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel,Radiotherapy Department, Maria Sklodowska-Curie National Research and Institute of Oncology, Gliwice, Poland
| | - Dorota Gabrys
- Radiotherapy Department, Maria Sklodowska-Curie National Research and Institute of Oncology, Gliwice, Poland
| | - Kyubo Kim
- Department of Radiation Oncology, Ewha Womans University College of Medicine, Seoul, Republic of Korea
| | - Duvern Ramiah
- Radiation Oncology Department, University of the Witwatersrand and Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, South Africa
| | - 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
| | - Philip Poortmans
- Iridium kankernetwerk and University of Antwerp, Wilrijk Antwerp, Belgium
| |
Collapse
|
43
|
Philippson C, Larsen S, Simon S, Vandekerkhove C, De Caluwe A, Van Gestel D, Chintinne M, Veys I, De Neubourg F, Noterman D, Roman M, Nogaret JM, Desmet A. Intraoperative electron radiotherapy in early invasive ductal breast cancer: 6-year median follow-up results of a prospective monocentric registry. Breast Cancer Res 2022; 24:83. [DOI: 10.1186/s13058-022-01582-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 11/17/2022] [Indexed: 11/25/2022] Open
Abstract
Abstract
Background
Intraoperative electron radiotherapy (IOERT) can be used to treat early breast cancer during the conservative surgery thus enabling shorter overall treatment times and reduced irradiation of organs at risk. We report on our first 996 patients enrolled prospectively in a registry trial.
Methods
At Jules Bordet Institute, from February 2010 onwards, patients underwent partial IOERT of the breast. Women with unifocal invasive ductal carcinoma, aged 40 years or older, with a clinical tumour size ≤ 20 mm and tumour-free sentinel lymph node (on frozen section and immunohistochemical analysis). A 21 Gy dose was prescribed on the 90% isodose line in the tumour bed with the energy of 6 to 12 MeV (Mobetron®-IntraOp Medical).
Results
Thirty-seven ipsilateral tumour relapses occurred. Sixteen of those were in the same breast quadrant. Sixty patients died, and among those, 12 deaths were due to breast cancer. With 71.9 months of median follow-up, the 5-year Kaplan–Meier estimate of local recurrence was 2.7%.
Conclusions
The rate of breast cancer local recurrence after IOERT is low and comparable to published results for IORT and APBI. IOERT is highly operator-dependent, and appropriate applicator sizing according to tumour size is critical. When used in a selected patient population, IOERT achieves a good balance between tumour control and late radiotherapy-mediated toxicity morbidity and mortality thanks to insignificant irradiation of organs at risk.
Collapse
|
44
|
Jeibouei S, Shams F, Mohebichamkhorami F, Sanooghi D, Faal B, Akbari ME, Zali H. Biological and clinical review of IORT-induced wound fluid in breast cancer patients. Front Oncol 2022; 12:980513. [DOI: 10.3389/fonc.2022.980513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 10/19/2022] [Indexed: 11/22/2022] Open
Abstract
Intraoperative radiotherapy (IORT) has become a growing therapy for early-stage breast cancer (BC). Some studies claim that wound fluid (seroma), a common consequence of surgical excision in the tumor cavity, can reflect the effects of IORT on cancer inhibition. However, further research by our team and other researchers, such as analysis of seroma composition, affected cell lines, and primary tissues in two-dimensional (2D) and three-dimensional (3D) culture systems, clarified that seroma could not address the questions about IORT effectiveness in the surgical site. In this review, we mention the factors involved in tumor recurrence, direct or indirect effects of IORT on BC, and all the studies associated with BC seroma to attain more information about the impact of IORT-induced seroma to make a better decision to remove or remain after surgery and IORT. Finally, we suggest that seroma studies cannot decipher the mechanisms underlying the effectiveness of IORT in BC patients. The question of whether IORT-seroma has a beneficial effect can only be answered in a trial with a clinical endpoint, which is not even ongoing.
Collapse
|
45
|
Cuzick J, Sasieni P. Interpreting the results of noninferiority trials-a review. Br J Cancer 2022; 127:1755-1759. [PMID: 36104512 PMCID: PMC9643416 DOI: 10.1038/s41416-022-01937-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 07/18/2022] [Accepted: 07/27/2022] [Indexed: 11/08/2022] Open
Abstract
Noninferiority trials are becoming increasing common, but are often poorly reported and misunderstood. A better understanding of the new components of a noninferiority trial and their interpretation is needed. Noninferiority trials are an extension of conventional superiority trials, which provide a basis for determining if a new treatment, which may have advantages other than efficacy, has sufficient efficacy to be useful in certain situations. A key feature is the need to specify a clinical noninferiority margin above which the lower boundary of the confidence interval for the difference between the new treatment and the conventional treatment must lie. In most cases a nontreated control arm is not included, and when the efficacy of the new treatment is less than that of the standard treatment, determining its efficacy versus no treatment can be a major challenge. Treatments meeting a clinical noninferiority requirement can be statistically significantly superior to standard treatment, of similar efficacy (i.e., no significant difference), or even significantly inferior in a conventional analysis. Noninferiority comparisons are an important addition to the reporting of clinical trials, but require prior consideration of several factors that conventional superiority analyses do not address.
Collapse
Affiliation(s)
- Jack Cuzick
- Centre for Cancer Prevention, Wolfson Institute of Population Health, Queen Mary University of London, Charterhouse Square, London, EC1M 6BQ, UK.
| | - Peter Sasieni
- School of Cancer & Pharmaceutical Sciences, Faculty of Life Sciences & Medicine, King's College London, London, UK
| |
Collapse
|
46
|
Refaat T, Gros SE, Small W. The case for risk-stratified IORT for early breast cancer. Brachytherapy 2022; 21:719-722. [PMID: 36167653 DOI: 10.1016/j.brachy.2022.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 08/17/2022] [Indexed: 12/14/2022]
Affiliation(s)
- Tamer Refaat
- Department of Radiation Oncology, Stritch School of Medicine, Cardinal Bernardin Cancer Center, Loyola University Chicago, Maywood, IL
| | - Sebastien E Gros
- Department of Radiation Oncology, Stritch School of Medicine, Cardinal Bernardin Cancer Center, Loyola University Chicago, Maywood, IL
| | - William Small
- Department of Radiation Oncology, Stritch School of Medicine, Cardinal Bernardin Cancer Center, Loyola University Chicago, Maywood, IL.
| |
Collapse
|
47
|
Anderson B, Arthur D, Hannoun-Levi JM, Kamrava M, Khan A, Kuske R, Scanderbeg D, Shah C, Shaitelman S, Showalter T, Vicini F, Wazer D, Yashar C. Partial breast irradiation: An updated consensus statement from the American brachytherapy society. Brachytherapy 2022; 21:726-747. [PMID: 36117086 DOI: 10.1016/j.brachy.2022.07.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Revised: 06/15/2022] [Accepted: 07/06/2022] [Indexed: 12/14/2022]
Abstract
PURPOSE In recent years, results with mature follow-up have been reported for several Phase III trials randomizing women to receive whole breast irradiation (WBI) versus varying modalities of partial breast irradiation (PBI). It is important to recognize that these methods vary in terms of volume of breast tissue treated, dose per fraction, and duration of therapy. As such, clinical and technical guidelines may vary among the various PBI techniques. METHODS Members of the American Brachytherapy Society with expertise in PBI performed an extensive literature review focusing on the highest quality data available for the numerous PBI options offered in the modern era. Data were evaluated for strength of evidence and published outcomes were assessed. RESULTS The majority of women enrolled on randomized trials of WBI versus PBI have been age >45 years with tumor size <3 cm, negative margins, and negative lymph nodes. The panel also concluded that PBI can be offered to selected women with estrogen receptor negative and/or Her2 amplified breast cancer, as well as ductal carcinoma in situ, and should generally be avoided in women with extensive lymphovascular space invasion. CONCLUSIONS This updated guideline summarizes published clinical trials of PBI methods. The panel also highlights the role of PBI for women facing special circumstances, such as history of cosmetic breast augmentation or prior breast irradiation, and discusses promising novel modalities that are currently under study, such as ultrashort and preoperative PBI. Updated consensus guidelines are also provided to inform patient selection for PBI and to characterize the strength of evidence to support varying PBI modalities.
Collapse
Affiliation(s)
- Bethany Anderson
- Department of Human Oncology, University of Wisconsin School of Medicine and Public Health, Madison, WI.
| | - Douglas Arthur
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, VA
| | | | | | - Atif Khan
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Robert Kuske
- Arizona Breast Cancer Specialists, Scottsdale, AZ
| | - Daniel Scanderbeg
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, San Diego, CA
| | - Chirag Shah
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland, OH
| | - Simona Shaitelman
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Timothy Showalter
- Department of Radiation Oncology, University of Virginia School of Medicine, Charlottesville, VA
| | | | - David Wazer
- Department of Radiation Oncology, Tufts Medical Center, Boston, MA
| | - Catheryn Yashar
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, San Diego, CA
| |
Collapse
|
48
|
Houvenaeghel G, de Nonneville A, Cohen M, Classe JM, Reyal F, Mazouni C, Faure C, Martinez A, Chauvet MP, Daraï E, Coutant C, Colombo PE, Gimbergues P, Azuar AS, Rouzier R, Tunon de Lara C, Crochet P, Rua S, Gonçalves A. Contribution of endocrine therapy in oestrogen receptor-positive pT1a-b breast cancer: Results of a retrospective study. Eur J Cancer 2022; 176:58-69. [PMID: 36194904 DOI: 10.1016/j.ejca.2022.08.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 08/26/2022] [Accepted: 08/26/2022] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Few data have been reported regarding endocrine therapy (ET) in patients with small pT1a-b ER-postive breast cancer (BC). Thus, we conducted a study to detect possible survival improvements due to ET in such patients. METHODS Our retrospective observational study included 5545 patients with pT1a-b ER-positive BC treated in 15 French centres, excluding patients with HER2-positive status, neoadjuvant chemotherapy, ER-negative status, unknown pN status or in situ BC. We estimated disease-free survival (DFS), recurrence-free survival (RFS) and overall survival (OS) via univariate analysis and multivariate Cox regression. RESULTS Most patients (80.3%: 4453) received ET and-when compared to those without ET-experienced increases of 2.5% and 3.3% in DFS and 1.9% and 4.3% in RFS after 5 and 7 years of follow-up, respectively, with little difference in OS. In Cox regression analysis, no ET was significantly associated with decreased DFS (hazard ratio, HR = 1.275, p = 0.047, 95% CI[1.003-1.620]) but not OS or RFS in all patients, while in 2363 patients with pT1a-b ER-positive grade 2-3 BC, no ET was significantly associated with decreased DFS (HR = 1.502, p = 0.049, 95% CI[1.001-2.252]), but not OS (HR = 1.361, p = 0.272). ET omission was not significantly associated with decreased survival in 3047 patients with pT1a-b ER-positive grade 1 BC. CONCLUSION Our results indicate that while ET provided a beneficial impact on survival to patients with pT1a-bN0 ER-positive BC-and especially in those with grade 2-3 tumours-no such impact was observed in grade 1 tumours. Consequently, ET should be discussed with these patients, particularly in those with pT1a grade 1 tumours.
Collapse
Affiliation(s)
- Gilles Houvenaeghel
- Department of Surgical Oncology, CRCM, Institut Paoli-Calmettes, Aix-Marseille Univ, CNRS, INSERM, 232 Bd de Sainte Marguerite, 13009 Marseille, France.
| | - Alexandre de Nonneville
- Department of Medical Oncology, CRCM, Institut Paoli-Calmettes, Aix-Marseille University, CNRS, INSERM, Marseille, France
| | - Monique Cohen
- Department of Surgical Oncology, CRCM, Institut Paoli-Calmettes, Aix-Marseille Univ, CNRS, INSERM, 232 Bd de Sainte Marguerite, 13009 Marseille, France
| | - Jean-Marc Classe
- Institut René Gauducheau, Site Hospitalier Nord, St Herblain, France
| | - Fabien Reyal
- Institut Curie, 26 Rue D'Ulm, 75248 Paris Cedex 05, France
| | - Chafika Mazouni
- Institut Gustave Roussy, 114 Rue Edouard Vaillant, Villejuif, France
| | | | - Alejandra Martinez
- Centre Claudius Regaud, Oncopole, 20-24 Rue Du Pont St Pierre, Toulouse, France
| | | | - Emile Daraï
- Hôpital Tenon, 4 Rue de La Chine, Paris, France
| | - Charles Coutant
- Centre Georges François Leclerc, 1 Rue Du Professeur Marion, Dijon, France
| | - Pierre-Emmanuel Colombo
- Centre Val D'Aurelles, ICM - 208, Avenue des Apothicaires Parc Euromédecine, 34298 Montpellier Cedex 5, France
| | | | | | - Roman Rouzier
- Hôpital René Huguenin, 35 Rue Dailly, Sa]int Cloud, France
| | | | - Patrice Crochet
- Department of Obstetrics and Gynocology, Hôpital de La Conception, 147 Boulevard Baille, 13005 Marseille, France
| | - Sandrine Rua
- Department of Surgical Oncology, CRCM, Institut Paoli-Calmettes, Aix-Marseille Univ, CNRS, INSERM, 232 Bd de Sainte Marguerite, 13009 Marseille, France
| | - Anthony Gonçalves
- Department of Medical Oncology, CRCM, Institut Paoli-Calmettes, Aix-Marseille University, CNRS, INSERM, Marseille, France
| |
Collapse
|
49
|
Impact of preoperative magnetic resonance imaging on surgery and eligibility for intraoperative radiotherapy in early breast cancer. PLoS One 2022; 17:e0274385. [PMID: 36256643 PMCID: PMC9578617 DOI: 10.1371/journal.pone.0274385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 08/26/2022] [Indexed: 11/17/2022] Open
Abstract
We looked at the usefulness of magnetic resonance imaging (MRI) in decision-making and surgical management of patients selected for intraoperative radiotherapy (IORT). We also compared lesion size measurements in different modalities (ultrasound (US), mammogram (MMG), MRI) against pathological size as the gold standard. 63 patients eligible for IORT based on clinical and imaging criteria over a 34-month period were enrolled. All had MMG and US, while 42 had additional preoperative MRI for locoregional preoperative staging. Imaging findings and pathological size concordances were analysed across the three modalities. MRI changed the surgical management of 5 patients (11.9%) whereby breast-conserving surgery (BCS) and IORT was cancelled due to detection of satellite lesion, tumor size exceeding 30mm and detection of axillary nodal metastases. Ten of 42 patients (23.8%) who underwent preoperative MRI were subjected to additional external beam radiotherapy (EBRT); 7 due to lymphovascular invasion (LVI), 2 due to involved margins, and 1 due to axillary lymph node metastatic carcinoma detected in the surgical specimen. Five of 21 (23.8%) patients without prior MRI were subjected to additional EBRT post-surgery; 3 had LVI and 2 had involved margins. The rest underwent BCS and IORT as planned. MRI and MMG show better imaging-pathological size correlation. Significant increase in the mean 'waiting time' were seen in the MRI group (34.1 days) compared to the conventional imaging group (24.4 days). MRI is a useful adjunct to conventional imaging and impacts decision making in IORT. It is also the best imaging modality to determine the actual tumour size.
Collapse
|
50
|
Xu L, Zhou C, Qiu J, Lv Q, Du Z. Can Radiotherapy After Breast-Conserving Surgery be Omitted in Elderly Patients with Early-Stage, Hormone-Receptor Negative Breast Cancer? A Population-Based Study and Proposed Nomogram. Adv Ther 2022; 39:4707-4722. [PMID: 35953665 DOI: 10.1007/s12325-022-02279-y] [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: 04/09/2022] [Accepted: 07/20/2022] [Indexed: 01/30/2023]
Abstract
INTRODUCTION We aimed to evaluate whether radiotherapy (RT) after breast-conserving surgery (BCS) can be omitted in elderly patients with early-stage, hormone receptor-negative breast cancer. METHODS Patients aged 65 years and older with T1-2N0-1, hormone receptor-negative breast cancer in 2010-2015 were extracted from the Surveillance, Epidemiology, and End Results program. Propensity score matching was used to balance the baseline of different groups. Survival analysis was performed using Kaplan-Meier plot and log-rank test. Independent risk factors were identified by multivariate Cox analysis. A nomogram predicting breast cancer-specific survival (BCSS) and a risk stratification model were constructed and validated. RESULTS A total of 4465 patients were included and 27.7% (1237/4465) patients did not receive postoperative RT. RT was significantly associated with improved overall survival (OS) (HR = 0.552 P < 0.001) and BCSS (HR = 0.559, P < 0.001) in the matched cohort. The same results were found after adjusting independent risk factors by multivariate analysis. On the basis of the nomogram predicting BCSS of patients without RT by incorporating independent risk factors (age, race, HER2 status, T stage, and N stage), we built a risk stratification model which indicated that RT improved OS (HR = 0.511, P < 0.001) and BCSS (HR = 0.517, P < 0.001) in the high-risk group (total score > 150), but not in the low-risk group (total score ≤ 120). The C-index and all calibration curves demonstrated sufficient accuracies and good predictive capabilities. CONCLUSIONS RT is indeed beneficial for the whole cohort in this study. However, it may be omitted in the low-risk subgroup without significantly sacrificing survival. For patients in the high-risk group, RT following BCS remained beneficial. This study highlights the need for prospective randomized trials to study RT de-escalation strategies.
Collapse
Affiliation(s)
- Li Xu
- Department of Breast Surgery, West China Hospital, Sichuan University, 37 Guoxue Street, Chengdu, China
| | - Chen Zhou
- Department of Breast Surgery, West China Hospital, Sichuan University, 37 Guoxue Street, Chengdu, China
| | - Juanjuan Qiu
- Department of Breast Surgery, West China Hospital, Sichuan University, 37 Guoxue Street, Chengdu, China
| | - Qing Lv
- Department of Breast Surgery, West China Hospital, Sichuan University, 37 Guoxue Street, Chengdu, China
| | - Zhenggui Du
- Department of Breast Surgery, West China Hospital, Sichuan University, 37 Guoxue Street, Chengdu, China.
| |
Collapse
|