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Ciérvide R, Hernando O, López M, Montero Á, Zucca D, Sánchez E, Álvarez B, García-Aranda M, Chen Zhao X, Valero J, Alonso R, Martí J, de la Casa MÁ, Alonso L, García J, Garcia de Acilu P, Prado A, Fernandez Leton P, Rubio C. Stereotactic body radiation therapy (SBRT) for spinal metastases: 12 years of a single center experience. Clin Transl Oncol 2023; 25:3395-3404. [PMID: 37058207 DOI: 10.1007/s12094-023-03188-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 04/03/2023] [Indexed: 04/15/2023]
Abstract
OBJECTIVE To assess the clinical outcomes of patients with spine metastases treated with SBRT at our institution. MATERIALS AND METHODS Patients with spine metastases treated with SBRT (1 fraction/18 Gy or 5 fractions/7 Gy) during the last 12 years have been analyzed. All patients were simulated supine in a vacuum cushion or with a shoulder mask. CT scans and MRI image registration were performed. Contouring was based on International Spine-Radiosurgery-Consortium-Consensus-Guidelines. Highly conformal-techniques (IMRT/VMAT) were used for treatment planning. Intra and interfraction (CBCT or X-Ray-ExacTrac) verification were mandatory. RESULTS From February 2010 to January 2022, 129 patients with spinal metastases were treated with SBRT [1 fraction/18 Gy (75%) or 5 fractions/7 Gy] (25%). For patients with painful metastases (74/129:57%), 100% experienced an improvement in pain after SBRT. With a median follow-up of 14.2 months (average 22.9; range 0.5-140) 6 patients (4.6%) experienced local relapse. Local progression-free survival was different, considering metastases's location (p < 0.04). The 1, 2 and 3 years overall survival (OS) were 91.2%, 85.1% and 83.2%, respectively. Overall survival was significantly better for patients with spine metastases of breast and prostate cancers compared to other tumors (p < 0.05) and significantly worse when visceral metastases were present (p < 0.05), when patients were metastatic de novo (p < 0.05), and in those patients receiving single fraction SBRT (p: 0.01). CONCLUSIONS According to our experience, SBRT for patients with spinal metastases was effective in terms of local control and useful to reach pain relief. Regarding the intent of the treatment, an adequate selection of patients is essential to propose this ablative approach.
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Affiliation(s)
- Raquel Ciérvide
- Department of Radiation Oncology, Hospital Universitario HM Sanchinarro, HM Hospitales, Madrid, Spain.
| | - Ovidio Hernando
- Department of Radiation Oncology, Hospital Universitario HM Sanchinarro, HM Hospitales, Madrid, Spain
| | - Mercedes López
- Department of Radiation Oncology, Hospital Universitario HM Sanchinarro, HM Hospitales, Madrid, Spain
| | - Ángel Montero
- Department of Radiation Oncology, Hospital Universitario HM Sanchinarro, HM Hospitales, Madrid, Spain
| | - Daniel Zucca
- Department of Radiation Oncology, Hospital Universitario HM Sanchinarro, HM Hospitales, Madrid, Spain
| | - Emilio Sánchez
- Department of Radiation Oncology, Hospital Universitario HM Sanchinarro, HM Hospitales, Madrid, Spain
| | - Beatriz Álvarez
- Department of Radiation Oncology, Hospital Universitario HM Sanchinarro, HM Hospitales, Madrid, Spain
| | - Mariola García-Aranda
- Department of Radiation Oncology, Hospital Universitario HM Sanchinarro, HM Hospitales, Madrid, Spain
| | - Xin Chen Zhao
- Department of Radiation Oncology, Hospital Universitario HM Sanchinarro, HM Hospitales, Madrid, Spain
| | - Jeannette Valero
- Department of Radiation Oncology, Hospital Universitario HM Sanchinarro, HM Hospitales, Madrid, Spain
| | - Rosa Alonso
- Department of Radiation Oncology, Hospital Universitario HM Sanchinarro, HM Hospitales, Madrid, Spain
| | - Jaime Martí
- Department of Radiation Oncology, Hospital Universitario HM Sanchinarro, HM Hospitales, Madrid, Spain
| | - Miguel Ángel de la Casa
- Department of Radiation Oncology, Hospital Universitario HM Sanchinarro, HM Hospitales, Madrid, Spain
| | - Leire Alonso
- Department of Radiation Oncology, Hospital Universitario HM Sanchinarro, HM Hospitales, Madrid, Spain
| | - Juan García
- Department of Radiation Oncology, Hospital Universitario HM Sanchinarro, HM Hospitales, Madrid, Spain
| | - Paz Garcia de Acilu
- Department of Radiation Oncology, Hospital Universitario HM Sanchinarro, HM Hospitales, Madrid, Spain
| | - Alejandro Prado
- Department of Radiation Oncology, Hospital Universitario HM Sanchinarro, HM Hospitales, Madrid, Spain
| | - Pedro Fernandez Leton
- Department of Radiation Oncology, Hospital Universitario HM Sanchinarro, HM Hospitales, Madrid, Spain
| | - Carmen Rubio
- Department of Radiation Oncology, Hospital Universitario HM Sanchinarro, HM Hospitales, Madrid, Spain
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Murchison S, Nichol A, Speers C, Gondara L, Levasseur N, Lohrisch C, Vallieres I, Truong P. Locoregional Recurrence and Survival Outcomes in Breast Cancer Treated With Modern Neoadjuvant Chemotherapy: A Contemporary Population-based Analysis. Clin Breast Cancer 2022; 22:e773-e787. [DOI: 10.1016/j.clbc.2022.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Revised: 06/09/2022] [Accepted: 07/05/2022] [Indexed: 11/03/2022]
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Gradishar WJ, Moran MS, Abraham J, Aft R, Agnese D, Allison KH, Anderson B, Burstein HJ, Chew H, Dang C, Elias AD, Giordano SH, Goetz MP, Goldstein LJ, Hurvitz SA, Isakoff SJ, Jankowitz RC, Javid SH, Krishnamurthy J, Leitch M, Lyons J, Mortimer J, Patel SA, Pierce LJ, Rosenberger LH, Rugo HS, Sitapati A, Smith KL, Smith ML, Soliman H, Stringer-Reasor EM, Telli ML, Ward JH, Wisinski KB, Young JS, Burns J, Kumar R. Breast Cancer, Version 3.2022, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw 2022; 20:691-722. [PMID: 35714673 DOI: 10.6004/jnccn.2022.0030] [Citation(s) in RCA: 406] [Impact Index Per Article: 203.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The therapeutic options for patients with noninvasive or invasive breast cancer are complex and varied. These NCCN Clinical Practice Guidelines for Breast Cancer include recommendations for clinical management of patients with carcinoma in situ, invasive breast cancer, Paget disease, phyllodes tumor, inflammatory breast cancer, and management of breast cancer during pregnancy. The content featured in this issue focuses on the recommendations for overall management of ductal carcinoma in situ and the workup and locoregional management of early stage invasive breast cancer. For the full version of the NCCN Guidelines for Breast Cancer, visit NCCN.org.
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Affiliation(s)
| | | | - Jame Abraham
- Case Comprehensive Cancer Center/University Hospitals Seidman Cancer Center and Cleveland Clinic Taussig Cancer Institute
| | - Rebecca Aft
- Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine
| | - Doreen Agnese
- The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute
| | | | | | | | | | - Chau Dang
- Memorial Sloan Kettering Cancer Center
| | | | | | | | | | | | | | | | - Sara H Javid
- Fred Hutchinson Cancer Research Center/University of Washington
| | | | | | - Janice Lyons
- Case Comprehensive Cancer Center/University Hospitals Seidman Cancer Center and Cleveland Clinic Taussig Cancer Institute
| | | | | | | | | | - Hope S Rugo
- UCSF Helen Diller Family Comprehensive Cancer Center
| | | | | | | | | | | | | | - John H Ward
- Huntsman Cancer Institute at the University of Utah
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Murchison S, Truong P. Locoregional therapy in breast cancer patients treated with neoadjuvant chemotherapy. Expert Rev Anticancer Ther 2021; 21:865-875. [PMID: 33719866 DOI: 10.1080/14737140.2021.1903876] [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: 10/21/2022]
Abstract
Introduction: Neoadjuvant chemotherapy (NAC) is increasingly used preoperatively in breast cancer patients to achieve disease downstaging, reduce distant dissemination, and assess chemosensitivity. While NAC indications are expanding, knowledge of its impact on subsequent locoregional treatment with surgery and radiation therapy (RT) decisions is evolving. Radiation oncologists are often called upon to estimate locoregional recurrence (LRR) risks and provide recommendations for adjuvant RT to the breast/chest wall and regional lymph nodes postoperatively. In the non-NAC setting, adjuvant RT decisions are guided by the pathology findings after definitive surgery. In the NAC setting, decisions for or against adjuvant RT are complex, particularly in patients who achieve complete pathologic response (pCR).Areas covered: This review will examine contemporary data on NAC in patients with breast cancer and discuss its impact on surgical and RT decisions. We will also evaluate controversies in the role of LRRT for these patients, focussing on prognostic factors that include biological subtypes and pCR after NAC.Expert opinion: Advances in personalized medicine and diagnostic techniques have shifted paradigms and increased complexities in locoregional treatment decisions, particularly in the setting of NAC. Despite the challenges, our goals while we await prospective data remain focused on improving survival, minimizing toxicity, and optimizing function and cosmesis.
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Affiliation(s)
- Sonja Murchison
- Department of Radiation Oncology, University of British Columbia, Vancouver, Canada.,Department of Radiation Oncology, BC Cancer, Victoria, Canada
| | - Pauline Truong
- Department of Radiation Oncology, University of British Columbia, Vancouver, Canada.,Department of Radiation Oncology, BC Cancer, Victoria, Canada
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Zhang J, Lu CY, Chen CH, Chen HM, Wu SY. Effect of pathologic stages on postmastectomy radiation therapy in breast cancer receiving neoadjuvant chemotherapy and total mastectomy: A Cancer Database Analysis. Breast 2020; 54:70-78. [PMID: 32947148 PMCID: PMC7501458 DOI: 10.1016/j.breast.2020.08.017] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Revised: 08/14/2020] [Accepted: 08/29/2020] [Indexed: 02/07/2023] Open
Abstract
PURPOSE To use pathologic indicators to determine which patients benefit from postmastectomy radiation therapy (PMRT) for breast cancer after neoadjuvant chemotherapy (NACT) and total mastectomy (TM). PATIENTS AND METHODS We enrolled 4236 patients with breast invasive ductal carcinoma who received NACT followed by TM. Cox regression analysis was used to calculate hazard ratios (HRs) and confidence intervals; independent predictors were controlled for or stratified in the analysis. RESULTS After multivariate Cox regression analyses, the adjusted HRs derived for PMRT for all-cause mortality were 0.65 (0.52-0.81, P < 0.0001) and 0.58 (0.47-0.71, P < 0.0001) in postchemotherapy pathologic tumor stages T2-4 (ypT3-4) and postchemotherapy pathologic nodal stages N2-3 (ypN2-3), respectively. Moreover, adjusted HRs derived for PMRT with all-cause mortality were 0.51 (0.38-0.69, P < 0.0001), 0.60 (0.40-0.88, P = 0.0096), and 0.64 (0.48-0.86, P = 0.0024) in pathological stages IIIA, IIIB, and IIIC, respectively. Additionally, the PMRT group showed significant locoregional control irrespective of the pathologic response, even ypT0, ypN0, or pathological complete response (pCR), compared with the No-PMRT group. The multivariate analysis showed no statistical differences between the PMRT and No-PMRT groups for distant metastasis-free survival in any pathologic response of ypT0-4, ypN0-3, and pathologic American Joint Committee on Cancer stages pCR to IIIC. CONCLUSION For patients with breast cancer ypT3-4, ypN2-3, or pathologic stages IIIA-IIIC receiving NACT and TM, benefit from PMRT if it is associated with OS benefits, regardless of the clinical stage of the disease. Compared with No-PMRT, PMRT improved locoregional recurrence-free survival, even pCR, in patients with breast cancer receiving NACT and TM.
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Affiliation(s)
- Jiaqiang Zhang
- Department of Anesthesiology and Perioperative Medicine, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Chang-Yun Lu
- Department of General Surgery, Lo-Hsu Medical Foundation, Lotung Poh-Ai Hospital, Yilan, Taiwan
| | - Chien-Hsin Chen
- Department of Colorectal Surgery, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Ho-Min Chen
- Big Data Center, Lo-Hsu Medical Foundation, Lotung Poh-Ai Hospital, Yilan, Taiwan
| | - Szu-Yuan Wu
- Big Data Center, Lo-Hsu Medical Foundation, Lotung Poh-Ai Hospital, Yilan, Taiwan; Department of Food Nutrition and Health Biotechnology, College of Medical and Health Science, Asia University, Taichung, Taiwan; Division of Radiation Oncology, Lo-Hsu Medical Foundation, Lotung Poh-Ai Hospital, Yilan, Taiwan; Department of Healthcare Administration, College of Medical and Health Science, Asia University, Taichung, Taiwan; School of Dentistry, College of Oral Medicine, Taipei Medical University, Taipei, Taiwan.
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Montero Á, Ciérvide R, Poortmans P. When Can We Avoid Postmastectomy Radiation Following Primary Systemic Therapy? Curr Oncol Rep 2019; 21:95. [DOI: 10.1007/s11912-019-0850-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Nakajima N, Oguchi M, Kumai Y, Yoshida M, Inoda H, Yoshioka Y, Iwase T, Ito Y, Akiyama F, Ohno S. Clinical outcomes and prognostic factors in patients with stage II-III breast cancer treated with neoadjuvant chemotherapy followed by surgery and postmastectomy radiation therapy in the modern treatment era. Adv Radiat Oncol 2018; 3:271-279. [PMID: 30202796 PMCID: PMC6128027 DOI: 10.1016/j.adro.2018.04.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Revised: 03/27/2018] [Accepted: 04/16/2018] [Indexed: 12/18/2022] Open
Abstract
Purpose There are no randomized studies on the indication for postmastectomy radiation therapy (PMRT) in patients who receive neoadjuvant chemotherapy (NAC) followed by a mastectomy. The aim of this study was to determine clinical outcomes and identify reliable prognostic factors in patients with locally advanced breast cancer treated with NAC followed by a mastectomy and PMRT. Methods and materials We retrospectively evaluated the relationship between clinicopathological factors and outcomes in 351 patients with stage II or III breast cancer who underwent NAC followed by radical mastectomy and PMRT between March 2005 and December 2013. Results The median follow-up duration was 81 months (Range, 12-156 months). For all patients, the 5-year locoregional recurrence-free survival (LRFS), distant metastasis-free survival (DMFS), and overall survival (OS) rates were 91.3 %, 69.8 %, and 83.4 %, respectively. On multivariate analysis, estrogen-receptor positivity, and complete response of cancer in axillary nodes (ypN0) were significant prognostic factors for better LRFS, while lympho-vascular invasion and clinical stage IIIC were independent prognostic factors for worse LRFS. The number of axillary node metastasesafter surgery was an independent prognostic factor of DMFS and OS. Patients with hormone receptor- and human epidermal growth factor receptor 2 positivity had significantly better 5-year LRFS rates. Conclusions We identified several prognostic factors in our study. In particular, the number of axillary node metastases is significantly related to OS.
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Affiliation(s)
- Naomi Nakajima
- Department of Radiation Oncology, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
- Corresponding author. Department of Radiation Oncology, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, 3-8-31, Ariake, Koto, Tokyo 135-8550, Japan.
| | - Masahiko Oguchi
- Department of Radiation Oncology, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Yasuko Kumai
- Department of Radiation Oncology, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Masahiro Yoshida
- Department of Radiation Oncology, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Hirotaka Inoda
- Department of Radiation Oncology, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Yasuo Yoshioka
- Department of Radiation Oncology, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Takuji Iwase
- Breast Oncology Center, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Yoshinori Ito
- Breast Oncology Center, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Futoshi Akiyama
- Division of Pathology, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Shinji Ohno
- Breast Oncology Center, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
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Kishan AU, McCloskey SA. Postmastectomy radiation therapy after neoadjuvant chemotherapy: review and interpretation of available data. Ther Adv Med Oncol 2016; 8:85-97. [PMID: 26753007 DOI: 10.1177/1758834015617459] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Postmastectomy radiotherapy (PMRT) has been shown to decrease locoregional recurrence and improve overall survival in patients with tumors greater than 5 cm or positive nodes. Because neoadjuvant chemotherapy (NAC) can cause significant downstaging, the indications for PMRT in the setting of NAC remain controversial and thus careful consideration of clinical stage at presentation, pathologic response to NAC, and other clinical characteristics, such as grade and biomarker status is required. The current review synthesizes both prospective and retrospective data to provide evidence for recommending PMRT after NAC for patients presenting with cT3-4 disease, cN2-3 disease, and residual nodal disease, as well as rationale for omitting PMRT in patients with cT1-2N0-1 disease who achieve a pathologic complete response. Other scenarios, including nodal complete response in the presence of other risk factors, are also explored. The topics of pre-NAC clinical staging and pathologic axillary nodal staging are reviewed, and radiation portal design is briefly discussed.
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Affiliation(s)
- Amar U Kishan
- Department of Radiation Oncology, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Susan A McCloskey
- Department of Radiation Oncology, 1223 16th Street, Santa Monica, CA 90404, USA
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Dialani V, Chadashvili T, Slanetz PJ. Role of imaging in neoadjuvant therapy for breast cancer. Ann Surg Oncol 2015; 22:1416-24. [PMID: 25727555 DOI: 10.1245/s10434-015-4403-9] [Citation(s) in RCA: 82] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2014] [Indexed: 12/20/2022]
Abstract
Neoadjuvant chemotherapy (NAC) involves administration of chemotherapeutic agents to patients with newly diagnosed breast cancer prior to definitive surgical treatment. Assessment of disease response to chemotherapeutic agents in vivo prior to any surgical intervention is necessary as medical oncologists are commonly tailoring or changing therapy during NAC based on response. It can also maximize the pathologic complete response (pCR) rate, resulting in more women undergoing breast conservation rather than mastectomy. Although some studies show a pCR to NAC in only 13-26 % of women, recent studies have shown higher pCR rates, especially for HER2-positive disease treated with targeted anti-HER2 therapy. Thus, accurate imaging tools for quantifying disease response are critical in the evaluation and management of patients undergoing NAC. There is currently no standard imaging method for monitoring response to therapy. Response to therapy tends to vary by tumor subtype and can be accurately assessed on imaging. We review the role of imaging before and after neoadjuvant therapy and discuss the advantages and limitations of currently available modalities, including mammography, ultrasonography, magnetic resonance imaging, and nuclear imaging.
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Affiliation(s)
- Vandana Dialani
- Division of Breast Imaging, Department of Radiology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
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Bernier J. Post-mastectomy radiotherapy after neodjuvant chemotherapy in breast cancer patients: A review. Crit Rev Oncol Hematol 2015; 93:180-9. [DOI: 10.1016/j.critrevonc.2014.10.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2014] [Revised: 10/20/2014] [Accepted: 10/21/2014] [Indexed: 11/28/2022] Open
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Bogusevicius A, Cepuliene D, Sepetauskiene E. The integrated evaluation of the results of oncoplastic surgery for locally advanced breast cancer. Breast J 2013; 20:53-60. [PMID: 24237716 DOI: 10.1111/tbj.12222] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
The optimal surgical management of locally advanced breast cancer (LABC) remains undefined. The aim of the study was to obtain long-term results of oncoplastic surgery in terms of overall survival, loco-regional recurrence, and quality of life in case of LABC. Prospective cohort study enrolled 60 patients with stage III breast cancer. Forty-two (70%) patients received neo-adjuvant chemotherapy, 28 patients were considered suitable for surgery as initial treatment option. Type II oncoplastic surgery was performed for all patients: hemimastectomy and breast reconstruction with latissimus dorsi flap - for 29 (48.3%), lumpectomy - 31 (51.7%), and reconstruction with subaxillary flap for four (6.7%), with bilateral reduction mammoplasty - 14 (23.3%) and with J-plastic - 13 (21.7%) patients. Adjuvant chemotherapy and hormonal therapy followed surgery for all, except one, patients. Sequential radiotherapy was administered for all patients. The mean period of follow-up was 86 months. Postoperative morbidity rate was 5%. Local-regional recurrence was detected in six (10%) patients. After reoperation no local relapse was diagnosed. However, three of these patients had systemic dissemination of the disease. Distant metastasis was detected in 23 (38.3%) patients. Distant metastasis-free survival at 5 years was 61.7%. Fourteen patients died (23.3%). A total of 87.2% of the patients had good and excellent esthetic outcome. Oncoplastic breast-conserving surgery can be proposed for selected patients with LABC with acceptable complication, local recurrence rate, and good esthetic results.
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Affiliation(s)
- Algirdas Bogusevicius
- Department of Surgery of Breast Diseases, Lithuanian University of Health Sciences, Kaunas, Lithuania
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Fowble BL, Einck JP, Kim DN, McCloskey S, Mayadev J, Yashar C, Chen SL, Hwang ES. Role of postmastectomy radiation after neoadjuvant chemotherapy in stage II-III breast cancer. Int J Radiat Oncol Biol Phys 2012; 83:494-503. [PMID: 22579377 DOI: 10.1016/j.ijrobp.2012.01.068] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2011] [Revised: 01/19/2012] [Accepted: 01/21/2012] [Indexed: 11/15/2022]
Abstract
PURPOSE To identify a cohort of women treated with neoadjuvant chemotherapy and mastectomy for whom postmastectomy radiation therapy (PMRT) may be omitted according to the projected risk of local-regional failure (LRF). METHODS AND MATERIALS Seven breast cancer physicians from the University of California cancer centers created 14 hypothetical clinical case scenarios, identified, reviewed, and abstracted the available literature (MEDLINE and Cochrane databases), and formulated evidence tables with endpoints of LRF, disease-free survival, and overall survival. Using the American College of Radiology appropriateness criteria methodology, appropriateness ratings for postmastectomy radiation were assigned for each scenario. Finally, an overall summary risk assessment table was developed. RESULTS Of 24 sources identified, 23 were retrospective studies from single institutions. Consensus on the appropriateness rating, defined as 80% agreement in a category, was achieved for 86% of the cases. Distinct LRF risk categories emerged. Clinical stage II (T1-2N0-1) patients, aged >40 years, estrogen receptor-positive subtype, with pathologic complete response or 0-3 positive nodes without lymphovascular invasion or extracapsular extension, were identified as having ≤ 10% risk of LRF without radiation. Limited data support stage IIIA patients with pathologic complete response as being low risk. CONCLUSIONS In the absence of randomized trial results, existing data can be used to guide the use of PMRT in the neoadjuvant chemotherapy setting. Using available studies to inform appropriateness ratings for clinical scenarios, we found a high concordance of treatment recommendations for PMRT and were able to identify a cohort of women with a low risk of LRF without radiation. These low-risk patients will form the basis for future planned studies within the University of California Athena Breast Health Network.
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Affiliation(s)
- Barbara L Fowble
- Department of Radiation Oncology, Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA 94143-1708, USA.
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Ho AL, Tyldesley S, Macadam SA, Lennox PA. Skin-Sparing Mastectomy and Immediate Autologous Breast Reconstruction in Locally Advanced Breast Cancer Patients: A UBC Perspective. Ann Surg Oncol 2011; 19:892-900. [DOI: 10.1245/s10434-011-1989-4] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2011] [Indexed: 11/18/2022]
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But-Hadžić J, Bilban-Jakopin C, Hadžić V. The Role of Radiation Therapy in Locally Advanced Breast Cancer. Breast J 2010; 16:183-8. [DOI: 10.1111/j.1524-4741.2009.00885.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Parmar V, Badwe RA. Breast conservation in locally advanced breast cancer. Indian J Surg Oncol 2010; 1:3-7. [PMID: 22930610 DOI: 10.1007/s13193-010-0003-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2009] [Accepted: 10/10/2009] [Indexed: 10/19/2022] Open
Abstract
Absence of breast cancer screening in India, lack of awareness in rural population, social inhibitions and poor socioeconomic status leads to a situation where a large proportion of women in India are still presenting with locally advanced breast cancer (LABC) at the time of initial diagnosis, although, there are relatively more of early stage cases detected in the metros and urban areas than maybe a decade ago. With advances in care and introduction of newer chemotherapeutic agents, it has now become feasible to offer neoadjuvant therapy with effective tumor downsizing, thus making it possible to even consider breast conservation surgery in select patients with locally advanced and unresectable disease at presentation. With reports suggesting apparent safety of the procedure, breast conservation treatment after chemotherapy is now being offered as routine care in most major centers for selective women with LABC. Multimodality therapy is the standard of care with neoadjuvant systemic therapy for all women with LABC.
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Chia S, Swain SM, Byrd DR, Mankoff DA. Locally Advanced and Inflammatory Breast Cancer. J Clin Oncol 2008; 26:786-90. [DOI: 10.1200/jco.2008.15.0243] [Citation(s) in RCA: 140] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Stephen Chia
- From the Department of Medical Oncology, British Columbia Cancer Agency, Vancouver, British Columbia, Canada; Washington Cancer Institute, Washington Hospital Center, Washington, DC; and Departments of Surgery and Radiology, Seattle Cancer Care Alliance and University of Washington, Seattle, WA
| | - Sandra M. Swain
- From the Department of Medical Oncology, British Columbia Cancer Agency, Vancouver, British Columbia, Canada; Washington Cancer Institute, Washington Hospital Center, Washington, DC; and Departments of Surgery and Radiology, Seattle Cancer Care Alliance and University of Washington, Seattle, WA
| | - David R. Byrd
- From the Department of Medical Oncology, British Columbia Cancer Agency, Vancouver, British Columbia, Canada; Washington Cancer Institute, Washington Hospital Center, Washington, DC; and Departments of Surgery and Radiology, Seattle Cancer Care Alliance and University of Washington, Seattle, WA
| | - David A. Mankoff
- From the Department of Medical Oncology, British Columbia Cancer Agency, Vancouver, British Columbia, Canada; Washington Cancer Institute, Washington Hospital Center, Washington, DC; and Departments of Surgery and Radiology, Seattle Cancer Care Alliance and University of Washington, Seattle, WA
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Ahern V, Boyages J, Gebski V, Moon D, Wilcken N. Selective Mastectomy in the Management of Locally Advanced Breast Cancer. Int J Radiat Oncol Biol Phys 2007; 68:1010-7. [PMID: 17398030 DOI: 10.1016/j.ijrobp.2007.01.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2006] [Revised: 01/10/2007] [Accepted: 01/11/2007] [Indexed: 11/23/2022]
Abstract
PURPOSE To evaluate local control for patients with locally advanced noninflammatory breast cancer (LABC) managed by selective mastectomy. METHODS AND MATERIALS Between 1979 and 1996, 176 patients with LABC were prospectively managed by chemotherapy (CT)-irradiation (RT)-CT without routine mastectomy. All surviving patients were followed for a minimum of 5 years. RESULTS A total of 132 patients (75%) had a T4 tumor and 22 (12.5%) supraclavicular nodal disease. The clinical complete response rate was 91% (160/176), which included 13 patients who underwent mastectomy and 2 an iridium wire implant. The first site of failure was local for 43 patients (breast +/- axilla for 38); 27 of these patients underwent salvage mastectomy and 11 did not for an overall mastectomy rate of 23% (40/176). If all 176 patients had undergone routine mastectomy (136 extra mastectomies), 11 additional patients may have avoided an unsalvageable first local relapse. The others would have either have not had a local relapse or would have suffered local relapse after distant disease. No tumor or treatment related factor was found to predict local disease at death. Median disease-free and overall survival for all patients was 26 and 52 months, respectively. CONCLUSIONS Selective mastectomy in LABC may not jeopardize local control or survival.
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Affiliation(s)
- Verity Ahern
- Department of Radiation Oncology, Westmead Hospital, NSW 2145, Sydney, Australia.
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18
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Hui Z, Li Y, Yu Z, Liao Z. Survey on use of postmastectomy radiotherapy for breast cancer in China. Int J Radiat Oncol Biol Phys 2006; 66:1135-42. [PMID: 16979834 DOI: 10.1016/j.ijrobp.2006.06.053] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2006] [Revised: 05/01/2006] [Accepted: 06/22/2006] [Indexed: 10/24/2022]
Abstract
PURPOSE To comprehensively assess the current use of postmastectomy radiotherapy (PMRT) throughout China. METHODS AND MATERIALS A questionnaire on the indications and techniques for PMRT for breast cancer was mailed to all 715 radiotherapy centers in mainland China. RESULTS Of the 715 questionnaires sent out, 210 were answered (29.4%). The median interval between surgery and PMRT was 6 weeks. "Sandwich" sequencing of chemotherapy and PMRT was the most common combination, performed in 75.7% of the responding clinics. Of the respondents, 11.9% used PMRT for T1-T2N0 breast cancer, 63.8% for T1-T2N0 with tumors located in the center or inner quadrant, 87.6% for Stage T1-T2 and one to three positive lymph nodes (LN+), and 97.1% for T3 or Stage III tumors and/or four or more LN+. The supraclavicular region was the most common radiation target used by the respondents (96.2%), followed by the internal mammary chain (85.2%), chest wall (79.0%), and axilla (74.8%). Photon-based tangential fields were the most common technique used for chest wall irradiation (45.8%). The median total dose to each target was 50 Gy, with 2-Gy fractions. CONCLUSION A consensus has been reached in China that PMRT is needed for patients with T3 or Stage III disease and/or four or more LN+ and that irradiation to the chest wall and supraclavicular region is necessary in such patients. However, most Chinese radiation centers are also likely to apply PMRT to patients with one to three LN+ and to irradiate the internal mammary chain and the axilla.
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Affiliation(s)
- Zhouguang Hui
- Department of Radiation Oncology, Cancer Institute (Hospital), Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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19
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Abstract
With over 200,000 new cases of invasive breast cancer treated each year, various types of breast reconstruction have become popular and safe. Immediate breast reconstruction seems to confer both benefit and patient satisfaction. A variety of techniques including subcutaneous expanders/implants, flap transfers, and free tissue transfers are described.
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Affiliation(s)
- Justin H Piasecki
- Division of Plastic and Reconstructive Surgery, University of Wisconsin-Madison, USA.
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20
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Solimando DA, Waddell JA. Methotrexate, Vinblastine, Doxorubicin, and Cisplatin (MVAC) Regimen for Urothelial Tract Tumors. Hosp Pharm 2004. [DOI: 10.1177/001857870403900905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The increasing complexity of cancer chemotherapy makes it mandatory that pharmacists be familiar with these highly toxic agents. This column focuses on the commercially available and investigational agents used to treat malignant diseases and reviews issues related to the preparation, dispensing, and administration of cancer chemotherapy.
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Affiliation(s)
- Dominic A. Solimando
- Oncology Pharmacy Services, Inc., 4201 Wilson Boulevard #110-545, Arlington, VA 22203
| | - J. Aubrey Waddell
- Oncology Pharmacy Residency Program, Department of Pharmacy, Walter Reed Army Medical Center, 6900 Georgia Avenue, NW, Room 2P02, Washington, DC 20307-5001
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21
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Abstract
The ASCO guidelines panel found that PMRT reduces the risks of both local-regional recurrence and distant recurrence, and improves survival rates for patients with invasive breast cancer with involved axillary lymph nodes receiving systemic therapy. The benefits of PMRT, however, vary with regards to particular patient subsets (such as those defined by the number of involved axillary nodes). The panel agreed that PMRT is indicated routinely for patients with four or more positive axillary nodes, tumors larger than 5 cm in size, or locally advanced cancers. There was insufficient evidence for the panel to make recommendations or suggestions for the use of PMRT for patients with T1-2 tumors with one to three positive axillary nodes or for all patients receiving neoadjuvant systemic therapy. Physicians and patients are encouraged to participate in randomized trials exploring such issues, such as the ongoing intergroup study for patients with one to three positive axillary nodes.
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Affiliation(s)
- Abram Recht
- Department of Radiation Oncology, Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA.
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22
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Abstract
The diagnosis and treatment of breast cancer have changed in response to not only new technologies but also cultural and social aspects of the disease. While breast-conserving surgery and adjuvant therapy are the preferred treatments for many breast cancers, neoadjuvant therapy is often used in advanced disease. In this review we examine the treatment options that are influenced by pathologic and clinical factors. Invasive breast cancer is a potentially curable disease if it is regarded and managed by a multidisciplinary approach from the outset.
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Affiliation(s)
- Atilla Soran
- University of Pittsburgh Cancer Institute/Magee-Womens Hospital, Pittsburgh, Pennsylvania
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23
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Abdel-Fattah M, Lotfy NS, Bassili A, Anwar M, Mari E, Bedwani R, Tognoni G. Current treatment modalities of breast-cancer patients in Alexandria, Egypt. Breast 2001; 10:523-9. [PMID: 14965633 DOI: 10.1054/brst.2000.0285] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2000] [Revised: 11/29/2000] [Accepted: 12/05/2000] [Indexed: 11/18/2022] Open
Abstract
Despite great advances in the treatment of breast cancer during recent years, many breast cancer patients still do not receive appropriate treatment. Data were collected during a 1-year period from nine general hospitals aiming at evaluating the quality of care delivered to breast cancer patients in Alexandria, Egypt. A total of 565 breast cancer patients were involved. The highest frequency of cases was diagnosed in stage II followed by stage III. Patey's modified radical mastectomy was the most commonly performed operation (82.65% of cases), regardless of the clinical stage or health facilities. Hormonal receptor status was rarely performed. There was no consensus regarding the type of systemic therapy (hormonal, chemotherapy or combined) to be administered for each clinical stage and menopausal status. Concerning postoperative radiotherapy, it was invariably the rule, regardless of the clinical stage. We conclude that, despite some improvement over the last few years (shorter diagnostic delay, larger use of standard classifications, and less radical surgery), the quality of management of breast cancer in Egyptian general hospitals is still not satisfactory.
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Affiliation(s)
- M Abdel-Fattah
- Medical Statistics Department, Medical Research Institute, Alexandria University, Alexandria, Egypt.
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Murakami M, Kuroda Y, Nishimura S, Sano A, Okamoto Y, Taniguchi T, Nakajima T, Kobashi Y, Matsusue S. Intraarterial infusion chemotherapy and radiotherapy with or without surgery for patients with locally advanced or recurrent breast cancer. Am J Clin Oncol 2001; 24:185-91. [PMID: 11319296 DOI: 10.1097/00000421-200104000-00017] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
We analyzed response, side effects, and local control rates of a multimodal treatment consisting of intraarterial infusion chemotherapy (IAIC) and radiotherapy with or without surgery for patients with locally advanced or recurred breast cancer. Thirty-three patients, clinically diagnosed as stage IIB in 1, IIIA in 2, IIIB in 12, IV in 18, were treated from 1991 to 1998. Twenty-five were primary and eight were recurrent cases after surgery. IAIC started as initial treatment up to three times maximum. In most cases, doxorubicin 50 mg, cisplatin 50 mg, and mitomycin 10 mg were infused in the subclavian and/or internal mammary artery. After IAIC, patients in primary cases underwent radical mastectomy or breast conservation surgery, after radiotherapy at a total dose of 50 Gy/25 fractions/5 weeks with a boost of 10 Gy. In recurrent cases, a full dose of radiotherapy was delivered. Clinical objective and complete response rates were 78% and 9% after IAIC. Despite a high rate of residual positive margin (67%) or clinically residual carcinoma, local recurrence developed only in 2 patients (6%) and local control rates at 5 years were calculated as 89%. Bone marrow suppression was frequent, and skin vesiculation (15%) and ulceration (9%) were experienced after IAIC. Skin ulcer (6%), brachial plexus neuropathy (3%), and radiation pneumonitis (3%) occurred as late toxicity. IAIC was effective as an induction treatment and radiotherapy played a role of local control for patients with locally advanced or recurrent breast cancer.
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Affiliation(s)
- M Murakami
- Department of Radiology, Tenri Hospital. Tenri City, Nara Prefecture, Japan
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Recht A, Edge SB, Solin LJ, Robinson DS, Estabrook A, Fine RE, Fleming GF, Formenti S, Hudis C, Kirshner JJ, Krause DA, Kuske RR, Langer AS, Sledge GW, Whelan TJ, Pfister DG. Postmastectomy radiotherapy: clinical practice guidelines of the American Society of Clinical Oncology. J Clin Oncol 2001; 19:1539-69. [PMID: 11230499 DOI: 10.1200/jco.2001.19.5.1539] [Citation(s) in RCA: 659] [Impact Index Per Article: 28.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE To determine indications for the use of postmastectomy radiotherapy (PMRT) for patients with invasive breast cancer with involved axillary lymph nodes or locally advanced disease who receive systemic therapy. These guidelines are intended for use in the care of patients outside of clinical trials. POTENTIAL INTERVENTION The benefits and risks of PMRT in such patients, as well as subgroups of these patients, were considered. The details of the PMRT technique were also evaluated. OUTCOMES The outcomes considered included freedom from local-regional recurrence, survival (disease-free and overall), and long-term toxicity. EVIDENCE An expert multidisciplinary panel reviewed pertinent information from the published literature through July 2000; certain investigators were contacted for more recent and, in some cases, unpublished information. A computerized search was performed of MEDLINE data; directed searches based on the bibliographies of primary articles were also performed. VALUES Levels of evidence and guideline grades were assigned by the Panel using standard criteria. A "recommendation" was made when level I or II evidence was available and there was consensus as to its meaning. A "suggestion" was made based on level III, IV, or V evidence and there was consensus as to its meaning. Areas of clinical importance were pointed out where guidelines could not be formulated due to insufficient evidence or lack of consensus. RECOMMENDATIONS The recommendations, suggestions, and expert opinions of the Panel are described in this article. VALIDATION Seven outside reviewers, the American Society of Clinical Oncology (ASCO) Health Services Research Committee members, and the ASCO Board of Directors reviewed this document.
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Affiliation(s)
- A Recht
- Beth Israel Deaconess Medical Center, Boston, MA, USA
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Abstract
Over the past 20 years, the prognosis for women diagnosed with locally advanced breast cancer (LABC; clinical stages IIB through IIIB) has improved significantly with recognition of the efficacy of multimodal therapy for reducing both local and distant recurrences, even in patients with inflammatory breast cancer (IBC). Most patients will respond to induction, or neoadjuvant, chemotherapy (NAC) with an anthracycline-based regimen, enabling many patients with large but operable tumors to undergo breast-conserving surgery (BCS) and enabling resection in most patients with inoperable disease. However, only a small percentage of patients achieve a pathologic complete response (CR) with this approach. Long-term disease-free survival (DFS) and overall survival (OS) correlate with the extent of residual disease in the breast and axillary nodes following NAC. The addition of paclitaxel or docetaxel, either in combination with an anthracycline or as a separate regimen administered before or after anthracycline-based therapy, increases clinical and pathologic response rates and may improve DFS. With the possible exception of patients with IBC, BCS does not compromise outcome. Partial mastectomy should be accompanied by standard nodal dissection in patients with clinically or radiographically positive axillae; in patients with negative axillae, sentinel lymph node (SLN) sampling, with subsequent axillary dissection reserved for patients with involved nodes, may reduce postoperative morbidity. Patients who received only anthracycline-based NAC who are found to have significant residual disease in the breast or involved axillary nodes at surgery should receive adjuvant chemotherapy with paclitaxel. Postoperative radiation to the residual breast or chest wall and regional nodal areas reduces locoregional recurrences, but its impact on OS remains controversial. Adjuvant hormonal therapy with tamoxifen improves DFS and OS in patients with hormone receptor (HR)-positive tumors, and ovarian ablation should be considered in premenopausal patients with HR-positive tumors and multiple involved nodes or stage IIIB disease. Neoadjuvant hormonal therapy with either tamoxifen or an aromatase inhibitor may benefit frail or elderly patients with HR-positive tumors for whom chemotherapy is not an option. No advantage has been demonstrated for high-dose chemotherapy requiring hematopoietic stem-cell support as either NAC or adjuvant therapy in LABC. Newer treatment approaches, including trastuzumab (Herceptin, Genentech, Inc., South San Francisco, CA), in patients with Her-2-overexpressing tumors or other biologic agents, do not have a proven role in the management of LABC at this time.
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Affiliation(s)
- W M Sikov
- Department of Medicine, Room 320, The Miriam Hospital, 164 Summit Avenue, Providence, RI 02906, USA
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28
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Abstract
Radiation therapy for breast cancer has gone through two revolutions in the last two decades: the routine use of radiation therapy in conjunction with breast-conserving surgery as an equivalent treatment to mastectomy, and the use of radiation therapy following mastectomy in advanced or node-positive disease. Indeed, the perception of postmastectomy radiation has gone full circle: from having no benefit when used for all cases, to being detrimental because of cardiac irradiation, to the present in which the selective use of irradiation in high-risk patients provides both an improvement in local control and an improvement of 8% to 10% in the survival rate. Improvements in radiation technique have reduced complications, in particular late cardiac deaths. The major issues still to be resolved are the targets for postmastectomy irradiation, determining which patients do not need radiation therapy for DCIS and for node-negative disease, and the efficacy of delivering radiation to just the affected quadrant rather than to the whole breast. At present, most patients approach radiation therapy for breast cancer with the knowledge that it has a very high probability of being successful.
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Affiliation(s)
- A G Taghian
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, USA.
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