Long-term cosmesis after lumpectomy and brachytherapy in the management of carcinoma of the previously irradiated breast

Radiotherapy and hyperthermia for breast cancer patients at high risk of recurrence

PURPOSE

To evaluate the long-term efficacy of combined radiotherapy (RT) and hyperthermia (HT) in a large mono-institutional cohort of breast cancer (BC) patients affected by recurrent, newly diagnosed non-resectable or high risk resected tumor.

MATERIALS AND METHODS

Records of BC patients treated with RT + HT between 1995 and 2018 were retrospectively analyzed. RT doses of 50-70 Gy concurrent to a twice per week superficial HT were applied. For HT, a temperature between 41 and 42 °C was applied for approximately 1 h. Primary endpoint was local control (LC), secondary endpoints comprised toxicity, overall survival (OS), and progression-free survival (PFS).

RESULTS

A total of 191 patients and 196 RT + HT treatments were analyzed. In 154 cases (78.6%) RT + HT was performed for patients with recurrent BC. Among these, 93 (47.4% of the entire cohort) had received RT prior to RT + HT. Median follow up was 12.7 years. LC at 2, 5, and 10 years was 76.4, 72.8, and 69.5%, respectively. OS at 2, 5, and 10 years was 73.5, 52.3, and 35.5%, respectively. PFS at 2, 5, and 10 years was 55.6, 41, and 33.6%, respectively. Predictive factors for LC were tumor stage, distant metastases, estrogen/progesterone receptor expression, resection status and number of HT fractions. At multivariate analysis tumor stage and receptor expression were significant. No acute or late toxicities higher than grade 3 were observed.

CONCLUSION

Combined RT + HT offers long-term high LC rates with acceptable toxicity for patients with recurrent, newly diagnosed non-resectable or resected BC at high risk of relapse.

Outcomes of ipsilateral breast tumor recurrence after breast conserving surgery: Repeat lumpectomy as an alternative to salvage mastectomy

BACKGROUND

We examined the outcomes of salvage mastectomy and repeat lumpectomy for management of ipsilateral breast tumor recurrence.

METHODS

Between 2013 and 2019, 113 patients with an ipsilateral breast tumor recurrence after breast conserving surgery were identified. Patients and tumor characteristics at initial diagnosis and at recurrence were collected. Outcomes evaluated included second recurrence and overall survival. Complications at 30-days and 90-days after surgery for ipsilateral breast tumor recurrence were evaluated.

RESULTS

Seventy-two percent of patients underwent salvage mastectomy (n = 84) and 28% underwent repeat lumpectomy (n = 32 overall, n = 13 reirradiation). Salvage mastectomy patients were younger at initial diagnosis (P = .007) with longer time to ipsilateral breast tumor recurrence from first diagnosis (P = .03). At 2.5 years median follow-up, the overall incidence of second recurrence was 8% with 5% rate (n = 4) in salvage mastectomy group versus 16% (n = 5) in repeat lumpectomy group; however, among patients undergoing repeat lumpectomy with reirradiation (n = 13), only one patient developed a second recurrence (8%). There was no significant difference in rates of second local recurrence (P = .11), disease free survival (P = .13), or overall survival (P = .95) between repeat lumpectomy with reirradiation and salvage mastectomy.

CONCLUSION

At a short-term follow-up, repeat lumpectomy with reirradiation could be considered in a select group of patients presenting with an ipsilateral breast tumor recurrence with multidisciplinary input with low rates of postoperative complications and equivalent survival outcomes.

Prognosis of Surgical Treatment After Ipsilateral Breast Tumor Recurrence

BACKGROUND

Ipsilateral breast tumor recurrence (IBTR) was determined to be a powerful independent risk factor of distant disease and increased mortality. Although mastectomy is the standard salvage treatment for IBTR after breast conserving treatment, there is evidence that repeat breast conserving surgery (rBCS) might be a feasible alternative treatment.

MATERIALS AND METHODS

The data of patients who were diagnosed with IBTR between 1998 and 2013 were obtained from the Surveillance, Epidemiology, and End Results database. Breast cancer-specific survival (BCSS) and overall survival (OS) were calculated using the Kaplan-Meier method. The Cox proportional hazards model was used for multivariate analysis, and propensity score matching analysis was applied to compensate for the differences in some baseline characteristics.

RESULTS

A total of 475 patients (22.9%) who underwent rBCS and 1600 (77.1%) who underwent mastectomy after IBTR were included in the study. During a median follow-up of 130 mo, no significant differences were observed in BCSS and OS between the rBCS and mastectomy groups of patients before and after propensity score matching. Multivariate analysis revealed that race, the American Joint Committee on Cancer stage of the recurrent tumor, and reirradiation were independent prognostic factors for both BCSS and OS.

CONCLUSIONS

The results of our study indicate that rBCS can be a feasible alternative treatment option for patients with IBTR. Nevertheless, further studies should be conducted to identify the prognosis of patients after rBCS as well as the best candidates for a second breast conserving surgery.

Breast-conserving surgery with intraoperative radiotherapy in recurrent breast cancer: the patient's perspective

Purpose

When ipsilateral breast-tumor recurrence (IBTR) following breast-conserving surgery (BCS) occurs, the cure of a potentially life-threatening disease is the main goal. If, however, this is diagnosed early, prognosis is still good and patient-reported outcomes become more important. Despite the fact that many patients would prefer a further BCS, international breast cancer guidelines still recommend mastectomy, mainly because previous radiation implies limited options. Our comparative study evaluates the long-term quality-of-life and outcome in patients with IBTR who received BCS plus intraoperative radiotherapy (IORT) versus mastectomy.

Methods

Patients with IBTR were retrospectively divided into three groups according to the local treatment: group 1 (n = 26) was treated with BCS + IORT; group 2 (n = 35) received a standard mastectomy; group 3 (n = 52) had a mastectomy with subsequent reconstruction. Outcomes were analyzed after a mean follow-up of 5 years after IBTR. Quality-of-life was evaluated by the validated questionnaire BREAST-Q in 50 patients who fulfilled the inclusion criteria.

Results

Quality-of-life scores varied within the groups, ranging from 51.4 to 91.3 (out of 100 points). We observed satisfactory scores in all items, with no statistical difference within the groups. Disease-free survival of all groups did not statistically differ, and overall mortality was very low (0.9%). The postinterventional complication rate was lower after BCS (19.2% versus 34.3% after mastectomy and 30.8% after mastectomy with reconstruction).

Conclusion

For patients with previous surgery and radiation who demand a second BCS in the recurrent situation, this surgical technique can be offered in combination with IORT. Our long-term results imply oncological safety, lower complication rate, and good patient satisfaction.

The Role of Partial Breast Radiation in the Previously Radiated Breast

OBJECTIVES

The aim of this study was to analyze breast cancer patients who previously had mantle-field or breast radiation (RT) followed by retreatment with external beam partial breast irradiation (EB PBI).

MATERIALS AND METHODS

We retrospectively reviewed all women with newly diagnosed early-stage breast cancer treated with lumpectomy and partial breast irradiation between 2007 and 2017 who had undergone prior chest or breast RT.

RESULTS

Of 11 patients recorded, 8 (73%) had Hodgkin lymphoma, and 3 (27%) had ipsilateral breast cancer diagnosis. Median age at initial and second diagnosis was 28 and 48 years, respectively. The lymphoma patients received a dose of 35 Gy in 16 to 20 fractions to a classic mantle-upper abdomen field. Patients with an initial diagnosis of breast cancer received whole-breast RT (2 with 50 Gy/25 fractions, 1 with 40 Gy in 16 fractions). Median time from initial to second diagnosis was 22.6 years (range, 13.5 to 32.6 y). All had early-stage (I to II) invasive ductal carcinoma and were treated with lumpectomy or repeat lumpectomy and EB PBI. Four received a dose of 45 Gy/25 fractions, 4 to 50 Gy/25 fractions, and 3 to 42.4 Gy/16 fractions. All patients received adjuvant systemic treatment. Two patients had toxicity, 1 had grade 1 induration, and the other had grade 2 fat atrophy and grade 1 fibrosis. One patient developed a contralateral breast cancer. No locoregional recurrences were reported at the median follow-up of 4.6 years (range, 0.6 to 10.5 y).

CONCLUSION

EB PBI after lumpectomy seems to be a safe and effective RT treatment option for selected patients with prior RT and localized early-stage breast cancer.

Proton beam therapy reirradiation for breast cancer: Multi-institutional prospective PCG registry analysis

To investigate adverse events (AEs, CTCAE v4.0) and clinical outcomes for proton beam therapy (PBT) reirradiation (reRT) for breast cancer. From 2011 to 2016, 50 patients received PBT reRT for breast cancer in the prospective Proton Collaborative Group (PCG) registry. Acute AEs occurred within 180 days from start of reRT. Late AEs began or persisted beyond 180 days. Fisher's exact and Mann-Whitney rank-sum tests were utilized. Kaplan-Meier methods were used to estimate overall survival (OS) and local recurrence-free survival (LFRS). Median follow-up was 12.7 months (0-41.8). Median prior RT dose was 60 Gy (10-96.7). Median reRT dose was 55.1 Gy (45.1-76.3). Median cumulative dose was 110.6 Gy (70.6-156.8). Median interval between RT courses was 103.8 months (5.5-430.8). ReRT included regional nodes in 84% (66% internal mammary node [IMN]). Surgery included the following: 44% mastectomy, 22% wide local excision, 6% lumpectomy, 2% reduction mammoplasty, and 26% no surgery. Grade 3 AEs were experienced by 16% of patients (10% acute, 8% late) and were associated with body mass index (BMI) > 30 kg/m² (P = 0.04), bilateral recurrence (P = 0.02), and bilateral reRT (P = 0.004). All grade 3 AEs occurred in patients receiving IMN reRT (P = 0.08). At 1 year, LRFS was 93%, and OS was 97%. Patients with gross disease at time of PBT trended toward worse 1-year LRFS (100% without vs. 84% with, P = 0.06). PBT reRT is well tolerated with favorable local control. BMI > 30, bilateral disease, and IMN reRT were associated with grade 3 AEs. Toxicity was acceptable despite median cumulative dose > 110 Gy.

Second breast-conserving surgery and interstitial brachytherapy vs. salvage mastectomy for the treatment of local recurrences: 5-year results

PURPOSE

The purpose of this study was to report the clinical outcomes of a second breast-conserving therapy (2nd BCT) with perioperative interstitial brachytherapy (iBT) vs. those of salvage mastectomy (sMT) in the treatment of ipsilateral breast tumor recurrences (IBTRs).

METHODS AND MATERIALS

Between 1999 and 2015, 195 patients with IBTR after a previous breast-conserving treatment were salvaged either with reexcision and perioperative high-dose-rate iBT (n = 39), or with sMT (n = 156). In the 2nd BCT group, a total dose of 22 Gy in five fractions of 4.4 Gy was delivered to the tumor bed with intraoperatively implanted catheters for 3 consecutive days.

RESULTS

The median followup time was 59 months (1-189) in the 2nd BCT, and 56 months (3-189) in the sMT group. The mean size of IBTR was 16 mm (2-70) vs. 24 mm (2-90), respectively (p = 0.0005), but there were no other significant differences in patient- or IBTR-related parameters between the two groups. During the followup period, 4 of 39 (10.2%) and 28 of 156 (17.9%) second local recurrences (2nd LR) occurred in the 2nd BCT and the sMT group, respectively. The 5-year actuarial rate of 2nd LR was 6% vs. 18% (p = 0.22), the 5-year probability of disease-free, cancer-specific and overall survival was 69% vs. 65% (p = 0.13), 85% vs. 78% (p = 0.32), and 81% vs. 66% (p = 0.15), respectively. In the 2nd BCT group, the rate of good to excellent cosmesis was 70%.

CONCLUSIONS

2nd BCT with perioperative high-dose-rate iBT is a safe and feasible option for the management of IBTR, resulting in similar 5-year oncological outcomes and better cosmetic results compared with sMT.

Repeat breast-conserving therapy for ipsilateral breast cancer recurrence: A systematic review

The standard of care for patients with an ipsilateral breast tumour recurrence (IBTR) after breast-conserving therapy (BCT) is a salvage mastectomy. However, there is growing interest in the feasibility of repeat BCT for these patients. This systematic review contains the latest insights on BCT options for patients with an IBTR after initial BCT. A PubMed literature search was performed for articles on BCT options for IBTR after primary lumpectomy followed by radiotherapy. Weighted estimates were calculated for 5- and 10-year local control, distant metastasis-free and overall survival rates. Secondary outcomes were toxicity, cosmesis and quality of life. In total, 34 studies were eligible for analysis, of which 5 reported on repeat breast-conserving surgery (BCS) alone, 10 with mixed populations (BCS ± RT and/or mastectomy), 18 on repeat BCS followed by re-irradiation (whole-breast or partial) and one on quality of life. The weighted estimates for 5-year overall survival for repeat BCS and repeat BCS followed by reirradiation were 77% and 87%, respectively. Five-year local control was 76% for repeat BCS alone and 89% for repeat BCS followed by re-irradiation. Grade III-IV toxicity rates after re-irradiation varied from 0 to 21%, whereas the cosmesis was excellent-good in 29-100% of patients and unacceptable in 0-18%. Repeat BCS followed by re-irradiation, with either whole breast or partial breast re-irradiation, seems a feasible alternative to mastectomy in case of IBTR, in selected patients. Toxicity rates are low and the cosmetic outcome is good, but the size and follow-up of the published patient series is limited.

Hyperthermic chest wall re-irradiation in recurrent breast cancer: a prospective observational study

PURPOSE

To prospectively investigate the role of re-irradiation (re-RT) combined with hyperthermia (HT) in a contemporary cohort of patients affected by recurrent breast cancer (RBC).

METHODS

Within the prospective registry HT03, patients with resected RBC and previous irradiation were included. Re-RT was applied to the recurrence region with doses of 50-50.4 Gy, with a boost up to 60-60.4 Gy to the microscopically or macroscopically positive resection margins (R1/R2) region. Concurrent HT was performed at 40-42 ℃. Primary endpoint was LC. Acute and late toxicity, overall survival, cancer-specific survival (CSS), and progression-free survival (PFS) were also evaluated.

RESULTS

20 patients and 21 RBC were analyzed. Median re-RT dose was 50.4 Gy and a median of 11 HT fractions were applied. Re-RT+HT was well tolerated, with three patients who experienced a grade (G) 3 acute skin toxicity and no cases of ≥G3 late toxicity. With a median follow up of 24.7 months, two local relapses occurred. Ten patients experienced regional and/or distant disease progression. Five patients died, four of them from breast cancer. PFS was favorable in patients treated with re-RT+HT for the first recurrence with doses of 60 Gy. A trend towards better CSS was found in patients with negative or close margins and after doses of 60 Gy.

CONCLUSION

Full-dose re-RT+HT for RBC is well tolerated, provides good LC, and seems to be more effective when applied at the time of the first relapse and after doses of 60 Gy. The registry will be continued for validation in a larger cohort and with longer follow-up.

Local and Regional Breast Cancer Recurrences: Salvage Therapy Options in the New Era of Molecular Subtypes

Isolated local or regional recurrence of breast cancer (BC) leads to an increased risk of metastases and decreased survival. Ipsilateral breast recurrence can occur at the initial tumor bed or in another quadrant of the breast. Depending on tumor patterns and molecular subtypes, the risk and time to onset of metastatic recurrence differs. HER2-positive and triple-negative (TNG) BC have a risk of locoregional relapse between six and eight times than luminal A. Thus, the management of local and locoregional relapses must take into account the prognostic factors for metastatic disease development. It is important to personalize the overall management, including or not systemic treatment according to the metastatic risk. All isolated recurrence cases should be treated with curative intent. Complete surgical resection is recommended whenever possible. Patients who did not receive postoperative irradiation during their initial management should receive full-dose radiotherapy to the chest wall and to the regional lymph nodes if appropriate. Overall, total mastectomy is the “gold standard” among patients who were previously treated by conservative surgery followed by radiation therapy. In terms of systemic therapy, the benefits of additional treatments are not conclusively proven in cases of isolated recurrence. The beneficial role of chemotherapy has been reported in at least one randomized trial, while endocrine therapy and anti-HER2 are common practice. This review will discuss salvage treatment options of local and locoregional recurrences in the new era of BC molecular subtypes.

Adjuvant intraoperative radiotherapy for selected breast cancers in previously irradiated women: Evidence for excellent feasibility and favorable outcomes

BACKGROUND

The present report provides preliminary outcomes with intraoperative radiotherapy delivered to women with breast cancer included in a re-irradiation program.

MATERIALS AND METHODS

From October 2010 to April 2014, thirty women were included in a re-irradiation protocol by exploiting IORT technique. The median time between the two irradiations was 10 years (range 3-50). All patients underwent conservative surgery, sentinel lymph node excision and IORT with electron beam delivered by a mobile linear accelerator. Primary endpoint was esthetic result and consequential/late toxicity; secondary endpoints were local control (LC), disease free survival (DFS) and overall survival (OS).

RESULTS

With a median follow up of 47 months (range 10-78), we analyzed 29 patients (1 lost at follow up). Twenty-seven patients (90%) had presented breast cancer local relapse or a new primary cancer in the same breast after a previous conservative surgery plus radiation treatment; three patients (10%) had previously received irradiation with mantle field for Hodgkin Lymphoma. Esthetic result was excellent in 3 pts (10%), good in 12 pts (41%), fair in 8 pts (28%) and poor in 6 pts (21%). 12 (41%) patients showed subcutaneous fibrosis at the last follow-up. LC, DFS and OS at five years was 92.3%, 86.3% and 91.2%, respectively.

CONCLUSION

Although we analyzed a small number of patients, our results are satisfactory and this approach is feasible even if it could not be considered the standard treatment. Further clinical trials exploring IORT are needed to identify possible subgroups of patients that might be suitable for this type of approach.

Reirradiation for locally recurrent breast cancer

The aim of this study is to review the current status of reirradiation therapy (Re-RT) for locally recurrent breast cancer. The overall outcome of breast/chest wall Re-RT is difficult to assess because of the wide range of different treatments that a patient may have undergone and the patient's individual features. The local control and complete response rates were reported to be 43-96% and 41-71%, respectively. The combination of Re-RT and hyperthermia seems to be related to improved outcomes. Toxicity rates vary between studies, and Re-RT is generally well tolerated. Re-RT may be considered an option for patients with breast cancer relapse after prior irradiation. Further studies are needed to determine the best irradiation volume and treatment modality for patients with locally recurrent disease.

Partial breast re-irradiation for local recurrence of breast carcinoma: Benefit and long term side effects

INTRODUCTION AND AIMS

To evaluate the outcome after partial breast re-irradiation for in-breast tumor recurrence (IBTR) following second breast conserving surgery (BCS) as alternative to salvage mastectomy.

METHODS AND RESULTS

A survey of the literature was performed including publications between 2002 and 2012 (PubMed). Strategies comprised partial breast radiotherapy by external beam radiotherapy (EBRT), interstitial brachytherapy (BT) in low-, high- and pulse-dose rate technique, combined EBRT/BT, and intraoperative radiotherapy (IORT). Published evidence is scarce, with altogether ten articles identified, in sum reporting about 310 patients. The vast majority (82%) was treated by brachytherapy. Selection criteria for a second breast conservation attempt were comparable within all reports: all women presented with T0-2 recurrent lesions, late onset after primary treatment (70 months, mean of means) and no evidence of metastatic disease before undergoing gross tumor resection with free surgical margins. Treatment doses were in a similar range for brachytherapy (LDR 30-55 Gy, HDR 30-34 Gy; PDR 40-50 Gy), biologically comparable to the only series exclusively using EBRT (50 Gy). Follow-up times amounted 49 months (mean of the means, range 21-89). Oncologic results were similar among the different methods with local control rates ranging between 76% and 100%, and disease free and overall survival rates comparable to mastectomy series. Acute toxicity was low in all cohorts. All authors reported cosmetic outcome, scoring results from excellent to good in 60-80% of patients, mostly without using standardized evaluation schemes. Major late effects were fibrosis in re-irradiated parenchyma as a function of dose and volume, asymmetry (primarily due to double surgery), and breast pain. There were hardly any G3 and no G4 late reactions noted.

DISCUSSION AND CONCLUSION

In a highly selected group of patients with IBTR, partial breast irradiation after second BCS is a viable alternative to mastectomy, yielding high breast preservation rates without compromising oncologic safety. Whereas the evidence for brachytherapy is more solid, there is still little information about the effectiveness of PBI via EBRT or novel strategies like IORT, which therefore should preferably be investigated within trials.

Characterization and treatment of local recurrence following breast conservation for ductal carcinoma in situ

PURPOSE

The optimal treatment strategy for ductal carcinoma in situ (DCIS) continues to evolve and should consider the consequences of initial treatment on the likelihood, type, and treatment of recurrences.

METHODS

We conducted a retrospective cohort study using two data sources of patients who experienced a recurrence (DCIS or invasive cancer) following breast-conserving surgery (BCS) for index DCIS: patients with an index DCIS diagnosed from 1997 to 2008 at the academic institutions of the National Comprehensive Cancer Network (NCCN; N = 88) and patients with an index DCIS diagnosed from 1990 to 2001 at community-based integrated healthcare delivery sites of the Health Maintenance Organization Cancer Research Network (CRN) (N = 182).

RESULTS

Just under half of local recurrences in both cohorts were invasive cancer. While 40 % of patients in both cohorts underwent mastectomy alone at recurrence, treatment of the remaining patients varied. In the earlier CRN cohort, most other patients underwent repeat BCS (39 %) with only 18 % receiving mastectomy with reconstruction, whereas only 16 % had repeat BCS and 44 % had mastectomy with reconstruction in the NCCN cohort. Compared with patients not treated with radiation, those who received radiation for index DCIS were less likely to undergo repeat BCS (NCCN: 6.6 vs. 37 %, p = 0.001; CRN: 20 vs. 48 %, p = 0.0004) and more likely to experience surgical complications after treatment of recurrence (NCCN: 15 vs. 4 %, p = 0.17; CRN: 40 vs. 25 %, p = 0.09).

CONCLUSION

We found that treatment of recurrences after BCS and subsequent complications may be affected by the use of radiotherapy for the index DCIS. Initial treatment of DCIS may have long-term implications that should be considered.

Treatment of recurrent breast cancer following breast conserving surgery

Patients with isolated ipsilateral breast cancer recurrence face completion mastectomy in the majority of cases. Selected patients may derive good outcomes from repeat breast conservation surgery and indeed repeat irradiation may be employed using one of many different modalities. Tumor biology rather than salvage surgery method is likely to influence outcome. Patients with isolated breast tumor recurrence are treated in the majority of cases with completion mastectomy, when for selected patients there exists little evidence that more radical surgery provides better outcomes in terms of further recurrence and overall survival, than repeated breast conserving surgery. Literature search identifying articles addressing the issue of repeat breast conserving surgery for ipsilateral breast tumor recurrence, and repeat radiotherapy(search terms include: repeat breast conserving surgery, salvage mastectomy, salvage breast conserving surgery,salvage radiotherapy, reirradiation). Thirty-five articles discussed the outcomes of repeat breast conserving surgery versus salvage mastectomy, methods of repeat breast irradiation, repeat sentinel lymph node biopsy and related factors. Repeat breast conserving surgery may represent a safe and feasible treatment method for isolated ipsilateral breast tumor recurrence.

Ductal carcinoma in situ of the breast: a surgical perspective

Ductal carcinoma in situ (DCIS) of the breast is a heterogeneous neoplasm with invasive potential. Risk factors include age, family history, hormone replacement therapy, genetic mutation, and patient lifestyle. The incidence of DCIS has increased due to more widespread use of screening and diagnostic mammography; almost 80% of cases are diagnosed with imaging with final diagnosis established by biopsy and histological examination. There are various classification systems used for DCIS, the most recent of which is based on the presence of intraepithelial neoplasia of the ductal epithelium (DIN). A number of molecular assays are now available that can identify high-risk patients as well as help establish the prognosis of patients with diagnosed DCIS. Current surgical treatment options include total mastectomy, simple lumpectomy in very low-risk patients, and lumpectomy with radiation. Adjuvant therapy is tailored based on the molecular profile of the neoplasm and can include aromatase inhibitors, anti-estrogen, anti-progesterone (or a combination of antiestrogen and antiprogesterone), and HER2 neu suppression therapy. Chemopreventive therapies are under investigation for DCIS, as are various molecular-targeted drugs. It is anticipated that new biologic agents, when combined with hormonal agents such as SERMs and aromatase inhibitors, may one day prevent all forms of breast cancer.

Breast cancer occurred after Hodgkin's disease: clinico-pathological features, treatments and outcome: analysis of 214 cases

BACKGROUND

Secondary tumours (ST) represent a major concern in survivors of Hodgkin's disease (HD). Breast cancer (BC) is the most frequent ST among young treated women.

MATERIAL AND METHODS

One hundred and eighty-nine women treated for HD by radiotherapy (RT) and/or chemotherapy (CT) subsequently developed 214 BCs.

RESULTS

Median age at HD diagnosis was 25 years (34% were less than 20). Median interval between HD and BC was 18.6 years, with a 42-year median age at first BC. According to the TNM classification, there were 30 (14%) T0 (non palbable lesions), 86 (40%) T1, 56 (26%) T2, 13 (6%) T3T4 and 29 (14%) Tx. There were 25 (13.2%) contralateral BC. 160 (75%) and 15 (7%) tumours were infiltrating ductal and lobular carcinomas, 7 (3.3%) were other subtypes and 27 (22%) DCIS. The rate of axillary nodal involvement was 32%. Among 203 operated tumours, 79 (39%) were treated by breast conserving surgery (BCS), with RT in 56 (71%) cases. CT and hormonal treatment were delivered in 51% and 45% of the patients. With a 50-month median follow-up, local recurrence occurred in 12% of the tumours (9% after mastectomy, 21% after lumpectomy alone and 13.7% after lumpectomy with RT). Metastasis occurred in 47 (26%) patients. The risk factors were pN+, pT, high SBR grade and young age (< 50 years). The ten-year overall and specific survival rates were 53% and 63.5%, respectively. The ten-year specific survival rates were 79% for pT0T1T2, 48% for pT3T4 (p = 0.0002) and 79% for pN0 versus 38.5% for pN+ (p = 0.00026). Among 67 deaths, 43 (73%) were due to BC.

CONCLUSION

Patients and physicians should be aware that BC is the most frequent secondary tumour in young women treated for HD. The new RT modalities (lower doses and involved fields) may decrease the risk in the future. However, these women require a careful monitoring as from 8 to 10 years after HD treatment, combining mammography, ultrasound and MRI according to several ongoing studies. BC with whole breast irradiation is feasible in some selected cases.

Second conservative treatment for ipsilateral breast cancer recurrence using high-dose rate interstitial brachytherapy: preliminary clinical results and evaluation of patient satisfaction

PURPOSE

To assess early clinical results and evaluate patient satisfaction in case of second conservative treatment (2nd CT) combining lumpectomy plus high-dose rate (HDR) interstitial brachytherapy for patients (pts) presenting with ipsilateral breast cancer recurrence (IBCR).

METHODS AND MATERIALS

From June 2005 to July 2009, 42 pts presenting with an IBCR underwent a second lumpectomy with intraoperative implantation of plastic tubes in the tumor bed. After performing the dose distribution analysis on the postimplant CT scan, a total dose of 34 Gy in 10 fractions over 5 consecutive days was delivered. Toxicity evaluation was based on the Common Terminology Criteria for Adverse Events v3.0 criteria. Applying a visual analogic scale (VAS) analysis, patient satisfaction regarding cosmetic result and 2nd CT possibility was performed after the end of brachytherapy.

RESULTS

Median followup was 21 months (range, 6-50 months) and median age at the time of local recurrence was 65 years (range, 30-85 years). Median delay between primary and recurrence was 11 years (range, 1-35 years). Median recurrence tumor size was 12 mm (range, 2-30 mm). Median number of plastic tubes and planes were nine (range, 5-12) and two (range, 1-3), respectively. Median clinical target volume was 68 cc (range, 31.2-146 cc). Second local control rate was 97%. Twenty-two pts (60%) developed complications. Cutaneous and subcutaneous fibrosis was the most frequent side effect. Median VAS satisfaction score regarding cosmetic result was 7 of 10 (range, 4-9), whereas median VAS satisfaction score for 2nd CT was 10 of 10 (range, 8-10).

CONCLUSION

A 2nd CT for IBCR using high-dose rate brachytherapy seems feasible with encouraging results in terms of second local control with an acceptable toxicity. Patient satisfaction regarding the possibility of second breast preservation should be considered.