The curative role of radiotherapy in the treatment of operable breast cancer

Parallel pathways: A chronicle of evolution in rectal and breast cancer surgery

In this editorial, we have analyzed the historical evolution of rectal and breast cancer surgery, focusing on the progressive reduction of demolitive approaches and the increasing use of more conservative strategies, accompanied by a growing emphasis on perioperative treatments aimed at enhancing surgical outcomes. All of these changes have been made possible due to an increased awareness and understanding of oncological diseases and improved perioperative treatments.

A method for beam's eye view breath-hold monitoring during breast volumetric modulated arc therapy

Background and purpose

Deep inspiration breath-hold (DIBH) is a technique that is widely utilised to spare the heart and lungs during breast radiotherapy. In this study, a method was developed to validate directly the intrafraction accuracy of DIBH during breast volumetric modulated arc therapy (VMAT) via internal chest wall (CW) monitoring.

Materials and methods

In-house software was developed to automatically extract and compare the treatment position of the CW in cine-mode electronic portal image device (EPID) images with the planned CW position in digitally reconstructed radiographs (DRR) for breast VMAT treatments. Feasibility of this method was established by evaluating the percentage of total dose delivered to the target volume when the CW was sufficiently visible for monitoring. Geometric accuracy of the approach was quantified by applying known displacements to an anthropomorphic thorax phantom. The software was used to evaluate (offline) the geometric treatment accuracy for ten patients treated using real-time position management (RPM)-guided DIBH.

Results

The CW could be monitored within the tangential sub-arcs which delivered a median 89% (range 73% to 97%) of the dose to target volume. The phantom measurements showed a geometric accuracy within 1 mm, with visual inspection showing good agreement between the software-derived and user-determined CW positions. For the RPM-guided DIBH treatments, the CW was found to be within ±5 mm of the planned position in 97% of EPID frames in which the CW was visible.

Conclusion

An intrafraction monitoring method with sub-millimetre accuracy was successfully developed to validate target positioning during breast VMAT DIBH.

Capsular inflammation after immediate breast reconstruction - Gene expression patterns and inflammatory cell infiltration in irradiated and non-irradiated breasts

BACKGROUND

Capsular contracture following post-mastectomy radiotherapy (PMRT) is commonly seen in patients undergoing implant-based immediate breast reconstruction (IBR). Further understanding of the underlying biology is needed for the development of preventive or therapeutic strategies. Therefore, we conducted a comparative study of gene expression patterns in capsular tissue from breast cancer patients who had received versus those who had not received PMRT after implant-based IBR.

METHODS

Biopsies from irradiated and healthy non-irradiated capsular tissue were harvested during implant exchange following IBR. Biopsies from irradiated (n = 13) and non-irradiated (n = 12) capsules were compared using Affymetrix microarrays to identify the most differentially regulated genes. Further analysis using immunohistochemistry was performed in a subset of materials to compare the presence of T cells, B cells, and macrophages.

RESULTS

Enrichment testing using Gene Ontology (GO) analysis revealed that the 227 most differentially expressed genes were mainly involved in an inflammatory response. Twenty-one GO biological processes were identified [p < 0.05, false discovery rate (FDR) < 5%], several with B-cell-associated inflammation. Cell-type Identification by Estimating Relative Subsets of RNA Transcripts (CIBERSORT) analysis identified macrophages as the most common inflammatory cell type in both groups, further supported by immunostaining of CD68. Radiation remarkably increased B-cell infiltration in the capsular region of biopsies, as quantified by immunostaining of CD20 (p = 0.016).

CONCLUSIONS

Transcript analysis and immunohistochemistry revealed inflammatory responses in capsular biopsies regardless of radiotherapy. However, the radiation response specifically involved B-cell-associated inflammatory responses.

Intraoperative Radiotherapy Is Not a Better Alternative to Whole Breast Radiotherapy as a Therapeutic Option for Early-Stage Breast Cancer

Objective

Intraoperative radiotherapy (IORT) in early-stage breast cancer has been studied over the years. However, it has not been demonstrated whether IORT is more suitable as a therapeutic option for early-stage breast cancer than whole breast radiotherapy (WBRT). Therefore, we performed a meta-analysis to compare the efficacy and safety of IORT to those of WBRT as therapeutic options for early-stage breast cancer patients receiving breast-conserving surgery (INPLASY2020120008).

Methods

PubMed, Embase, and Cochrane Library databases were searched from inception to October 2021. Computerized and manual searches were adopted to identify eligible randomized control trials from online databases. Risk ratio (RR) and 95% confidence intervals (CI) were calculated by random-effect models to assess the relative risk. Potential publication bias was quantified by Begg’s and Egger’s tests.

Results

Based on our inclusion criteria, 10 randomized control trials involving 5,698 patients were included in this meta-analysis. This meta-analysis showed that the IORT group was associated with a higher local recurrence risk (RR = 2.111, 95% CI, 1.130–3.943, p = 0.0191), especially in the long-term follow-up subgroup or published after 2020 subgroup or Caucasian subgroup (RR = 2.404, 95% CI, 1.183–4.885, p = 0.0154). Subgroup analysis showed that the IORT group had a higher recurrence risk than the WBRT group in the polycentric randomized controlled trial subgroup (RR = 1.213, 95% CI, 1.030–1.428, p = 0.0204). Pooled analysis showed that there was no statistically significant difference in overall survival, recurrence-free survival, distant metastasis-free survival, and cancer-specific survival between IORT and WBRT groups. Additionally, the risk of skin toxicity was reduced, but the incidences of fat toxicity, edema, and scar calcification were significantly increased in the patients who underwent IORT in comparison to those who underwent WBRT.

Conclusion

This meta-analysis revealed that IORT was not a better alternative to WBRT. More large-scale and well-designed clinical trials with longer follow-up periods are encouraged to further investigate the value of IORT.

Systematic Review Registration

https://inplasy.com/inplasy-2020-12-0008/.

Spatial barriers impact upon appropriate delivery of radiotherapy in breast cancer patients

Radiotherapy (RT) is the standard treatment for breast cancer patients after conserving surgery or mastectomy when patients are at high risk of relapse. Major obstacles to appropriate RT delivery are journey times. Since studies on access to RT were carried out mostly in large countries, this study investigated factors in an Italian region and the influence of RT delivery on survival. A total of 4735 female candidates for RT were included in the study. A geographic information system calculated journey times from patients' homes and surgery hospitals to RT centers. Logistic regression analyzed the influence of journey times, socioeconomic status, and other factors on RT delivery. Survival probabilities and excess mortality were assessed in 4364 propensity score-matched patients. Journey times of 40 min or less from residence and from surgery hospital to RT center played a major role in access to RT. A large survival difference emerged between treated and untreated breast cancer patients. The excess mortality for untreated patients compared with propensity score-matched women receiving RT was 3.1 (95% CI: 2.2-4.3). Expansion of RT facilities during the 11-year study period improved RT delivery and outcomes by increasing availability but mainly by shortening journey times.

Radiotherapy in Italy after Conservative Treatment of Early Breast Cancer. A Survey by the Italian Society of Radiation Oncology (AIRO)

Aims and Background

The aim of surveys on clinical practice is to stimulate discussion and optimize practice. In this paper the current Italian radiotherapy practice after breast-conserving surgery for early breast cancer is described and adherence to national and international guidelines is assessed. Furthermore, results are compared with an earlier survey in northern Italy and international reports.

Study Design

A multiple-choice questionnaire sent to all 138 Italian radiation oncology centers.

Results

48% of centers responded. Most performed breast-conserving surgery when tumor size was ≤3 cm. All centers routinely performed axillary dissection; 45 carried out sentinel node biopsy followed by axillary dissection when the sentinel node was positive. Most centers re-excised when resection margins were positive. The median interval between surgery and radiotherapy, when chemotherapy was not administered, was 60 days. Adjuvant chemotherapy was preferably administered before radiotherapy. Regional lymph nodes were never irradiated in 10 centers; in all others irradiation depended on the number of positive lymph nodes and/or involvement of axillary fat and/or tumor location in medial quadrants. All centers used standard fractionation; hypofractionated schemes were available in 6. Most centers used 4–6 MV photons. In 59 centers the boost dose of 10 Gy could be increased if margins were not negative. All centers ensured patient setup reproducibility. Treatment planning was computerized in 59 centers. The irradiation dose was prescribed at the ICRU point in 56 centers and portal films were made in 54 centers. Intraoperative radiotherapy was used in 4 centers: for partial breast irradiation in 1 and for boost administration in 3 centers.

Conclusions

Although the quality of radiotherapy delivery has improved in Italy in recent years, approaches that do not conform to international standards persist.

The Impact of Expander Inflation/Deflation Status During Adjuvant Radiotherapy on the Complications of Immediate Two-Stage Breast Reconstruction

BACKGROUND

The question of whether expander inflation/deflation status has any bearing on surgical complications in the setting of adjuvant radiation (XRT) has not been addressed. The objective of this study is to investigate whether the inflation/deflation status of the expander at the time of XRT is associated with complications in immediate two-stage expander-implant breast reconstruction.

METHODS

A retrospective review of 49 consecutive patients who underwent immediate two-stage expander-implant breast reconstruction and received post-mastectomy XRT was conducted. Full deflation of the expanders was performed in the deflation group (20 patients), while the expanders remained inflated in the inflation group at the time of XRT (29 patients). XRT-related complications of each stage of reconstructions were compared between the two groups, and multivariable regression analysis was performed to identify risk factors for XRT-related complications.

RESULTS

Overall XRT-related complications (65.0 vs. 6.9%, p < 0.001) and reconstruction failures (35.0 vs. 6.9%, p = 0.022) of the first-stage reconstructions were significantly higher in the deflation group. The most common cause of reconstruction failure in the deflation group was failure to re-expand due to skin fibrosis and contracture. In multivariable analysis, deflation of expanders was a significant risk factor for overall complications (odds = 94.4, p = 0.001) and reconstruction failures (odds = 9.09, p = 0.022) of the first-stage reconstructions.

CONCLUSIONS

Maximal inflation without deflation before XRT can be an option to minimize XRT-related complications and reconstruction failure of the first-stage reconstructions.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Trends in use and outcome of postoperative radiotherapy following mastectomy: A population-based study

PURPOSE

The objective of the present population-based study was to evaluate the role and effectiveness of postmastectomy radiation therapy (PMRT) in clinical practice.

METHODS

The study included 16,675 patients diagnosed with invasive breast cancer from 1988 to 2012 and resident within the catchment area of the Munich Cancer Registry. Use of PMRT, local recurrence-free survival (LRFS), cumulative incidence of time to local recurrence, relative survival and conditional overall survival (cOS), were analysed for different time periods (1988-1997 and 1998-2012).

RESULTS

Variables favouring the use of PMRT on multivariate logistic regression analysis included young age, large tumour size, positive resection margin and positive nodal status. Over time, a significant increase of PMRT was registered for patients with ⩾4 positive lymph nodes. Moreover, the present findings track a less frequent use of PMRT in elderly patients. After adjusting for age, tumour characteristics and therapies, the Cox regression analysis for LRFS identified PMRT as an independent predictor for improved local control (HR: 2.145; 95% CI: 1.787-2.574, p<0.0001). Patients with 1-3 involved lymph nodes had a 10-year cumulative incidence of local recurrence of 13.7% following mastectomy, compared to 6.5% following PMRT (p=0.0001). Comparable findings were obtained for patients presenting with ⩾4 positive lymph nodes. All effects were smaller or extinct in elderly patients aged ⩾70years. On multivariate analysis for cOS, no significant advantage for PMRT could be detected (HR: 1.084; 95% CI: 0.986-1.191, p=0.095).

CONCLUSION

The present study was useful in providing an overview on trends in the adoption of PMRT over a 25-year period. An increase in the use of PMRT from 1988 to 2012 was observed, especially in high-risk patients with ⩾4 positive lymph nodes. Patients selected for PMRT had an improved local control and an equivalent relative survival compared to patients who had no indication for PMRT.

Comparison of CT-volumed supraclavicular fossa radiotherapy planning and conventional simulator-planned defined by bony landmarks for early breast cancer

AIM

A comparison of techniques, CT planning of the supraclavicular fossa and field based simulation. We highlight CT planned SCF radiotherapy which would be useful for a centre introducing the technique.

BACKGROUND

Development of radiotherapy technique includes a move from field-based simulation to CT planning.

MATERIALS AND METHODS

We conducted a retrospective review of the first 50 patients receiving radiotherapy according to the 3D CT planning protocol. Production of the previous field based technique, by virtual simulation methods on the same 50 patient CT data sets allowed both techniques to be compared for beam energy, field size, planning target volume (PTV) minimum and maximum, mean doses, depth dose normalisation, V40% lung volume and brachial plexus.

RESULTS

88% CT-volumed plans received mean dose within ICRU recommended limits compared with only 8% using previous conventional technique. 76% required 10 MV to improve coverage and one patient (2%) an opposed posterior field. The mean normalisation depth was 4.5 cm (range 1.9-7.7 cm) compared with pre-set 3 cm of the conventional technique. With CT-volumed technique the whole lung volume exposed to V40%, including the tangential fields, reduced from 10.79% to 9.64% (p < 0.001) but the mean maximum brachial plexus dose increased from 48.9 Gy to 51.6 Gy (p < 0.001).

CONCLUSIONS

Dose coverage of the SCF PTV was greatly improved for plans produced from 3DCT volumes compared to field based techniques.

Ataxia telangiectasia-mutated gene polymorphisms and acute normal tissue injuries in cancer patients after radiation therapy: a systematic review and meta-analysis

PURPOSE

Studies of the association between ataxia telangiectasia-mutated (ATM) gene polymorphisms and acute radiation injuries are often small in sample size, and the results are inconsistent. We conducted the first meta-analysis to provide a systematic review of published findings.

METHODS AND MATERIALS

Publications were identified by searching PubMed up to April 25, 2014. Primary meta-analysis was performed for all acute radiation injuries, and subgroup meta-analyses were based on clinical endpoint. The influence of sample size and radiation injury incidence on genetic effects was estimated in sensitivity analyses. Power calculations were also conducted.

RESULTS

The meta-analysis was conducted on the ATM polymorphism rs1801516, including 5 studies with 1588 participants. For all studies, the cut-off for differentiating cases from controls was grade 2 acute radiation injuries. The primary meta-analysis showed a significant association with overall acute radiation injuries (allelic model: odds ratio = 1.33, 95% confidence interval: 1.04-1.71). Subgroup analyses detected an association between the rs1801516 polymorphism and a significant increase in urinary and lower gastrointestinal injuries and an increase in skin injury that was not statistically significant. There was no between-study heterogeneity in any meta-analyses. In the sensitivity analyses, small studies did not show larger effects than large studies. In addition, studies with high incidence of acute radiation injuries showed larger effects than studies with low incidence. Power calculations revealed that the statistical power of the primary meta-analysis was borderline, whereas there was adequate power for the subgroup analysis of studies with high incidence of acute radiation injuries.

CONCLUSIONS

Our meta-analysis showed a consistency of the results from the overall and subgroup analyses. We also showed that the genetic effect of the rs1801516 polymorphism on acute radiation injuries was dependent on the incidence of the injury. These support the evidence of an association between the rs1801516 polymorphism and acute radiation injuries, encouraging further research of this topic.

Supraclavicular and infraclavicular lymph node delineation in breast cancer patients: a proposal deriving from a comparative study

AIMS AND BACKGROUND

Current advances in radiotherapy for breast cancer require knowledge of the anatomy of irradiated areas to minimize geographic miss and spare organs at risk. This study aimed at defining a contouring approach for supraclavicular (SC) and infraclavicular (IC) nodes after mastectomy or conservative surgery in patients with breast cancer.

METHODS AND STUDY DESIGN

In 15 patients, SC and IC nodes were contoured on computed tomography slices according to Madu et al and Dijkema et al. After analyzing relapse sites, as reported by Reed et al, our approach was defined. The 3 methods were compared in all patients, quantifying differences in contours by percentage overlap (PO).

RESULTS

In our approach, SC node delineation is similar to Madu et al in the ventral and medial landmarks, but includes the lateral SC nodes described by Dijkema et al. The lateral landmarks are the scalenus anterior and medius muscle lateral border and the clavicle. Dorsal boundaries are the scalenus anterior and medius muscle ventral and lateral surfaces and the subclavian artery ventral border. In IC node delineation, major differences emerged in cranial and dorsal limits which, in our approach, are the pectoralis minor muscle upper edge and the subclavian axillary artery ventral side. Our mean and median volumes and POs were between the other 2 methods.

CONCLUSIONS

This study contributes to standardizing draining node contouring, so as to reduce variability and minimize geographic miss.

Factors influencing time between surgery and radiotherapy: A population based study of breast cancer patients

This study describes variation in the time interval between surgery and radiotherapy in breast cancer (BC) patients and assesses factors at patient, hospital and radiotherapy centre (RTC) level influencing this variation. To do so, the factors were investigated in BC patients using multilevel logistic regression. The study sample consisted of 15,961 patients from the Netherlands Cancer Registry at 79 hospitals and 19 (RTCs) with breast-conserving surgery or mastectomy directly followed by radiotherapy. The percentage of patients starting radiotherapy ≤42 days varied from 14% to 94%. Early year of incidence, higher age, higher stage, mastectomy, higher ASA category and no availability of radiotherapy facilities were significantly associated with a longer time interval between radiotherapy and surgery. More patients received radiotherapy ≤42 days in hospitals with on-site radiotherapy facilities (OR 1.36, p = 0.024). Among the remainder, significant variation was found at the RTC level (11.1%, σ(2) = 0.254, SE 0.054), and at the hospital level (6.4% σ2 = 0.443, SE 0.163) (ICC 0.064). The significant delay and unexplained variance remaining at the RCT and hospital level suggests delays caused by the patient referral pathway from hospital to RCT, and indicates potential for improvement at both levels.

Timing of radiotherapy following breast-conserving surgery: outcome of 1393 patients at a single institution

BACKGROUND

The role of postoperative radiotherapy in breast-conserving therapy is undisputed. However, optimal timing of adjuvant radiotherapy is an issue of ongoing debate. This retrospective clinical cohort study was performed to investigate the impact of a delay in surgery-radiotherapy intervals on local control and overall survival.

PATIENTS AND METHODS

Data from an unselected cohort of 1393 patients treated at a single institution over a 17-year period (1990-2006) were analyzed. Patients were assigned to two groups (CT+/CT-) according to chemotherapy status. A delay in the initiation of radiotherapy was defined as > 7 weeks (CT- group) and > 24 weeks (CT+ group).

RESULTS

The 10-year regional recurrence-free survival for the CT- and CT+ groups were 95.6 and 86.0 %, respectively. A significant increase in the median surgery-radiotherapy interval was observed over time (CT- patients: median of 5 weeks in 1990-1992 to a median of 6 weeks in 2005-2006; CT+ patients: median of 5 weeks in 1990-1992 to a median of 21 weeks in 2005-2006). There was no association between a delay in radiotherapy and an increased local recurrence rate (CT- group: p = 0.990 for intervals 0-6 weeks vs. ≥ 7 weeks; CT+ group: p = 0.644 for intervals 0-15 weeks vs. ≥ 24 weeks) or decreased overall survival (CT- group: p = 0.386 for intervals 0-6 weeks vs. ≥ 7 weeks; CT+ group: p = 0.305 for intervals 0-15 weeks vs. ≥ 24 weeks).

CONCLUSION

In the present cohort, a delay of radiotherapy was not associated with decreased local control or overall survival in the two groups (CT-/CT+). However, in the absence of randomized evidence, delays in the initiation of radiotherapy should be avoided.

Outcome of different timings of radiotherapy in implant-based breast reconstructions

BACKGROUND

The therapeutic role of postmastectomy radiation therapy has been demonstrated both in locally advanced breast cancer and in other high-risk conditions. Implant-based breast reconstruction for irradiated patients can generate higher complication rates. In this study, the authors observed the effects of radiation on temporary expanders and permanent implants. The estimate of the totally failed reconstruction rate was the principal endpoint of this study. Capsular contracture rates and patients' and surgeons' subjective evaluations were the secondary endpoints.

METHODS

Two hundred fifty-seven patients were consecutively involved in this study. The population was stratified into two groups: group 1, postmastectomy radiation therapy on permanent implants (n = 109 patients); and group 2, postmastectomy radiation therapy on tissue expanders (n = 50 patients). A nonirradiated control group made up of 98 patients was selected randomly. All patients underwent a two-stage immediate breast reconstruction with subpectoral temporary expanders and permanent implants.

RESULTS

The totally failed reconstruction rate was significantly higher in group 2, with 40 percent of unsuccessful reconstructions compared with 6.4 percent in group 1 and 2.3 percent in the control group (p < 0.0001). The capsular contracture rate was significantly higher for groups 1 and 2 compared with the control group. The shape and symmetry assessment and the patients' opinions demonstrated a higher incidence of good results in group 1 in comparison with group 2. The best scores were always obtained by the control group.

CONCLUSION

This study demonstrated that radiotherapy during tissue expansion may compromise the outcome of implant-based breast reconstruction.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, II.

Should Postmastectomy Radiotherapy to the Chest Wall and Regional Lymph Nodes Be Standard for Patients with 1-3 Positive Lymph Nodes?

The indication for adjuvant postmastectomy radiotherapy (PMRT) in breast cancer patients with small tumors and 1-3 macrometastases in the axilla remains a controversial issue, despite the recommendation that PMRT should be applied in these patients in the most recent overview by the Early Breast Cancer Trialists' Collaborative Group. In this report, we discuss the available data on the benefit from PMRT in patients diagnosed with N1 breast cancer. Based on this, we recommend adjuvant PMRT to the chest wall and regional lymph nodes in patients diagnosed with early node-positive breast cancer.

Predictors of state-of-the-art management of early breast cancer in Switzerland

BACKGROUND

The aim of this study was to investigate predictors of state-of-the-art management of early breast cancer in Switzerland.

PATIENTS AND METHODS

The study included 3499 women aged 25-79 years diagnosed with invasive breast cancer stages I-IIIA in 2003-2005. Patients were identified through population-based cancer registries and treated in all kinds of settings. Concordance with national and international recommendations was assessed for 10 items covering surgery, radiotherapy, systemic adjuvant therapy and histopathology reporting. We used multivariate logistic regression to identify independent predictors of high (10 points) and low (≤7 points) concordance.

RESULTS

In one-third of the patients, management met guidelines in all items, whereas in about one-fifth, three or more items did not comply. Treatment by a surgeon with caseload in the upper tercile and team involved in clinical research were independent predictors of a high score, whereas treatment by a surgeon with a caseload in the lower tercile was associated with a low score. Socioeconomic characteristics such as income and education were not independent predictors, but patient's place of residence and age independently predicted management according to recommendations.

CONCLUSION

Specialization and involvement in clinical research seem to be key elements for enhancing the quality of early breast cancer management at population level.

Geographic variation in breast cancer care in Switzerland

PURPOSE

Regional disparities in breast cancer outcomes have been reported in Switzerland. The purpose of this study is to investigate geographic variation in early diagnosis and management of breast cancer.

METHODS

We used data from a representative sample of 4820 women diagnosed with invasive breast cancer between January 1, 2003 and December 31, 2005 identified by seven Swiss population based cancer registries. We collected retrospectively detailed information on mode of detection, tumor characteristics and treatments. Differences across geographic regions were tested for statistical significance using chi-square tests and uni- and multivariate logistic regression.

RESULTS

Considerable disparities in early detection and management of early breast cancer were found across regions. In particular, the proportion of early detected cancer varied from 43% in Valais to 27% in St. Gallen-Appenzell. Mastectomy rates varied from 24% in Geneva to 38% in St. Gallen-Appenzell and Grisons-Glarus. Higher reconstruction rates were observed in regions with lower rates of mastectomy. The use of sentinel node procedure in patients with nodal negative disease was high in Geneva and low in Eastern Switzerland. Differences in compliance with recommendations on the use of endocrine therapy and chemotherapy were less pronounced but statistically significant.

CONCLUSIONS

This analysis shows considerable geographic variation in breast cancer care in a health system characterized by high expenditures, universal access to services and high decentralization. Further study into the causes and effects of this variation on short- and long term patient outcomes is needed.

[Evidence-based radiotherapy in the treatment of early-stage invasive breast cancer: traditional clinical features and biomarkers]

Adjuvant radiotherapy after modified radical mastectomy and breast-conserving surgery for early-stage invasive breast cancer substantially reduces the risk of locoregional failure and is evidence-based. Using traditional clinical and pathological factors, patients can be classified into subgroups by the risk of locoregional recurrence. In the high-risk groups the absolute benefit of irradiation is larger. However, the patients are over-treated in every subgroup. Substantial proportion of the patients remains free of locoregional recurrence even in the absence of irradiation, and some patients develop locoregional recurrence despite postoperative irradiation. Molecular markers may provide sufficient information to allow accurate individual risk assessment to identify patients who might benefit from irradiation. Despite of hundreds of reports on tumor markers, results are controversial and the number of validated markers for clinical practice is small. Prognostic and predictive factors commonly used in radiotherapy practice are ER, PgR and HER-2. Adjuvant radiotherapy not only reduces locoregional recurrence rates but also improves cancer-specific survival in patients receiving systemic therapy. The highest mortality reduction is observed in mastectomy patients with good prognostic factors (<4 positive nodes, tumor size <2 cm, Grade 1 malignancy, ER- and PgR-positive, HER-2-negative). After mastectomy the chest wall, and after breast conserving surgery the ipsilateral breast are the sites at greatest risk of recurrence. The risk of axillary recurrence is low in patients undergoing axillary dissection. Axillary and supraclavicular recurrences generally forecast a grim prognosis, and they are indicators of distant dissemination. Improvement in survival resulting from the use of irradiation is more related to the prevention of local recurrences. Post-irradiation local recurrence increases the risk of mortality, but with good prognostic factors the 10-year survival is 80-90%. Patients with </=2 cm ipsilateral breast recurrence might receive a second conservative surgery. The radiation dose to the lung and heart can be significantly reduced by individualized CT-based treatment planning. The rate of Grade 3 atrophic dermatitis and fibrosis is 3-4%. The estimated incidence of ipsilateral breast angiosarcoma is less than 0.2%, but the mortality rate is high.

Sequencing chemotherapy and radiotherapy in locoregional advanced breast cancer patients after mastectomy - a retrospective analysis

BACKGROUND

Combined chemo- and radiotherapy are established in breast cancer treatment. Chemotherapy is recommended prior to radiotherapy but decisive data on the optimal sequence are rare. This retrospective analysis aimed to assess the role of sequencing in patients after mastectomy because of advanced locoregional disease.

METHODS

A total of 212 eligible patients had a stage III breast cancer and had adjuvant chemotherapy and radiotherapy after mastectomy and axillary dissection between 1996 and 2004. According to concerted multi-modality treatment strategies 86 patients were treated sequentially (chemotherapy followed by radiotherapy) (SEQgroup), 70 patients had a sandwich treatment (SW-group) and 56 patients had simultaneous chemoradiation (SIM-group) during that time period. Radiotherapy comprised the thoracic wall and/or regional lymph nodes. The total dose was 45-50.4 Gray. As simultaneous chemoradiation CMF was given in 95.4% of patients while in sequential or sandwich application in 86% and 87.1% of patients an anthracycline-based chemotherapy was given.

RESULTS

Concerning the parameters nodal involvement, lymphovascular invasion, extracapsular spread and extension of the irradiated region the three treatment groups were significantly imbalanced. The other parameters, e.g. age, pathological tumor stage, grading and receptor status were homogeneously distributed. Looking on those two groups with an equally effective chemotherapy (EC, FEC), the SEQ- and SW-group, the sole imbalance was the extension of LVI (57.1 vs. 25.6%, p < 0.0001).5-year overall- and disease free survival were 53.2%/56%, 38.1%/32% and 64.2%/50%, for the sequential, sandwich and simultaneous regime, respectively, which differed significantly in the univariate analysis (p = 0.04 and p = 0.03, log-rank test). Also the 5-year locoregional or distant recurrence free survival showed no significant differences according to the sequence of chemo- and radiotherapy. In the multivariate analyses the sequence had no independent impact on overall survival (p = 0.2) or disease free survival (p = 0.4). The toxicity, whether acute nor late, showed no significant differences in the three groups. The grade III/IV acute side effects were 3.6%, 0% and 3.5% for the SIM-, SW- and SEQ-group. By tendency the SIM regime had more late side effects.

CONCLUSION

No clear advantage can be stated for any radio- and chemotherapy sequence in breast cancer therapy so far. This could be confirmed in our retrospective analysis in high-risk patients after mastectomy. The sequential approach is recommended according to current guidelines considering a lower toxicity.

Estrogen receptor, progesterone receptor, HER-2, and response to postmastectomy radiotherapy in high-risk breast cancer: the Danish Breast Cancer Cooperative Group

PURPOSE

To examine the importance of estrogen receptor (ER), progesterone receptor (PgR), human epidermal growth factor receptor 2 (HER-2), and constructed subtypes in a large study randomly assigning patients to receive or not receive postmastectomy radiotherapy (PMRT).

PATIENTS AND METHODS

The present analysis included 1,000 of the 3,083 high-risk breast cancer patients randomly assigned to PMRT in the Danish Breast Cancer Cooperative Group (DBCG) protocol 82 trials b and c. Tissue microarray sections were stained for ER, PgR, and HER-2. Median follow-up time for patients alive was 17 years. End points were locoregional recurrence as isolated first event, distant metastases, and overall survival. For statistical analyses four subgroups were constructed from hormonal receptors (Rec). Rec+ was defined as ER+ and/or PgR+. Rec-as both ER-and PgR-. The four subgroups were Rec+/HER-2-, Rec+/HER-2+, Rec-/HER-2-(triple negative), and Rec-/HER-2+.

RESULTS

A significantly improved overall survival after PMRT was seen only among patients characterized by good prognostic markers such as hormonal receptor-positive and HER-2- patients (including the two Rec+ subtypes). No significant overall survival improvement after PMRT was found among patients with an a priori poor prognosis, the hormonal receptor-negative and HER-2+ patients, and in particular the Rec-/HER-2+ subtype. Furthermore, comparing hazard ratios and 95% CIs, significantly smaller improvements in locoregional recurrence control after PMRT were found for ER-and PgR-tumors compared with the ER+ and PgR+ tumors (P = .003 and .04, respectively), and for the triple-negative (P = .02), and the Rec-/HER-2+ subtypes (P = .003) compared with the Rec+/HER-2-subtype.

CONCLUSION

Hormonal receptor status, HER-2, and the constructed subtypes may be predictive of locoregional recurrence and survival after postmastectomy radiotherapy.

Progress and promise: highlights of the international expert consensus on the primary therapy of early breast cancer 2007

The 10th St Gallen (Switzerland) expert consensus meeting in March 2007 refined and extended a target-oriented approach to adjuvant systemic therapy of early breast cancer. Target definition is inextricably intertwined with the availability of target-specific therapeutic agents. Since 2005, the presence of HER2 on the cell surface has been used as an effective target for trastuzumab much as steroid hormone receptors are targets for endocrine therapies. An expert Panel reaffirmed the primary importance of determining endocrine responsiveness of the cancer as a first approach to selecting systemic therapy. Three categories were acknowledged: highly endocrine responsive, incompletely endocrine responsive and endocrine non-responsive. The Panel accepted HER2-positivity to assign trastuzumab, and noted that adjuvant trastuzumab has only been assessed together with chemotherapy. They largely endorsed previous definitions of risk categories. While recognizing the existence of several molecularly-based tools for risk stratification, the Panel preferred to recommend the use of high-quality standard histopathological assessment for both risk allocation and target identification. Chemotherapy, although largely lacking specific target information, is the only option in cases which are both endocrine receptor-negative and HER2-negative. Chemotherapy is conventionally given with or preceding trastuzumab for patients with HER2-positive disease, and may be used for patients with endocrine responsive disease in cases where the sufficiency of endocrine therapy alone is uncertain. Recommendations are provided not as specific therapy guidelines but rather as a general guidance emphasizing main principles for tailoring therapeutic choice.

The effect of delaying adjuvant radiation treatment after conservative surgery for early breast cancer

We examined the effect of delaying radiation treatment after conservative surgery on the risk of breast cancer local recurrence (LR). From January 1997 to December 2001, 969 women with early-stage breast cancer were treated at the Radiation Oncology Department in Chieti. We analyzed 802 of them who underwent conservative surgery followed by whole-breast radiotherapy. The patients were divided into two groups: women who did not receive chemotherapy and women who received chemotherapy. The time intervals from surgery to breast irradiation used for the analysis were <16 or more weeks for no-chemotherapy-treated women, and <25 and 25 or more weeks for chemotherapy-treated women. The relationship between LR and factors such as age, tumor size, margin status, and surgery-radiotherapy time interval was evaluated. The 8-year LR risk was estimated using the Kaplan-Meier method. LR was observed in 33 (4.1%) of the 802 patients. The overall 8-year LR risk was 6.5% (+/-1.51). In the no-chemotherapy group, the risk of LR was associated with a younger age and a positive margin status. In the chemotherapy group LR was associated with a younger age and a tumor size >3 cm. Surgery-radiotherapy interval was not associated with LR in both groups of patients. Delay in the start of radiotherapy does not increase the risk of LR in patients with early breast cancer treated or not treated with chemotherapy.

Strategies in treating male breast cancer

Male breast cancer is rare. Median age at diagnosis is approximately 65 years, and > 35% of male breast cancers occur in elderly men. Retroareolar lump is the most frequent symptom, and 25-30% of tumours are T(4) lesions. Infiltrating ductal carcinoma represents almost 90% of the cases, and 10% are ductal carcinoma in situ. Axillary nodal involvement is present in 50-60% of the cases. Estrogen and progesterone receptors are positive in 75-92% and 54-77% of the cases. Mastectomy with axillary dissection remains the standard treatment. Sentinel lymph node biopsy could be proposed in small tumours (< or = 2 cm). Locoregional radiotherapy is very often indicated. Tamoxifen is the standard adjuvant treatment, but chemotherapy is proposed in young men with axillary nodal involvement and/or negative hormone receptors. Tumour size and, more particularly, histopathological axillary involvement are the strongest predictive factors for both locoregional recurrence and metastasis. Globally, the prognosis is similar to that in women (at identical stage), but the intercurrent death rate is higher due to the important impact of comorbidities and second neoplasm.

Is the benefit of postmastectomy irradiation limited to patients with four or more positive nodes, as recommended in international consensus reports? A subgroup analysis of the DBCG 82 b&c randomized trials

BACKGROUND AND AIM

Numerous consensus reports recommend that postmastectomy radiotherapy (RT) in addition to systemic therapy is indicated in high-risk patients with 4+ positive nodes, but not in patients with 1-3 positive nodes. A subgroup analysis of the DBCG 82 b&c trials was performed to evaluate the loco-regional recurrence rate and survival in relation to number of positive nodes.

MATERIALS AND METHODS

In the DBCG 82 b&c trials 3083 pre- and postmenopausal high-risk women were randomized to postoperative RT in addition to adjuvant systemic therapy. Since many patients had relatively few lymph nodes removed (median 7), the present analysis was limited to 1152 node positive patients with 8 or more nodes removed.

RESULTS

The overall 15-year survival rate in the subgroup was 39% and 29% (p=0.015) after RT and no RT, respectively. RT reduced the 15-year loco-regional failure rate from 51% to 10% (p<0.001) in 4+ positive node patients and from 27% to 4% (p<0.001) in patients with 1-3 positive nodes. Similarly, the 15-year survival benefit after RT was significantly improved in both patients with 1-3 positive nodes (57% vs 48%, p=0.03) and in patients with 4+ positive nodes (21% vs 12%, p=0.03).

CONCLUSION

The survival benefit after postmastectomy RT was substantial and similar in patients with 1-3 and 4+ positive lymph nodes. Furthermore, it was not strictly associated with the risk of loco-regional recurrence, which was most pronounced in patients with 4+ positive nodes. The indication for RT seems therefore to be at least equally beneficial in patients with 1-3 positive nodes, and future consensus should be modified accordingly.

Boost radiotherapy in young women with ductal carcinoma in situ: a multicentre, retrospective study of the Rare Cancer Network

BACKGROUND

Outcome data in young women with ductal carcinoma in situ (DCIS) are rare. The benefits of boost radiotherapy in this group are also unknown. We aimed to assess the effect of boost radiotherapy in young patients with DCIS.

METHODS

We included 373 women from 18 institutions who met the following inclusion criteria: having tumour status Tis and nodal status (N)0, age 45 years or younger at diagnosis, and having had breast-conserving surgery. 57 (15%) patients had no radiotherapy after surgery, 166 (45%) had radiotherapy without boost (median dose 50 Gy [range 40-60]), and 150 (40%) had radiotherapy with boost (60 Gy [53-76]). The primary outcome was local relapse-free survival.

FINDINGS

Median follow-up was 72 months (range 1-281). 55 (15%) patients had local relapse. Local relapse-free survival at 10 years was 46% (95% CI 24-67) for patients given no radiotherapy, 72% (61-83) for those given radiotherapy without boost, and 86% (78-93) for those given radiotherapy and boost (difference between all three groups, p<0.0001). Age, margin status, and radiotherapy dose were significant predictors of local relapse-free survival. Compared with patients who had no radiotherapy, those who had radiotherapy had a decreased risk of local relapse (without boost, hazard ratio 0.33 [95% CI 0.16-0.71], p=0.004; with boost, 0.15 [0.06-0.36], p<0.0001).

INTERPRETATION

In the absence of randomised trials, boost radiotherapy should be considered in addition to surgery for breast-conserving treatment for DCIS.

When May Adjuvant Radiotherapy be Avoided in Operable Breast Cancer?

Randomised trials in which the omission of radiotherapy has been tested after breast-conserving surgery, with or without adjuvant systemic therapy, show a significant four- to five-fold reduction in local recurrence. As yet, no subgroup of women managed by breast-conserving surgery has been identified from whom radiotherapy can be withheld. Few randomised data have been published on the effect of omission of radiotherapy on local control, quality of life and costs, particularly in older women for whom the risk of local recurrence is generally lower. Ongoing trials are evaluating the role of radiotherapy in this population of low risk, older women. Adjuvant radiotherapy after breast-conserving surgery or mastectomy significantly reduces the incidence of local recurrence. In women who have had a mastectomy at high risk of recurrence (> 20% risk of recurrence at 10 years), adjuvant radiotherapy improves survival if combined with adjuvant systemic therapy. Among women with T3 tumours, and those with four or more involved axillary nodes treated by mastectomy, postoperative radiotherapy is the standard of care. For women at intermediate risk of recurrence (i.e. <15% 10-year risk of recurrence after surgery and systemic therapy alone), with one to three involved nodes or node negative with other risk factors, the role of radiotherapy is unclear. Clinical trials to assess the role of postmastectomy radiotherapy (PMRT) in this setting are needed. For pT1-2, pNO tumours without other risk factors, there is no evidence at present that PMRT is needed.

Local Therapy, Systemic Benefit: Challenging the Paradigm of Biological Predeterminism

This paper briefly reviews the historical evolution of paradigms that have been purported to characterise the clinical behaviour of breast cancer, with the intention of guiding treatment approaches. Results from randomised clinical trials and the explosion of knowledge in the area of cancer biology have discredited the monolithic paradigms that had dominated thinking about breast cancer in the past. Contemporary notions of breast cancer biology recognise that, although some cancers disseminate well before becoming clinically detectable, acquisition of a metastatic phenotype can occur at any point (or not at all) in the local evolution of the tumour. As a consequence, both systemic and timely local--regional therapies can be expected to influence disease dissemination and patient survival. This is consistent with results observed in clinical trials, overviews of which indicate that prevention of four local recurrences will, on the average, prevent one death from breast cancer. Optimisation of local-regional treatment is an important goal in breast cancer management.

A French national survey on infiltrating breast cancer: analysis of clinico-pathological features and treatment modalities in 1159 patients

BACKGROUND

Despite the approximate 42,000 yearly new cases of breast cancer in France, there have been very few exhaustive studies on the clinicopathological features and treatment options of this disease.

METHODS

Thus, a prospective, non-selective, nationwide survey on infiltrating breast cancer (IBC) was conducted in France from September 2001 to April 2002, in order to assess the epidemiological features of newly diagnosed disease, the prognostic and predictive variables with a special emphasis on hormone receptors, and the current approaches to therapy in everyday clinical practice.

RESULTS

In total, 1159 patients were evaluable (median age 57 years); two-thirds of women were postmenopausal and 38% had undergone hormonal replacement therapy (HRT). Ductal and lobular infiltrating cancers represented 82.3% and 11.6% of cases, respectively. Most tumours expressed oestrogen (79.7%) and progesterone (69.7%) receptors. Overexpression of the human epidermal growth factor receptor-2 oncogene was found in 20.6% of the assessed cases. IBC diagnosed in women under HRT presented significantly better clinico-pathological features than in non-users. All patients underwent surgery as first treatment: 77.5% breast-conserving surgery (BCS) and 22.5% mastectomy; 1024 patients also underwent axillary surgery. The overall axillary lymph-node involvement rate was 44.4%. Radiotherapy was proposed in 98% and 83% of the women who had undergone BCS and mastectomy, respectively. Adjuvant chemotherapy was delivered in 58.7% of patients and hormonal treatment was provided in 76.5% of patients; tamoxifen was the most widely used hormonal treatment.

CONCLUSIONS

This study showed a trend for global downstaging of IBC (with favourable clinico-pathological features), leading to a high rate of BCS. Postoperative treatments were widely used, in accordance with national and international guidelines. Use of aromatase inhibitors and taxanes was limited, but is likely to rise in the future.

Breathing adapted radiotherapy for breast cancer: Comparison of free breathing gating with the breath-hold technique

BACKGROUND AND PURPOSE

Adjuvant radiotherapy after breast-conserving surgery for breast cancer implies a risk of late cardiac and pulmonary toxicity. This is the first study to evaluate cardiopulmonary dose sparing of breathing adapted radiotherapy (BART) using free breathing gating, and to compare this respiratory technique with voluntary breath-hold.

PATIENTS AND METHODS

17 patients were CT-scanned during non-coached breathing manoeuvre including free breathing (FB), end-inspiration gating (IG), end-expiration gating (EG), deep inspiration breath-hold (DIBH) and end-expiration breath-hold (EBH). The Varian Real-time Position Management system (RPM) was used to monitor respiratory movement and to gate the scanner. For each breathing phase, a population based internal margin (IM) was estimated based on average chest wall excursion, and incorporated into an individually optimised three-field mono-isocentric wide tangential photon field treatment plan for each scan. The target included the remaining breast, internal mammary nodes and periclavicular nodes.

RESULTS

The mean anteroposterior chest wall excursion during FB was 2.5mm. For IG and EG, the mean excursions within gating windows were 1.1 and 0.7 mm, respectively, whereas for DIBH and EBH the excursions were 4.1 and 2.6mm, respectively. For patients with left-sided cancer, the median heart volume receiving more than 50% of the prescription dose was reduced from 19.2% for FB to 2.8% for IG and 1.9% for DIBH, and the median left anterior descending (LAD) coronary artery volume was reduced from 88.9% to 22.4% for IG and 3.6% for DIBH. Simultaneously, the median ipsilateral relative lung volume irradiated to >50% of the prescribed target dose for both right- and left-sided cancers was reduced from 45.6% for FB to 29.5% for IG and 27.7% for DIBH. For EBH and EG, both the irradiated heart, LAD and lung volumes increased compared to FB.

CONCLUSIONS

This is the first study to demonstrate the dosimetric benefits of free breathing gated breast cancer radiotherapy. IG compared favourably with DIBH, substantially reducing cardiac doses simultaneous with significant pulmonary tissue sparing.

High frequency of promoter hypermethylation of RASSF1A in tumorous and non-tumourous tissue of breast cancer

AIM

To determine the presence of RASSF1A promoter methylation in tumorous and non-tumorous tissues of breast cancer.

METHODS

Methylation-specific PCR was used to detect RASSF1A methylation in DNA extracted from tumorous and paired non-tumorous tissues of 40 breast cancer patients. The associations of RASSF1A hypermethylation with clinicopathological characteristics in tumorous and non-tumorous breast tissues were analysed.

RESULTS

RASSF1A promoter hypermethylation was detected in 38 of the 40 breast cancer tissues (95%) and 37 of the paired non-tumorous tissues (92.5%). When compared with the non-tumorous tissues, aberrant methylation was detected to be higher in 24 of the tumorous tissues (60%). The latter was found to be associated with lower histological grade tumours (p=0.048).

CONCLUSION

RASSF1A promoter hypermethylation occurred at a high frequency in breast cancer tumorous and non-tumorous tissues; the majority of tumours have a higher level of methylation status when compared with non-tumorous tissues. This supports the notion that RASSF1A methylation is an early and premalignant alteration.

Selective use of post-mastectomy flap irradiation in high-risk breast cancer patients

The incidence of local recurrence after mastectomy can be reduced by chest wall radiotherapy. However, only a minority of patients are at substantial risk. No UK national guidelines exist for the use of mastectomy flap radiotherapy. This study evaluated a protocol, whereby only high-risk patients were treated with post-mastectomy flap radiotherapy; identified histologically by grade, vascular invasion and nodal status. All women treated by simple mastectomy for invasive breast cancer at the Nottingham Breast Unit from January 1993 to December 1995 were studied (n=292). Postoperative flap radiotherapy was given to 147 high-risk women (50.3%). Median follow-up was 76 months. Overall, 12 women (4.1%) developed a chest wall recurrence; six were single spot recurrences and the remaining six were either multiple spot (n=3) or field change (field change dermal invasion, n=3). The chest wall recurrence rate was 2.7% in those treated with radiotherapy. A low rate of local recurrence has been achieved with selective use of mastectomy flap radiotherapy.

Guidelines to assure quality in breast cancer surgery

The outcome of breast cancer surgery, with respect to cosmetic results, loco regional control and prognostic information from nodal staging, may vary substantially. Optimal breast cancer care starts with a proper surgical act, which can only be performed when optimal imaging and preoperative diagnosis are available. Next, on the basis of all peroperative findings, the right surgical procedure should be indicated after multidisciplinary consultation and discussion, keeping the objective of the final outcome in mind. The surgical act itself is best performed by an experienced surgeon who has maintained their experience after sufficient training. The outcome of the different procedures can be measured according to simple criteria and prospective registration. All possible surgical procedures, the indication-objectives, the training-objectives and outcome measures are described.

Early and late skin reactions to radiotherapy for breast cancer and their correlation with radiation-induced DNA damage in lymphocytes

Introduction

Radiotherapy outcomes might be further improved by a greater understanding of the individual variations in normal tissue reactions that determine tolerance. Most published studies on radiation toxicity have been performed retrospectively. Our prospective study was launched in 1996 to measure the in vitro radiosensitivity of peripheral blood lymphocytes before treatment with radical radiotherapy in patients with breast cancer, and to assess the early and the late radiation skin side effects in the same group of patients. We prospectively recruited consecutive breast cancer patients receiving radiation therapy after breast surgery. To evaluate whether early and late side effects of radiotherapy can be predicted by the assay, a study was conducted of the association between the results of in vitro radiosensitivity tests and acute and late adverse radiation effects.

Methods

Intrinsic molecular radiosensitivity was measured by using an initial radiation-induced DNA damage assay on lymphocytes obtained from breast cancer patients before radiotherapy. Acute reactions were assessed in 108 of these patients on the last treatment day. Late morbidity was assessed after 7 years of follow-up in some of these patients. The Radiation Therapy Oncology Group (RTOG) morbidity score system was used for both assessments.

Results

Radiosensitivity values obtained using the in vitro test showed no relation with the acute or late adverse skin reactions observed. There was no evidence of a relation between acute and late normal tissue reactions assessed in the same patients. A positive relation was found between the treatment volume and both early and late side effects.

Conclusion

After radiation treatment, a number of cells containing major changes can have a long survival and disappear very slowly, becoming a chronic focus of immunological system stimulation. This stimulation can produce, in a stochastic manner, late radiation-related adverse effects of varying severity. Further research is warranted to identify the major determinants of normal tissue radiation response to make it possible to individualize treatments and improve the outcome of radiotherapy in cancer patients.

Locoregional recurrence risks in elderly breast cancer patients treated with mastectomy without adjuvant radiotherapy

This study examined tumour and treatment characteristics in elderly women treated with mastectomy without radiotherapy and compared their outcomes to younger counterparts. Data were analysed for 2362 women aged 50 years and older referred to the British Columbia Cancer Agency, Canada between 1989 and 1997. The women had invasive T1-4, N0-N3, M0 breast cancer treated with mastectomy without adjuvant radiotherapy. Clinical characteristics and patient outcomes were compared between two age cohorts: 50-69 (n = 1423) and 70+ years (n = 939). Median follow-up was 8.3 years. Tumours > 5 cm were present in 5% of women aged 50-69 and 3.5% of women aged 70+, respectively. The distribution of nodal stage was similar in the two age cohorts but older women were more likely to have fewer axillary nodes removed (P = 0.009). Fewer women aged 70+ had grade III histology (P = 0.002) and estrogen receptor (ER)-negative status (P < 0.001). The rates of systemic therapy use were comparable in the two age groups. With tumours > 5 cm, locoregional recurrence (LRR) were 13.7% and 30.0% in women aged 50-69 and 70+, respectively. With 1-3 positive nodes (N+), LRR were 14.8% and 13.0% in women aged 50-69 and 70+. In the presence of 4 N+, LRR were 16.8% and 30.8% in women aged 50-69 and 70+. On multivariate analysis, age was not significantly associated with LRR (P = 0.62). Independent prognostic factors for LRR were grade III histology, lymphovascular invasion and positive nodal status. This study suggests that despite more favourable tumour characteristics and comparable systemic therapy use, women aged 70+ years have similar or higher postmastectomy LRR risks compared to younger women. Chronologic age alone should not preclude these women from consideration of adjuvant radiotherapy.

Breathing adapted radiotherapy of breast cancer: reduction of cardiac and pulmonary doses using voluntary inspiration breath-hold

BACKGROUND AND PURPOSE

Adjuvant radiotherapy of breast cancer using wide tangential photon fields implies a risk of late cardiac and pulmonary toxicity. This CT-study evaluates the detailed potential dosimetric consequences of applying breathing adapted radiotherapy (BART), and the feasibility of a monitored voluntary breath-hold technique for right-sided as well as for left-sided tumours.

PATIENTS AND METHODS

After breast-conserving surgery, 16 patients were CT-scanned in distinct respiratory phases using the varian real-time position management system for the monitoring of respiratory anterioposterior chest wall excursion. Each patient underwent three scans: during free breathing (FB), voluntary expiration breath-hold (EBH) and voluntary deep inspiration breath-hold (DIBH). For each scan, an optimised treatment plan was designed with conformal tangential fields encompassing the clinical target volume (CTV) of the breast and ipsilateral internal mammary nodes, and an anterior supraclavicular field.

RESULTS

Breath-hold was well accepted by the patients, with a median duration of 24 s for both EBH and DIBH. The mean anterioposterior chest wall excursions were 2.5, 2.6 and 4.1 mm during FB, EBH and DIBH, respectively. During EBH, the mean front chest wall position was 2.7 mm posterior to its mid-FB position, and during DIBH 12.6 mm anterior to its mid-FB position. For right-sided tumours, the median ipsilateral relative lung volume receiving >50% of the prescribed CTV dose was 39, 49 and 32% for FB, EBH and DIBH, respectively. For left-sided tumours, the corresponding percentages were 37, 46 and 31%. The median heart volume receiving >50% of the prescription dose was reduced from 8% for FB to 1% for DIBH, and the median left anterior descending coronary artery volume was reduced from 54 to 5%.

CONCLUSIONS

Irradiated cardiac volumes can consistently be reduced for left-sided breast cancers using DIBH for wide tangential treatment fields. Additionally, substantial dose reductions in the lung are observed for both right- and left-sided tumours.

Trends in postoperative radiotherapy delay and the effect on survival in breast cancer patients treated with conservation surgery

The adequate timing of adjuvant radiotherapy (RT) in breast cancer has become a subject of increasing interest in recent years. A population-based study was undertaken to determine the influence of demographic and clinical factors on the postoperative RT delay in patients treated with breast-conserving surgery (BCS) and to assess the impact of delay on survival. In total, 7800 breast cancer patients treated with BCS and adjuvant RT between 1986 and 1998 in Yorkshire were included in the study. The median interval between surgery and the start of RT (S–RT interval) was 8 weeks (7 weeks for chemotherapy negative and 11 for chemotherapy positive patients). This interval increased substantially over time from 5 weeks during 1986–1988, irrespective of patients' chemotherapy status, to 10 and 17 weeks among chemotherapy negative and chemotherapy positive patients, respectively, in 1997–1998. The S–RT interval was also significantly influenced by travel time to RT centre, year and at which RT centre patient had the treatment (P<0.001). Overall, 5-year survival was 82%. Patients with S–RT intervals longer than 9 weeks had a trend towards an increased relative risk of death. This reached a statistical significance at 20–26 weeks (RR 1.49, 95% CI (1.16–1.92)). The findings of our study suggest that delaying the initiation of RT for 20–26 weeks after surgery is associated with decreased survival in patients treated with conservation surgery.