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Grimm A, Wollmann E, Sperk E, Weiß C, Sütterlin M, Berlit S, Tuschy B. Intraoperative radiotherapy (IORT) of early breast cancer with low-energy x-rays in breast-conserving surgery : Prospective identification of pre- and intraoperative factors influencing the feasibility of IORT. Strahlenther Onkol 2024; 200:296-305. [PMID: 37792017 DOI: 10.1007/s00066-023-02149-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 08/21/2023] [Indexed: 10/05/2023]
Abstract
PURPOSE The aim of this study is to identify pre- and intraoperative factors indicating the feasibility of intraoperative radiotherapy (IORT) during breast-conserving surgery (BCS). MATERIALS AND METHODS From January 2018 to December 2019, a total of 128 women undergoing BCS due to early breast cancer were included in this prospective observational study, independent of whether IORT was planned or not. Patient and tumor characteristics as well as surgical parameters that could potentially influence the feasibility of IORT were recorded for the entire collective. In addition, a preoperative senological assessment was performed and analyzed to assess the feasibility of IORT. Logistic regression was then used to identify relevant preoperative parameters and to generate a formula predicting the feasibility of IORT. RESULTS Of the 128 included women undergoing BCS, 46 were preoperatively rated to be feasible, 20 to be questionably feasible for IORT. Ultimately, IORT was realized in 30 patients. The most frequent reasons for omission of IORT were insufficient tumor-to-skin distance and/or an excessively large tumor cavity. Small clinical tumor size and large tumor-to-skin distance according to preoperative ultrasound were significantly related to accomplishment of IORT. CONCLUSION We observed that preoperative ultrasound-based tumor-skin distance is a significant factor in addition to already known parameters to predict feasibility of IORT. Based on our findings we developed a formula to optimize IORT planning which might serve as an additional tool to improve patient selection for IORT in early breast cancer.
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Affiliation(s)
- Anja Grimm
- Department of Obstetrics and Gynecology, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany.
- Department of Obstetrics and Gynecology, University Medical Center Mannheim, Theodor-Kutzer Ufer 1-3, Mannheim, Germany.
| | - Eva Wollmann
- Department of Obstetrics and Gynecology, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany
| | - Elena Sperk
- Department of Radiation Oncology, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany
- Mannheim Cancer Center, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany
| | - Christel Weiß
- Department of Medical Statistics and Biomathematics, Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany
| | - Marc Sütterlin
- Department of Obstetrics and Gynecology, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany
| | - Sebastian Berlit
- Department of Obstetrics and Gynecology, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany
| | - Benjamin Tuschy
- Department of Obstetrics and Gynecology, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany
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Shaitelman SF, Anderson BM, Arthur DW, Bazan JG, Bellon JR, Bradfield L, Coles CE, Gerber NK, Kathpal M, Kim L, Laronga C, Meattini I, Nichols EM, Pierce LJ, Poppe MM, Spears PA, Vinayak S, Whelan T, Lyons JA. Partial Breast Irradiation for Patients With Early-Stage Invasive Breast Cancer or Ductal Carcinoma In Situ: An ASTRO Clinical Practice Guideline. Pract Radiat Oncol 2024; 14:112-132. [PMID: 37977261 DOI: 10.1016/j.prro.2023.11.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 11/06/2023] [Accepted: 11/07/2023] [Indexed: 11/19/2023]
Abstract
PURPOSE This guideline provides evidence-based recommendations on appropriate indications and techniques for partial breast irradiation (PBI) for patients with early-stage invasive breast cancer and ductal carcinoma in situ. METHODS ASTRO convened a task force to address 4 key questions focused on the appropriate indications and techniques for PBI as an alternative to whole breast irradiation (WBI) to result in similar rates of ipsilateral breast recurrence (IBR) and toxicity outcomes. Also addressed were aspects related to the technical delivery of PBI, including dose-fractionation regimens, target volumes, and treatment parameters for different PBI techniques. The guideline is based on a systematic review provided by the Agency for Healthcare Research and Quality. Recommendations were created using a predefined consensus-building methodology and system for grading evidence quality and recommendation strength. RESULTS PBI delivered using 3-dimensional conformal radiation therapy, intensity modulated radiation therapy, multicatheter brachytherapy, and single-entry brachytherapy results in similar IBR as WBI with long-term follow-up. Some patient characteristics and tumor features were underrepresented in the randomized controlled trials, making it difficult to fully define IBR risks for patients with these features. Appropriate dose-fractionation regimens, target volume delineation, and treatment planning parameters for delivery of PBI are outlined. Intraoperative radiation therapy alone is associated with a higher IBR rate compared with WBI. A daily or every-other-day external beam PBI regimen is preferred over twice-daily regimens due to late toxicity concerns. CONCLUSIONS Based on published data, the ASTRO task force has proposed recommendations to inform best clinical practices on the use of PBI.
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Affiliation(s)
- Simona F Shaitelman
- Department of Breast Radiation Oncology, University of Texas MD - Anderson Cancer Center, Houston, Texas.
| | - Bethany M Anderson
- Department of Radiation Oncology, University of Wisconsin, Madison, Wisconsin
| | - Douglas W Arthur
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, Virginia
| | - Jose G Bazan
- Department of Radiation Oncology, City of Hope Comprehensive Cancer Center, Duarte, California
| | - Jennifer R Bellon
- Department of Radiation Oncology, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Boston, Massachusetts
| | - Lisa Bradfield
- American Society for Radiation Oncology, Arlington, Virginia
| | - Charlotte E Coles
- Department of Oncology, University of Cambridge, Cambridge, United Kingdom
| | - Naamit K Gerber
- Department of Radiation Oncology, New York University Grossman School of Medicine, New York, New York
| | - Madeera Kathpal
- Department of Radiation Oncology, Duke University Wake County Campus, Raleigh, North Carolina
| | - Leonard Kim
- Department of Radiation Oncology, MD - Anderson Cancer Center at Cooper, Camden, New Jersey
| | - Christine Laronga
- Department of Breast Oncology, Moffitt Cancer Center, Tampa, Florida
| | - Icro Meattini
- Department of Radiation Oncology, University of Florence, Florence, Italy
| | - Elizabeth M Nichols
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Lori J Pierce
- Department of Radiation Oncology, University of Michigan School of Medicine, Ann Arbor, Michigan
| | - Matthew M Poppe
- Department of Radiation Oncology, Huntsman Cancer Institute, Salt Lake City, Utah
| | - Patricia A Spears
- Patient Representative, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Shaveta Vinayak
- Department of Medical Oncology, University of Washington, Seattle, Washington
| | - Timothy Whelan
- Department of Oncology, McMaster University, Hamilton, Ontario, Canada
| | - Janice A Lyons
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Cleveland, Ohio
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3
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Rafik ST, Vaidya JS, MacRobert AJ, Yaghini E. Organic Nanodelivery Systems as a New Platform in the Management of Breast Cancer: A Comprehensive Review from Preclinical to Clinical Studies. J Clin Med 2023; 12:jcm12072648. [PMID: 37048731 PMCID: PMC10095028 DOI: 10.3390/jcm12072648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 03/05/2023] [Accepted: 03/20/2023] [Indexed: 04/05/2023] Open
Abstract
Breast cancer accounts for approximately 25% of cancer cases and 16.5% of cancer deaths in women, and the World Health Organization predicts that the number of new cases will increase by almost 70% over the next two decades, mainly due to an ageing population. Effective diagnostic and treatment strategies are, therefore, urgently required for improving cure rates among patients since current therapeutic modalities have many limitations and side effects. Nanomedicine is evolving as a promising approach for cancer management, including breast cancer, and various types of organic and inorganic nanomaterials have been investigated for their role in breast cancer diagnosis and treatment. Following an overview on breast cancer characteristics and pathogenesis and challenges of the current treatment strategies, the therapeutic potential of biocompatible organic-based nanoparticles such as liposomes and polymeric micelles that have been tested in breast cancer models are reviewed. The efficacies of different drug delivery and targeting strategies are documented, ranging from synthetic to cell-derived nanoformulations together with a summary of the interaction of nanoparticles with externally applied energy such as radiotherapy. The clinical translation of nanoformulations for breast cancer treatment is summarized including those undergoing clinical trials.
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Affiliation(s)
- Salma T. Rafik
- Division of Surgery and Interventional Science, Faculty of Medical Sciences, University College London (UCL), London W1W 7TY, UK
- Department of Clinical Pharmacology, Faculty of Medicine, Alexandria University, Alexandria 21516, Egypt
| | - Jayant S. Vaidya
- Division of Surgery and Interventional Science, Faculty of Medical Sciences, University College London (UCL), London W1W 7TY, UK
| | - Alexander J. MacRobert
- Division of Surgery and Interventional Science, Faculty of Medical Sciences, University College London (UCL), London W1W 7TY, UK
| | - Elnaz Yaghini
- Division of Surgery and Interventional Science, Faculty of Medical Sciences, University College London (UCL), London W1W 7TY, UK
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Can S, Atilla Ö, Karaçetin D. Calculated and measured radiation dose for the low energy xoft axxent eBT X-ray source. BMC Res Notes 2023; 16:25. [PMID: 36855193 PMCID: PMC9976427 DOI: 10.1186/s13104-023-06287-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 02/08/2023] [Indexed: 03/02/2023] Open
Abstract
PURPOSE In this study, it was aimed to evaluate the functionality to deliver different prescription dose except 20 Gy for the Xoft Axxent Ebt (electronic Brachytherapy) system and analyzing the system in terms of radiation dosimetry in water and 0.9% isotonic Sodium Chloride (NaCl) solution. MATERIALS AND METHODS In the Xoft Axxent eBT, different prescription dose in single fraction were calculated for different balloon applicator volumes based on source position and irradiation times. EBT-XD Gafchromic film was calibrated at 6MV photon energy. A balloon applicator filled with 0.9% isotonic NaCl solution was used to deliver a radiation dose of 20 Gy, 16 Gy, 10 Gy on the applicator surface. Then the balloon applicator was filled with water and the same measurements were repeated. Finally, the balloon applicator was irradiated by positioning it at different distances in the water phantom to simulate the isodose contour. RESULTS At the time the balloon applicator was filled with water and 0,9% NaCl solution, the difference between the planned dose and the absorbed dose was ~ 2% vs. 15% for 30 cc, ~ 5% vs. 14% for 35 cc and ~ 3,5% vs. 10% for 40 cc respectively. Finally, the absorbed dose at a distance of 1 cm from the applicator surface was measured as 9.63 Gy. CONCLUSION In this study, it was showed that different prescription dose could be possible to deliver in the Xoft Axxent eBT system based on the standard plan. In addition, the absorbed dose was higher than the planned dose depending on the effective atomic number of NaCl solution comparing to water due to photoelectric effect in low energy photons. By measuring the dose distributions at different distances from the balloon applicator surface, the absorbed dose in tissue equivalent medium was determined and the isodose contours characteristics was simulated.
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Affiliation(s)
- Sümeyra Can
- Basaksehir Cam and Sakura City Hospital Radiation Oncology Department, 34480, Basaksehir Istanbul, Turkey.
| | - Özge Atilla
- Basaksehir Cam and Sakura City Hospital Radiation Oncology Department, 34480 Basaksehir Istanbul, Turkey
| | - Didem Karaçetin
- Basaksehir Cam and Sakura City Hospital Radiation Oncology Department, 34480 Basaksehir Istanbul, Turkey
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In Reply to Ward et al. Int J Radiat Oncol Biol Phys 2023; 115:256-259. [DOI: 10.1016/j.ijrobp.2022.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 10/03/2022] [Indexed: 12/15/2022]
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Vaidya JS, Bulsara M, Wenz F, Sperk E, Massarut S, Alvarado M, Williams NR, Brew-Graves C, Bernstein M, Holmes D, Vinante L, Pigorsch S, Lundgren S, Uhl V, Joseph D, Tobias JS. The TARGIT-A Randomized Trial: TARGIT-IORT Versus Whole Breast Radiation Therapy: Long-Term Local Control and Survival. Int J Radiat Oncol Biol Phys 2023; 115:77-82. [PMID: 35998867 DOI: 10.1016/j.ijrobp.2022.08.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 08/04/2022] [Accepted: 08/06/2022] [Indexed: 11/16/2022]
Affiliation(s)
- Jayant S Vaidya
- Division of Surgery and Interventional Science, University College London, London, United Kingdom.
| | - Max Bulsara
- Division of Surgery and Interventional Science, University College London, London, United Kingdom; Department of Biostatistics, University of Notre Dame, Fremantle, WA, Australia
| | - Frederik Wenz
- University Medical Centre Freiburg, University of Frieberg, Frieberg, Germany
| | - Elena Sperk
- Department of Radiation Oncology, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany
| | - Samuele Massarut
- Department of Surgery, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
| | - Michael Alvarado
- Department of Surgery, University of California, San Francisco, California
| | | | | | | | - Dennis Holmes
- University of Southern California, John Wayne Cancer Institute & Helen Rey Breast Cancer Foundation, Los Angeles, California
| | - Lorenzo Vinante
- Department of Radiation Oncology, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
| | - Steffi Pigorsch
- Department of RadioOncology and Radiotherapy, Technical University of Munich, Munich, Germany
| | - Steinar Lundgren
- Department of Oncology, St Olav's University Hospital, Trondheim, Norway
| | - Valery Uhl
- Radiation Oncology, Summit Medical Center, Oakland, California
| | - David Joseph
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Perth, WA, Australia
| | - Jeffrey S Tobias
- Department of Clinical Oncology, University College London Hospitals, London, United Kingdom
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Farheen J, Hosmane NS, Zhao R, Zhao Q, Iqbal MZ, Kong X. Nanomaterial-assisted CRISPR gene-engineering - A hallmark for triple-negative breast cancer therapeutics advancement. Mater Today Bio 2022; 16:100450. [PMID: 36267139 PMCID: PMC9576993 DOI: 10.1016/j.mtbio.2022.100450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Revised: 09/16/2022] [Accepted: 10/02/2022] [Indexed: 11/05/2022] Open
Abstract
Triple-negative breast cancer (TNBC) is the most violent class of tumor and accounts for 20–24% of total breast carcinoma, in which frequently rare mutation occurs in high frequency. The poor prognosis, recurrence, and metastasis in the brain, heart, liver and lungs decline the lifespan of patients by about 21 months, emphasizing the need for advanced treatment. Recently, the adaptive immunity mechanism of archaea and bacteria, called clustered regularly interspaced short palindromic repeats (CRISPR) combined with nanotechnology, has been utilized as a potent gene manipulating tool with an extensive clinical application in cancer genomics due to its easeful usage and cost-effectiveness. However, CRISPR/Cas are arguably the efficient technology that can be made efficient via organic material-assisted approaches. Despite the efficacy of the CRISPR/Cas@nano complex, problems regarding successful delivery, biodegradability, and toxicity remain to render its medical implications. Therefore, this review is different in focus from past reviews by (i) detailing all possible genetic mechanisms of TNBC occurrence; (ii) available treatments and gene therapies for TNBC; (iii) overview of the delivery system and utilization of CRISPR-nano complex in TNBC, and (iv) recent advances and related toxicity of CRISPR-nano complex towards clinical trials for TNBC.
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Affiliation(s)
- Jabeen Farheen
- Institute of Smart Biomedical Materials, School of Materials Science and Engineering, Zhejiang Sci-Tech University, Hangzhou, 310018, PR China,Zhejiang-Mauritius Joint Research Centre for Biomaterials and Tissue Engineering, Zhejiang Sci-Tech University, Hangzhou, 310018, PR China
| | - Narayan S. Hosmane
- Department of Chemistry & Biochemistry, Northern Illinois University, DeKalb, IL, 60115, USA
| | - Ruibo Zhao
- Institute of Smart Biomedical Materials, School of Materials Science and Engineering, Zhejiang Sci-Tech University, Hangzhou, 310018, PR China,Zhejiang-Mauritius Joint Research Centre for Biomaterials and Tissue Engineering, Zhejiang Sci-Tech University, Hangzhou, 310018, PR China,Department of Materials, Imperial College London, London, SW7 2AZ, UK
| | - Qingwei Zhao
- Research Center for Clinical Pharmacy & Key Laboratory for Drug Evaluation and Clinical Research of Zhejiang Province, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310003, PR China
| | - M. Zubair Iqbal
- Institute of Smart Biomedical Materials, School of Materials Science and Engineering, Zhejiang Sci-Tech University, Hangzhou, 310018, PR China,Zhejiang-Mauritius Joint Research Centre for Biomaterials and Tissue Engineering, Zhejiang Sci-Tech University, Hangzhou, 310018, PR China,Corresponding author. Institute of Smart Biomedical Materials, School of Materials Science and Engineering, Zhejiang Sci-Tech University, Hangzhou, 310018, PR China.
| | - Xiangdong Kong
- Institute of Smart Biomedical Materials, School of Materials Science and Engineering, Zhejiang Sci-Tech University, Hangzhou, 310018, PR China,Zhejiang-Mauritius Joint Research Centre for Biomaterials and Tissue Engineering, Zhejiang Sci-Tech University, Hangzhou, 310018, PR China,Corresponding author. Institute of Smart Biomedical Materials, School of Materials Science and Engineering, Zhejiang Sci-Tech University, Hangzhou, 310018, PR China
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Vaidya JS, Vaidya UJ, Baum M, Bulsara MK, Joseph D, Tobias JS. Global adoption of single-shot targeted intraoperative radiotherapy (TARGIT-IORT) for breast cancer—better for patients, better for healthcare systems. Front Oncol 2022; 12:786515. [PMID: 36033486 PMCID: PMC9406153 DOI: 10.3389/fonc.2022.786515] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 06/28/2022] [Indexed: 12/30/2022] Open
Abstract
Micro abstractTargeted intraoperative radiotherapy (TARGIT-IORT) is delivered immediately after lumpectomy for breast cancer. We estimated its impact. At least 44,752 patients with breast cancer were treated with TARGIT-IORT in 260 centres in 35 countries, saving >20 million miles of travel and preventing ~2,000 non–breast cancer deaths. The TARGIT-IORT website (https://targit.org.uk/travel) provides maps and tools to find the nearest centre offering TARGIT-IORT and travel savings.BackgroundTargeted intraoperative radiotherapy (TARGIT-IORT) delivers radiotherapy targeted to the fresh tumour bed exposed immediately after lumpectomy for breast cancer. TARGIT-A trial found TARGIT-IORT to be as effective as whole-breast radiotherapy, with significantly fewer deaths from non–breast cancer causes. This paper documents its worldwide impact and provides interactive tools for clinicians and patients.MethodCentres using TARGIT-IORT provided the date of the first case and the total number of patients. We plotted these data on a customised Google Map. An interactive web-based tool provided directions to the closest centre. Using the data from the TARGIT-A trial, we estimated the total savings in travel miles, carbon footprint, and the number of non–breast cancer deaths that might be prevented.ResultsData from 242 (93%) of the 260 centres treating patients from 35 countries were available. From the first patient treated in 1998 to early 2020, at least 44,752 women with breast cancer have been treated with TARGIT-IORT. The TARGIT-IORT website (https://targit.org.uk/travel) displays the Google Map of centres with number of cases and an interactive tool for patients to find the nearest centre offering TARGIT-IORT and their travel savings. Scaling up to the already treated patients, >20 million miles of travel would have been saved and about 2,000 deaths prevented.ConclusionOne can ascertain the number of patients treated with a novel treatment. These data show how widely TARGIT-IORT has now been adopted and gives an indication of its beneficial worldwide impact on a large number of women with breast cancer.
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Affiliation(s)
- Jayant Sharad Vaidya
- Division of Surgery and Interventional Science, University College London, London, United Kingdom
- *Correspondence: Jayant Sharad Vaidya, ;
| | - Uma Jayant Vaidya
- Medical Sciences Division Brasenose College, University of Oxford, Oxford, United Kingdom
| | - Michael Baum
- Division of Surgery and Interventional Science, University College London, London, United Kingdom
| | - Max Kishor Bulsara
- Division of Surgery and Interventional Science, University College London, London, United Kingdom
- Department of Biostatistics, University of Notre Dame, Fremantle, WA, Australia
| | - David Joseph
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Perth, WA, Australia
| | - Jeffrey S. Tobias
- Department of Clinical Oncology, University College London Hospitals, London, United Kingdom
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Vaidya JS, Bulsara M, Baum M, Wenz F, Massarut S, Pigorsch S, Alvarado M, Douek M, Saunders C, Flyger H, Eiermann W, Brew-Graves C, Williams NR, Potyka I, Roberts N, Bernstein M, Brown D, Sperk E, Laws S, Sütterlin M, Corica T, Lundgren S, Holmes D, Vinante L, Bozza F, Pazos M, Blanc-Onfroy ML, Gruber G, Polkowski W, Dedes KJ, Niewald M, Blohmer J, McReady D, Hoefer R, Kelemen P, Petralia G, Falzon M, Joseph D, Tobias JS. New clinical and biological insights from the international TARGIT-A randomised trial of targeted intraoperative radiotherapy during lumpectomy for breast cancer. Br J Cancer 2021; 125:380-389. [PMID: 34035435 PMCID: PMC8329051 DOI: 10.1038/s41416-021-01440-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 04/26/2021] [Accepted: 05/13/2021] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The TARGIT-A trial reported risk-adapted targeted intraoperative radiotherapy (TARGIT-IORT) during lumpectomy for breast cancer to be as effective as whole-breast external beam radiotherapy (EBRT). Here, we present further detailed analyses. METHODS In total, 2298 women (≥45 years, invasive ductal carcinoma ≤3.5 cm, cN0-N1) were randomised. We investigated the impact of tumour size, grade, ER, PgR, HER2 and lymph node status on local recurrence-free survival, and of local recurrence on distant relapse and mortality. We analysed the predictive factors for recommending supplemental EBRT after TARGIT-IORT as part of the risk-adapted approach, using regression modelling. Non-breast cancer mortality was compared between TARGIT-IORT plus EBRT vs. EBRT. RESULTS Local recurrence-free survival was no different between TARGIT-IORT and EBRT, in every tumour subgroup. Unlike in the EBRT arm, local recurrence in the TARGIT-IORT arm was not a predictor of a higher risk of distant relapse or death. Our new predictive tool for recommending supplemental EBRT after TARGIT-IORT is at https://targit.org.uk/addrt . Non-breast cancer mortality was significantly lower in the TARGIT-IORT arm, even when patients received supplemental EBRT, HR 0.38 (95% CI 0.17-0.88) P = 0.0091. CONCLUSION TARGIT-IORT is as effective as EBRT in all subgroups. Local recurrence after TARGIT-IORT, unlike after EBRT, has a good prognosis. TARGIT-IORT might have a beneficial abscopal effect. TRIAL REGISTRATION ISRCTN34086741 (21/7/2004), NCT00983684 (24/9/2009).
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Affiliation(s)
- Jayant S Vaidya
- Division of Surgery and Interventional Science, University College London, London, UK.
| | - Max Bulsara
- Department of Biostatistics, University of Notre Dame, Fremantle, WA, Australia
| | - Michael Baum
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Frederik Wenz
- Department of Radiation Oncology, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Samuele Massarut
- Department of Surgery, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
| | - Steffi Pigorsch
- Department of Radiation Oncology, Red Cross Hospital, Technical University of Munich, Munich, Germany
| | - Michael Alvarado
- Department of Surgery, University of California, San Francisco, CA, USA
| | - Michael Douek
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | | | - Henrik Flyger
- Department of Breast Surgery, University of Copenhagen, Copenhagen, Denmark
| | - Wolfgang Eiermann
- Department of Gynecology and Obstetrics, Red Cross Hospital, Technical University of Munich, Munich, Germany
| | - Chris Brew-Graves
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Norman R Williams
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Ingrid Potyka
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Nicholas Roberts
- Division of Surgery and Interventional Science, University College London, London, UK
| | | | - Douglas Brown
- Department of Surgery, Ninewells Hospital, Dundee, UK
| | - Elena Sperk
- Department of Radiation Oncology, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Siobhan Laws
- Department of Surgery, Royal Hampshire County Hospital, Winchester, UK
| | - Marc Sütterlin
- Department of Gynecology and Obstetrics, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Berlin, Germany
| | - Tammy Corica
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Perth, WA, Australia
| | - Steinar Lundgren
- Department of Oncology, St Olav's University Hospital, & Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Dennis Holmes
- John Wayne Cancer Institute & Helen Rey Breast Cancer Foundation, University of Southern California, Los Angeles, CA, USA
| | - Lorenzo Vinante
- Department of Radiation Oncology, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
| | - Fernando Bozza
- Department of Surgery, Instituto Oncologico Veneto (IVO) IRCCS, Padoa, Italy
| | - Montserrat Pazos
- Department of Radiation Oncology, University Hospital, Ludwig Maximilians Universitat, Munich, Germany
| | | | | | - Wojciech Polkowski
- Department of Surgical Oncology, Medical University of Lublin, Lublin, Poland
| | | | | | - Jens Blohmer
- Sankt Gertrauden-Krankenhaus, and The Charité-Universitätsmedizin Berlin, Berlin, Germany
| | | | | | - Pond Kelemen
- Ashikari Breast Center, New York Medical College, New York, NY, USA
| | - Gloria Petralia
- Department of Surgery, University College London Hospitals, London, UK
| | - Mary Falzon
- Department of Pathology University College London Hospitals, London, UK
| | - David Joseph
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Perth, WA, Australia
| | - Jeffrey S Tobias
- Department of Clinical Oncology, University College London Hospitals, London, UK
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Partial breast irradiation with intraoperative radiotherapy in the ELIOT trial. Lancet Oncol 2021; 22:e295-e296. [PMID: 34197756 DOI: 10.1016/s1470-2045(21)00278-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 04/30/2021] [Indexed: 11/23/2022]
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Hannoun-Levi JM, Chamorey E, Boulahssass R, Polgar C, Strnad V. Endocrine therapy with accelerated Partial breast irradiati On or exclusive ultra-accelerated Partial breast irradiation for women aged ≥ 60 years with Early-stage breast cancer (EPOPE): The rationale for a GEC-ESTRO randomized phase III-controlled trial. Clin Transl Radiat Oncol 2021; 29:1-8. [PMID: 33997321 PMCID: PMC8102143 DOI: 10.1016/j.ctro.2021.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Revised: 04/06/2021] [Accepted: 04/11/2021] [Indexed: 11/20/2022] Open
Abstract
Epidemiologic data confirm the increase of breast cancer incidence in the elderly. The risk of recurrence of breast cancer is basically low. De-escalation breast cancer adjuvant therapy is justified in selected elderly patients. Ultra-accelerated breast irradiation with endocrine therapy omission is under debate. Prospective randomized trial is warranted.
Purpose Breast cancer in the elderly has become a public health concern; there is a need to re-design its treatment with a view to de-escalation. Our paper sets out the rationale for a phase 3 randomized trial to evaluate less burdensome adjuvant procedures that remain effective and efficient. Materials and methods For low-risk breast cancer in the elderly, adjuvant treatment has been adjusted in order to make it more suitable and efficient. Hypofractionated radiation therapy based on accelerated or non-accelerated regimens as well as accelerated and ultra-accelerated partial breast irradiation (APBI) protocols were reviewed. Withdrawal of radiation (RT) or endocrine therapies (ET) from the adjuvant procedure were also investigated. Based on molecular and APBI classifications, inclusion criteria were discussed. Results Phase 3 randomized trials which compared standard vs. accelerated/non-accelerated hypofractionated regimens confirmed that the latter were non-inferior in terms of local control. Similarly, except for intraoperative-based techniques, APBI achieved non-inferior local control rates compared to whole breast irradiation for low-risk breast cancer. In phase 2 prospective trials using ultra APBI, encouraging results were observed regarding oncological outcome and toxicity profile. In phase 3 trials, adjuvant ET without RT significantly increased the rate of local relapse with no impact on overall survival while RT alone proved effective. Elderly patients aged 60 or more with low-risk, luminal A breast cancer were chosen as the target population in a phase 3 randomized trial comparing APBI + 5-year ET vs. uAPBI (16 Gy 1f) alone. Conclusion To investigate de-escalation adjuvant treatment for elderly breast cancer patients, we have defined a road map for testing more convenient strategies. This EPOPE phase 3 randomized trial is supported by the GEC-ESTRO breast cancer working group.
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Key Words
- ABS, American Brachytherapy Society
- APBI, Accelerated and partial breast irradiation
- ASTRO, American Society of Radiation Oncology
- BCS, Breast cancer surgery
- BCWG, Breast Cancer Working Group
- Brachytherapy
- Breast cancer in the elderly
- DCIS, Ductal carcinoma in situ
- DFS, Disease-free survival
- EPOPE, Endocrine therapy with accelerated Partial breast irradiatiOn or exclusive ultra-accelerated Partial breast irradiation for women aged ≥ 60 years with Early stage breast cancer
- EQD2, Equivalent Dose in 2Gy fractions
- ET, Endocrine therapy
- Endocrine therapy
- GEC-ESTRO, Groupe Européen de Curiethérapie/European Society for Therapeutic Radiation and Oncology
- HDB, High-dose rate Brachytherapy
- LCIS, Lobular carcinoma in situ
- MAPBI, Molecular and APBI GEC-ESTRO
- MIB, Multicatheter Interstitial Brachytherapy
- Oncogeriatric assessment
- QoL, Quality of Life
- RT, Radiotherapy
- Radiation therapy
- WBI, Whole breast irradiation
- uAPBI, ultra-Accelerated Partial Breast Irradiation
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Affiliation(s)
- Jean-Michel Hannoun-Levi
- Department of Radiation Oncology, Antoine Lacassagne Cancer Centre, University of Côte d'Azur, Nice, France
| | - Emmanuel Chamorey
- Department of Epidemiology and Biostatistics, Antoine Lacassagne Cancer Centre, University of Cote d'Azur, Nice, France
| | - Rabia Boulahssass
- Geriatric Unit. CHU de NICE, FHU ONCOAGE, University of Cote d'Azur, Nice, France
| | - Csaba Polgar
- Department of Oncology, Semmelweis University, Budapest, Hungary
| | - Vratislav Strnad
- Department of Radiation Oncology, Erlangen University Hospital, Erlangen, Germany
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Vaidya JS, Bulsara M, Sperk E, Massarut S, Douek M, Alvarado M, Pigorsch S, Holmes D, Bernstein M, Saunders C, Flyger H, Joseph D, Wenz F, Tobias JS. In Regard to Polgar et al. Int J Radiat Oncol Biol Phys 2021; 110:905-907. [PMID: 33640419 DOI: 10.1016/j.ijrobp.2021.01.059] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 01/26/2021] [Indexed: 10/22/2022]
Affiliation(s)
- Jayant S Vaidya
- Division of Surgery and Interventional Science, University College London, London, United Kingdom
| | - Max Bulsara
- Department of Biostatistics, University of Notre Dame Australia, Fremantle, Western Australia, Australia
| | - Elena Sperk
- Department of Radiation Oncology, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany
| | - Samuele Massarut
- Department of Surgery, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
| | - Michael Douek
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom
| | - Michael Alvarado
- Department of Surgery, University of California, San Francisco, San Francisco, California
| | - Steffi Pigorsch
- Department of Gynaecology and Obstetrics, Red Cross Hospital, Technical University of Munich, Munich, Germany
| | - Dennis Holmes
- University of Southern California, John Wayne Cancer Institute & Helen Rey Breast Cancer Foundation, Los Angeles, California
| | | | - Christobel Saunders
- School of Surgery, University of Western Australia, Crawley, Western Australia, Australia
| | - Henrik Flyger
- Department of Breast Surgery, University of Copenhagen, Copenhagen, Denmark
| | - David Joseph
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | | | - Jeffrey S Tobias
- Department of Clinical Oncology, University College London Hospitals, London, United Kingdom
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