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Kolberg HC, Kolberg-Liedtke C. Who does not benefit from whole-breast radiotherapy and how to find them? Lancet Oncol 2024; 25:1110-1111. [PMID: 39127061 DOI: 10.1016/s1470-2045(24)00391-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2024] [Accepted: 07/08/2024] [Indexed: 08/12/2024]
Affiliation(s)
- Hans-Christian Kolberg
- Department of Gynecology and Obstetrics, Marienhospital Bottrop, 46236 Bottrop, Germany.
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2
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Speers C, Anderson B. Can Less Be More? Evolving Strategies for Therapy De-escalation in Early-Stage Breast Cancer. Int J Radiat Oncol Biol Phys 2024; 119:1327-1330. [PMID: 39038902 DOI: 10.1016/j.ijrobp.2024.03.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Accepted: 03/13/2024] [Indexed: 07/24/2024]
Affiliation(s)
- Corey Speers
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Cleveland, OH.
| | - Bethany Anderson
- Department of Radiation Oncology, University of Wisconsin Carbone Cancer Center, Madison, WI.
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3
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Rubini D, Gagliardi F, Menditti VS, D’Ambrosio L, Gallo P, D’Onofrio I, Pisani AR, Sardaro A, Rubini G, Cappabianca S, Nardone V, Reginelli A. Genetic profiling in radiotherapy: a comprehensive review. Front Oncol 2024; 14:1337815. [PMID: 39132508 PMCID: PMC11310144 DOI: 10.3389/fonc.2024.1337815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 07/11/2024] [Indexed: 08/13/2024] Open
Abstract
This comprehensive review explores the pivotal role of radiotherapy in cancer treatment, emphasizing the diverse applications of genetic profiling. The review highlights genetic markers for predicting radiation toxicity, enabling personalized treatment planning. It delves into the impact of genetic profiling on radiotherapy strategies across various cancer types, discussing research findings related to treatment response, prognosis, and therapeutic resistance. The integration of genetic profiling is shown to transform cancer treatment paradigms, offering insights into personalized radiotherapy regimens and guiding decisions in cases where standard protocols may fall short. Ultimately, the review underscores the potential of genetic profiling to enhance patient outcomes and advance precision medicine in oncology.
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Affiliation(s)
- Dino Rubini
- Department of Precision Medicine, University of Campania “L. Vanvitelli”, Naples, Italy
| | - Federico Gagliardi
- Department of Precision Medicine, University of Campania “L. Vanvitelli”, Naples, Italy
| | | | - Luca D’Ambrosio
- Department of Precision Medicine, University of Campania “L. Vanvitelli”, Naples, Italy
| | - Paolo Gallo
- Department of Precision Medicine, University of Campania “L. Vanvitelli”, Naples, Italy
| | - Ida D’Onofrio
- Department of Precision Medicine, University of Campania “L. Vanvitelli”, Naples, Italy
| | | | - Angela Sardaro
- Interdisciplinary Department of Medicine, University of Bari ‘Aldo Moro’, Bari, Italy
| | - Giuseppe Rubini
- Interdisciplinary Department of Medicine, University of Bari ‘Aldo Moro’, Bari, Italy
| | - Salvatore Cappabianca
- Department of Precision Medicine, University of Campania “L. Vanvitelli”, Naples, Italy
| | - Valerio Nardone
- Department of Precision Medicine, University of Campania “L. Vanvitelli”, Naples, Italy
| | - Alfonso Reginelli
- Department of Precision Medicine, University of Campania “L. Vanvitelli”, Naples, Italy
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4
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Cieslak AM, Sonnhoff MA. [Validation of the genomic profile for personalized breast cancer treatment: POLAR study]. Strahlenther Onkol 2024; 200:652-654. [PMID: 38743274 DOI: 10.1007/s00066-024-02243-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/06/2024] [Indexed: 05/16/2024]
Affiliation(s)
- Adrianna Monika Cieslak
- Klinik für Strahlentherapie und Radioonkologie, Universitätsklinikum Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland.
| | - Mathias Alexander Sonnhoff
- Klinik für Strahlentherapie und spezielle Onkologie, Medizinische Hochschule Hannover, Carl-Neuberg-Straße 1, 30625, Hannover, Deutschland.
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5
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Bleaney CW, Abdelaal H, Reardon M, Anandadas C, Hoskin P, Choudhury A, Forker L. Clinical Biomarkers of Tumour Radiosensitivity and Predicting Benefit from Radiotherapy: A Systematic Review. Cancers (Basel) 2024; 16:1942. [PMID: 38792019 PMCID: PMC11119069 DOI: 10.3390/cancers16101942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Revised: 04/18/2024] [Accepted: 05/16/2024] [Indexed: 05/26/2024] Open
Abstract
Modern advanced radiotherapy techniques have improved the precision and accuracy of radiotherapy delivery, with resulting plans being highly personalised based on individual anatomy. Adaptation for individual tumour biology remains elusive. There is an unmet need for biomarkers of intrinsic radiosensitivity that can predict tumour response to radiation to facilitate individualised decision-making, dosing and treatment planning. Over the last few decades, the use of high throughput molecular biology technologies has led to an explosion of newly discovered cancer biomarkers. Gene expression signatures are now used routinely in clinic to aid decision-making regarding adjuvant systemic therapy. They have great potential as radiotherapy biomarkers. A previous systematic review published in 2015 reported only five studies of signatures evaluated for their ability to predict radiotherapy benefits in clinical cohorts. This updated systematic review encompasses the expanded number of studies reported in the last decade. An additional 27 studies were identified. In total, 22 distinct signatures were recognised (5 pre-2015, 17 post-2015). Seventeen signatures were 'radiosensitivity' signatures and five were breast cancer prognostic signatures aiming to identify patients at an increased risk of local recurrence and therefore were more likely to benefit from adjuvant radiation. Most signatures (15/22) had not progressed beyond the discovery phase of development, with no suitable validated clinical-grade assay for application. Very few signatures (4/17 'radiosensitivity' signatures) had undergone any laboratory-based biological validation of their ability to predict tumour radiosensitivity. No signatures have been assessed prospectively in a phase III biomarker-led trial to date and none are recommended for routine use in clinical guidelines. A phase III prospective evaluation is ongoing for two breast cancer prognostic signatures. The most promising radiosensitivity signature remains the radiosensitivity index (RSI), which is used to calculate a genomic adjusted radiation dose (GARD). There is an ongoing phase II prospective biomarker-led study of RSI/GARD in triple negative breast cancer. The results of these trials are eagerly anticipated over the coming years. Future work in this area should focus on (1) robust biological validation; (2) building biobanks alongside large radiotherapy randomised controlled trials with dose variance (to demonstrate an interaction between radiosensitivity signature and dose); (3) a validation of clinical-grade cost-effective assays that are deliverable within current healthcare infrastructure; and (4) an integration with biomarkers of other determinants of radiation response.
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Affiliation(s)
- Christopher W. Bleaney
- Translational Radiobiology Group, Division of Cancer Sciences, The Oglesby Cancer Research Building, The University of Manchester, 555 Wilmslow Road, Manchester M20 4GJ, UK (L.F.)
- Department of Clinical Oncology, The Christie NHS Foundation Trust, 550 Wilmslow Road, Manchester M20 4BX, UK
| | - Hebatalla Abdelaal
- Department of Clinical Oncology, The Christie NHS Foundation Trust, 550 Wilmslow Road, Manchester M20 4BX, UK
| | - Mark Reardon
- Translational Radiobiology Group, Division of Cancer Sciences, The Oglesby Cancer Research Building, The University of Manchester, 555 Wilmslow Road, Manchester M20 4GJ, UK (L.F.)
| | - Carmel Anandadas
- Department of Clinical Oncology, The Christie NHS Foundation Trust, 550 Wilmslow Road, Manchester M20 4BX, UK
| | - Peter Hoskin
- Translational Radiobiology Group, Division of Cancer Sciences, The Oglesby Cancer Research Building, The University of Manchester, 555 Wilmslow Road, Manchester M20 4GJ, UK (L.F.)
- Department of Clinical Oncology, The Christie NHS Foundation Trust, 550 Wilmslow Road, Manchester M20 4BX, UK
| | - Ananya Choudhury
- Translational Radiobiology Group, Division of Cancer Sciences, The Oglesby Cancer Research Building, The University of Manchester, 555 Wilmslow Road, Manchester M20 4GJ, UK (L.F.)
- Department of Clinical Oncology, The Christie NHS Foundation Trust, 550 Wilmslow Road, Manchester M20 4BX, UK
| | - Laura Forker
- Translational Radiobiology Group, Division of Cancer Sciences, The Oglesby Cancer Research Building, The University of Manchester, 555 Wilmslow Road, Manchester M20 4GJ, UK (L.F.)
- Department of Clinical Oncology, The Christie NHS Foundation Trust, 550 Wilmslow Road, Manchester M20 4BX, UK
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6
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Meattini I, Kunkler IH. Omission of radiation therapy after breast conserving surgery for older women at low-risk of local recurrence: One option among many. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:108058. [PMID: 38428108 DOI: 10.1016/j.ejso.2024.108058] [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: 02/19/2024] [Accepted: 02/22/2024] [Indexed: 03/03/2024]
Abstract
This editorial discusses the evolving landscape of early-stage breast cancer treatment, emphasizing the need to tailor therapies based on disease biology and genomic approaches. The focus is on the reconsideration of postoperative radiation therapy (RT) for older patients with low-risk, hormone receptor-positive (HR+), human epidermal growth factor receptor 2 negative (HER2-) breast cancer. Recent trials show modest long-term local recurrence rates with the omission of RT after BCS in certain cases, challenging the traditional approach. The commentary calls for continued research on predictive tests for treatment response and advocates for a multidisciplinary approach to decision-making, considering factors like quality of life. The nuanced risk/benefit ratio of RT in older patients is explored, emphasizing the importance of comprehensive assessment for optimal therapy.
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Affiliation(s)
- Icro Meattini
- Department of Experimental and Clinical Biomedical Sciences "M Serio", University of Florence, Florence, Italy; Radiation Oncology & Breast Unit, Oncology Department, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy.
| | - Ian H Kunkler
- Edinburgh Cancer Research Centre, Institute of Genetic and Molecular Medicine, University of Edinburgh, Western General Hospital, Edinburgh, UK
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Haque W, Butler EB, Teh BS. Personalized Radiation Therapy for Breast Cancer. Curr Oncol 2024; 31:1588-1599. [PMID: 38534954 PMCID: PMC10969188 DOI: 10.3390/curroncol31030121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Revised: 03/08/2024] [Accepted: 03/18/2024] [Indexed: 05/26/2024] Open
Abstract
Breast cancer is diagnosed in nearly 3 million people worldwide. Radiation therapy is an integral component of disease management for patients with breast cancer, and is used after breast-conserving surgery or a mastectomy to reduce the risk of a local recurrence. The following review describes the methods used to personalize radiation therapy by optimizing patient selection, using advanced treatment techniques to lessen the radiation dose to normal organs, and using hypofractionation in order to shorten the duration of radiation treatment.
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Affiliation(s)
- Waqar Haque
- Department of Radiation Oncology, Houston Methodist Hospital, Houston, TX 77030, USA; (E.B.B.); (B.S.T.)
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8
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Kaidar-Person O, Tramm T, Kuehn T, Gentilini O, Prat A, Montay-Gruel P, Meattini I, Poortmans P. Optimising of axillary therapy in breast cancer: lessons from the past to plan for a better future. LA RADIOLOGIA MEDICA 2024; 129:315-327. [PMID: 37922004 DOI: 10.1007/s11547-023-01743-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 10/12/2023] [Indexed: 11/05/2023]
Abstract
In this narrative review, we aim to explore the ability of radiation therapy to eradicate breast cancer regional node metastasis. It is a journey through data of older trials without systemic therapy showing the magnitude of axillary therapy (surgery versus radiation) on cancer control. Considering that both systemic and loco-regional therapies were shown to reduce any recurrence with a complex interaction, our review includes surgical, radiation, and radiobiology consideration for breast cancer, and provide our view of future practise. The aim is to provide information optimise radiation therapy in the era of primary systemic therapy.
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Affiliation(s)
- Orit Kaidar-Person
- Breast Radiation Unit, Sheba Tel Hashomer, Ramat Gan, Israel.
- School of Medicine, Tel-Aviv University, Tel-Aviv, Israel.
- Department Radiation Oncology (Maastro), GROW-School for Oncology and Reproduction, Maastricht University Medical Centre+, Maastricht, The Netherlands.
| | - Trine Tramm
- Department of Pathology, Aarhus University Hospital, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | | | - Oreste Gentilini
- Breast Surgery, IRCCS Ospedale San Raffaele, Milano, Italy
- Università Vita-Salute San Raffaele, UniSR, Milano, Italy
| | - Aleix Prat
- University of Barcelona, Barcelona, Spain
- Cancer Insititute, IDIBAPS, Barcelona, Spain
| | | | - Icro Meattini
- Department of Experimental and Clinical Biomedical Sciences "M. Serio", University of Florence, Florence, Italy
- Radiation Oncology Unit, Oncology Department, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
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9
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Jagsi R, Griffith KA, Harris EE, Wright JL, Recht A, Taghian AG, Lee L, Moran MS, Small W, Johnstone C, Rahimi A, Freedman G, Muzaffar M, Haffty B, Horst K, Powell SN, Sharp J, Sabel M, Schott A, El-Tamer M. Omission of Radiotherapy After Breast-Conserving Surgery for Women With Breast Cancer With Low Clinical and Genomic Risk: 5-Year Outcomes of IDEA. J Clin Oncol 2024; 42:390-398. [PMID: 38060195 DOI: 10.1200/jco.23.02270] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 11/03/2023] [Indexed: 12/08/2023] Open
Abstract
PURPOSE Multiple studies have shown a low risk of ipsilateral breast events (IBEs) or other recurrences for selected patients age 65-70 years or older with stage I breast cancers treated with breast-conserving surgery (BCS) and endocrine therapy (ET) without adjuvant radiotherapy. We sought to evaluate whether younger postmenopausal patients could also be successfully treated without radiation therapy, adding a genomic assay to classic selection factors. METHODS Postmenopausal patients age 50-69 years with pT1N0 unifocal invasive breast cancer with margins ≥2 mm after BCS whose tumors were estrogen receptor-positive, progesterone receptor-positive, and human epidermal growth factor receptor 2-negative with Oncotype DX 21-gene recurrence score ≤18 were prospectively enrolled in a single-arm trial of radiotherapy omission if they consented to take at least 5 years of ET. The primary end point was the rate of locoregional recurrence 5 years after BCS. RESULTS Between June 2015 and October 2018, 200 eligible patients were enrolled. Among the 186 patients with clinical follow-up of at least 56 months, overall and breast cancer-specific survival rates at 5 years were both 100%. The 5-year freedom from any recurrence was 99% (95% CI, 96 to 100). Crude rates of IBEs for the entire follow-up period for patients age 50-59 years and age 60-69 years were 3.3% (2/60) and 3.6% (5/140), respectively; crude rates of overall recurrence were 5.0% (3/60) and 3.6% (5/140), respectively. CONCLUSION This trial achieved a very low risk of recurrence using a genomic assay in combination with classic clinical and biologic features for treatment selection, including postmenopausal patients younger than 60 years. Long-term follow-up of this trial and others will help determine whether the option of avoiding initial radiotherapy can be offered to a broader group of women than current guidelines recommend.
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Affiliation(s)
- Reshma Jagsi
- Emory University, Atlanta, GA
- University of Michigan, Ann Arbor, MI
| | | | | | | | - Abram Recht
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | | | | | | | | | | | - Asal Rahimi
- University of Texas, Southwestern, Dallas, TX
| | | | | | - Bruce Haffty
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ
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10
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Chua BH. Omission of radiation therapy post breast conserving surgery. Breast 2024; 73:103670. [PMID: 38211516 PMCID: PMC10788792 DOI: 10.1016/j.breast.2024.103670] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 12/24/2023] [Accepted: 01/04/2024] [Indexed: 01/13/2024] Open
Abstract
Radiation therapy (RT) after breast conserving surgery decreases the risks of local recurrence and breast cancer mortality in the multidisciplinary management of patients with breast cancer. However, breast cancer is a heterogeneous disease, and the absolute benefit of post-operative RT in individual patients varies substantially. Clinical trials aiming to identify patients with low-risk early breast cancer in whom post-operative RT may be safely omitted, based on conventional clinical-pathologic variables alone, have not provided sufficiently tailored information on local recurrence risk assessment to guide treatment decisions. The majority of patients with early breast cancer continue to be routinely treated with RT after breast conserving surgery. This approach may represent over-treatment for a substantial proportion of the patients. The clinical impact of genomic signatures on local therapy decisions for early breast cancer has been remarkably modest due to the lack of high-level evidence supporting their clinical validity for assessment of the risk of local recurrence. Efforts to personalise breast cancer care must be supported by high level evidence to enable balanced, informed treatment decisions. These considerations underpin the importance of ongoing biomarker-directed clinical trials to generate the high-level evidence necessary for setting the future standard of care in personalised local therapy for patients with early breast cancer.
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Affiliation(s)
- Boon H Chua
- Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia; Nelune Comprehensive Cancer Centre, Prince of Wales Hospital, Randwick, NSW, Australia.
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11
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Hadar M, Friger M, Ariad S, Koretz M, Delgado B, Tokar M, Bayme M, Agassi R, Rosenthal M, Dyomin V, Belochitski O, Amir N, Libson S, Meirovitz A, Lazarev I, Abu-Ghanem S, Geffen DB. Stage I Breast Cancer in the Modern Era: A Retrospective Cohort Study of 328 Patients Diagnosed from 2002 to 2006 with a 14-Year Median Follow-Up. Oncology 2024; 102:663-675. [PMID: 38185110 DOI: 10.1159/000536119] [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: 11/17/2023] [Accepted: 12/26/2023] [Indexed: 01/09/2024]
Abstract
INTRODUCTION This study aimed to evaluate the long-term outcomes of stage I breast cancer (BC) patients diagnosed during the current era of screening mammography, immunohistochemistry receptor testing, and systemic adjuvant therapy. METHODS A retrospective cohort study was conducted on 328 stage I BC patients treated consecutively in a single referral center with a follow-up period of at least 12 years. The primary endpoints were invasive disease-free survival (IDFS) and overall survival (OS). The influence of tumor size, grade, and subtype on the outcomes was analyzed. RESULTS Most patients were treated by lumpectomy, sentinel node biopsy, and adjuvant endocrine therapy, and most (82%) were of subtype luminal A. Adjuvant chemotherapy was administered to 25.6% of our cohort. Only 24 patients underwent gene expression testing, which was introduced toward the end of the study period. Mean IDFS was 14.64 years, with a 15-year IDFS of 75.6%. Mean OS was 15.28 years with a 15-year OS of 74.9%. In a Cox multivariate analysis, no clinical or pathologic variable impacted on OS and only tumor size (<1 cm vs. 1-2 cm) impacted significantly on IDFS. During follow-up, 20.1% of the cohort developed second primary cancers, including BC. The median time to diagnosis of a second BC was 6.49 years. CONCLUSION The study results emphasize the importance of long-term follow-up and screening for subsequent malignancies of patients with stage I BC and support the need for using prognostic and predictive indicators beyond the routine clinicopathological characteristics in luminal A patients.
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Affiliation(s)
- Maayan Hadar
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
- Department of Oncology, The Legacy Heritage Oncology Center and the Dr. Larry Norton Institute, Soroka University Medical Center, Beer Sheva, Israel
| | - Michael Friger
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
- Department of Epidemiology, Biostatistics and Community Health, Beer Sheva, Israel
| | - Samuel Ariad
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
- Department of Oncology, The Legacy Heritage Oncology Center and the Dr. Larry Norton Institute, Soroka University Medical Center, Beer Sheva, Israel
| | - Michael Koretz
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
- Division of Surgery and the Eshkol Breast Center, Soroka University Medical Center, Beer Sheva, Israel
| | - Bertha Delgado
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
- Department of Pathology, Soroka University Medical Center, Beer Sheva, Israel
| | - Margarita Tokar
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
- Department of Oncology, The Legacy Heritage Oncology Center and the Dr. Larry Norton Institute, Soroka University Medical Center, Beer Sheva, Israel
| | - Michael Bayme
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
- Division of Surgery and the Eshkol Breast Center, Soroka University Medical Center, Beer Sheva, Israel
| | - Ravit Agassi
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
- Division of Surgery and the Eshkol Breast Center, Soroka University Medical Center, Beer Sheva, Israel
| | - Maia Rosenthal
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
- Department of Imaging and the Eshkol Breast Center, Soroka University Medical Center, Beer Sheva, Israel
| | - Victor Dyomin
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
- Department of Pathology, Soroka University Medical Center, Beer Sheva, Israel
| | - Olga Belochitski
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
- Department of Oncology, The Legacy Heritage Oncology Center and the Dr. Larry Norton Institute, Soroka University Medical Center, Beer Sheva, Israel
| | - Noa Amir
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
- Department of Oncology, The Legacy Heritage Oncology Center and the Dr. Larry Norton Institute, Soroka University Medical Center, Beer Sheva, Israel
| | - Shai Libson
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
- Division of Surgery and the Eshkol Breast Center, Soroka University Medical Center, Beer Sheva, Israel
| | - Amichay Meirovitz
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
- Department of Oncology, The Legacy Heritage Oncology Center and the Dr. Larry Norton Institute, Soroka University Medical Center, Beer Sheva, Israel
| | - Irena Lazarev
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
- Department of Oncology, The Legacy Heritage Oncology Center and the Dr. Larry Norton Institute, Soroka University Medical Center, Beer Sheva, Israel
| | - Sara Abu-Ghanem
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
- Department of Oncology, The Legacy Heritage Oncology Center and the Dr. Larry Norton Institute, Soroka University Medical Center, Beer Sheva, Israel
| | - David B Geffen
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
- Department of Oncology, The Legacy Heritage Oncology Center and the Dr. Larry Norton Institute, Soroka University Medical Center, Beer Sheva, Israel
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12
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Zaborowski AM, Doogan K, Clifford S, Dowling G, Kazi F, Delaney K, Yadav H, Brady A, Geraghty J, Evoy D, Rothwell J, McCartan D, Heeney A, Barry M, Walsh SM, Stokes M, Kell MR, Allen M, Power C, Hill ADK, Connolly E, Alazawi D, Boyle T, Corrigan M, O’Leary P, Prichard RS. Nodal positivity in patients with clinically and radiologically node-negative breast cancer treated with neoadjuvant chemotherapy: multicentre collaborative study. Br J Surg 2024; 111:znad401. [PMID: 38055888 PMCID: PMC10763529 DOI: 10.1093/bjs/znad401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 10/06/2023] [Accepted: 11/05/2023] [Indexed: 12/08/2023]
Abstract
BACKGROUND The necessity of performing a sentinel lymph node biopsy in patients with clinically and radiologically node-negative breast cancer after neoadjuvant chemotherapy has been questioned. The aim of this study was to determine the rate of nodal positivity in these patients and to identify clinicopathological features associated with lymph node metastasis after neoadjuvant chemotherapy (ypN+). METHODS A retrospective multicentre study was performed. Patients with cT1-3 cN0 breast cancer who underwent sentinel lymph node biopsy after neoadjuvant chemotherapy between 2016 and 2021 were included. Negative nodal status was defined as the absence of palpable lymph nodes, and the absence of suspicious nodes on axillary ultrasonography, or the absence of tumour cells on axillary nodal fine needle aspiration or core biopsy. RESULTS A total of 371 patients were analysed. Overall, 47 patients (12.7%) had a positive sentinel lymph node biopsy. Nodal positivity was identified in 22 patients (29.0%) with hormone receptor+/human epidermal growth factor receptor 2- tumours, 12 patients (13.8%) with hormone receptor+/human epidermal growth factor receptor 2+ tumours, 3 patients (5.6%) with hormone receptor-/human epidermal growth factor receptor 2+ tumours, and 10 patients (6.5%) with triple-negative breast cancer. Multivariable logistic regression analysis showed that multicentric disease was associated with a higher likelihood of ypN+ (OR 2.66, 95% c.i. 1.18 to 6.01; P = 0.018), whilst a radiological complete response in the breast was associated with a reduced likelihood of ypN+ (OR 0.10, 95% c.i. 0.02 to 0.42; P = 0.002), regardless of molecular subtype. Only 3% of patients who had a radiological complete response in the breast were ypN+. The majority of patients (85%) with a positive sentinel node proceeded to axillary lymph node dissection and 93% had N1 disease. CONCLUSION The rate of sentinel lymph node positivity in patients who achieve a radiological complete response in the breast is exceptionally low for all molecular subtypes.
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Affiliation(s)
| | - Katie Doogan
- Department of Breast Surgery, St Vincent’s University Hospital, Dublin, Ireland
| | - Siobhan Clifford
- Department of Breast Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Gavin Dowling
- Department of Breast Surgery, Beaumont Hospital, Dublin, Ireland
| | - Farah Kazi
- Department of Breast Surgery, St James’s Hospital, Dublin, Ireland
| | - Karina Delaney
- Department of Breast Surgery, St James’s Hospital, Dublin, Ireland
| | - Himanshu Yadav
- Cork Breast Research Centre, Cork University Hospital, Cork, Ireland
| | - Aaron Brady
- Department of Breast Surgery, Bon Secours Hospital Cork, Cork, Ireland
| | - James Geraghty
- Department of Breast Surgery, St Vincent’s University Hospital, Dublin, Ireland
| | - Denis Evoy
- Department of Breast Surgery, St Vincent’s University Hospital, Dublin, Ireland
| | - Jane Rothwell
- Department of Breast Surgery, St Vincent’s University Hospital, Dublin, Ireland
| | - Damian McCartan
- Department of Breast Surgery, St Vincent’s University Hospital, Dublin, Ireland
| | - Anna Heeney
- Department of Breast Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Mitchel Barry
- Department of Breast Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Siun M Walsh
- Department of Breast Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Maurice Stokes
- Department of Breast Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Malcolm R Kell
- Department of Breast Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Michael Allen
- Department of Breast Surgery, Beaumont Hospital, Dublin, Ireland
| | - Colm Power
- Department of Breast Surgery, Beaumont Hospital, Dublin, Ireland
| | - Arnold D K Hill
- Department of Breast Surgery, Beaumont Hospital, Dublin, Ireland
| | | | - Dhafir Alazawi
- Department of Breast Surgery, St James’s Hospital, Dublin, Ireland
| | - Terence Boyle
- Department of Breast Surgery, St James’s Hospital, Dublin, Ireland
| | - Mark Corrigan
- Cork Breast Research Centre, Cork University Hospital, Cork, Ireland
| | - Peter O’Leary
- Department of Breast Surgery, Bon Secours Hospital Cork, Cork, Ireland
| | - Ruth S Prichard
- Department of Breast Surgery, St Vincent’s University Hospital, Dublin, Ireland
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13
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Demircan NV, Bese N. New Approaches in Breast Cancer Radiotherapy. Eur J Breast Health 2024; 20:1-7. [PMID: 38187103 PMCID: PMC10765469 DOI: 10.4274/ejbh.galenos.2023.2023-11-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 11/27/2023] [Indexed: 01/09/2024]
Abstract
Breast cancer stands as the most prevalent malignancy, necessitating a well-established approach to its management due to its sustained prevalence over decades. The implementation of intensive treatments, combining various modalities, has yielded excellent survival outcomes. Consequently, the optimization of quality of life and the mitigation of long-term side effects emerge as critical considerations for clinicians. As a result, discussions regarding treatment de-intensification strategies have been initiated for all treatment modalities, including surgery, radiotherapy (RT), and chemotherapy. RT plays a crucial role in adjuvant therapy. The efficacy of RT in disease control and overall survival across all stages of breast cancer has been demonstrated in numerous clinical trials and meta-analyses utilizing extensive datasets. However, advancements in genetic tumor profiling and improved identification of disease subgroups have prompted a reevaluation of RT omission in low-risk groups as a strategy for treatment de-intensification. Conversely, technological improvements and shortened total treatment times with hypofractionation make RT a secure and feasible option for enhancing local control and survival with minimal impact on the quality of life.
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Affiliation(s)
| | - Nuran Bese
- MAA Acıbadem University Research Institute of Senology, İstanbul, Turkey
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14
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Reznitsky FM, Jensen JD, Knoop A, Jensen MB, Laenkholm AV. Evaluation of tumor-infiltrating lymphocytes, PD-L1, and PIK3CA mutations and association with prognosis in HER2-positive early stage breast cancer. Acta Oncol 2023; 62:1913-1920. [PMID: 37961947 DOI: 10.1080/0284186x.2023.2279685] [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: 08/19/2023] [Accepted: 10/31/2023] [Indexed: 11/15/2023]
Abstract
BACKGROUND Tumor-infiltrating lymphocytes (TILs) have predictive and prognostic potential in HER2-positive breast cancer (HER2+ BC). Programmed death-ligand 1 (PD-L1) is an immune checkpoint protein, with important roles in the tumor microenvironment, possibly in both tumor and immune cells (ICs), providing rationale for targeting with immune-checkpoint therapy. PIK3CA mutations are oncogenic, activating mutations, which are also of relevance in breast cancer. Herein, we investigate the frequency of TILs, PD-L1 and PIK3CA mutations, and whether these factors influence outcome, in early HER2+ BC. MATERIALS AND METHODS Stromal TILs (sTILs) and PD-L1 expressions were assessed using full tumor-sections and TMA, respectively, from 236 patients with HER2+ BC. TILs were assessed, according to a standardized method, as continuous measurement and according to three predefined categories: low (0-10%), intermediate (11-59%), and high (60-100%). PD-L1 immunohistochemistry (Ventana SP263) was evaluated and positivity defined as ≥1% expression in tumor and ICs. PIK3CA mutations (exons 9 and 20) were determined by pyrosequencing. RESULTS Fourteen percent of patients had high sTILs and 25% had a PIK3CA mutation. PD-L1 expression was more frequent in ICs (68%) than tumor cells (24%). Patients with low sTILs had a significantly worse overall survival (multivariate: HR 2.80; 95% CI 1.36-5.78; p = .02). DISCUSSION Patients with low sTILs had a significantly poorer survival, despite adequate treatment with adjuvant therapy.
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Affiliation(s)
- Frances M Reznitsky
- Department of Surgical Pathology, Zealand University Hospital, Roskilde, Denmark
- Department of Pathology, Herlev and Gentofte Hospital, Herlev, Denmark
| | | | - Ann Knoop
- Department of Oncology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Maj-Britt Jensen
- Danish Breast Cancer Group, Copenhagen University Hospital, Copenhagen, Denmark
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15
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Tam A, Mercier BD, Thomas RM, Tizpa E, Wong IG, Shi J, Garg R, Hampel H, Gray SW, Williams T, Bazan JG, Li YR. Moving the Needle Forward in Genomically-Guided Precision Radiation Treatment. Cancers (Basel) 2023; 15:5314. [PMID: 38001574 PMCID: PMC10669735 DOI: 10.3390/cancers15225314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 10/06/2023] [Accepted: 10/13/2023] [Indexed: 11/26/2023] Open
Abstract
Radiation treatment (RT) is a mainstay treatment for many types of cancer. Recommendations for RT and the radiation plan are individualized to each patient, taking into consideration the patient's tumor pathology, staging, anatomy, and other clinical characteristics. Information on germline mutations and somatic tumor mutations is at present rarely used to guide specific clinical decisions in RT. Many genes, such as ATM, and BRCA1/2, have been identified in the laboratory to confer radiation sensitivity. However, our understanding of the clinical significance of mutations in these genes remains limited and, as individual mutations in such genes can be rare, their impact on tumor response and toxicity remains unclear. Current guidelines, including those from the National Comprehensive Cancer Network (NCCN), provide limited guidance on how genetic results should be integrated into RT recommendations. With an increasing understanding of the molecular underpinning of radiation response, genomically-guided RT can inform decisions surrounding RT dose, volume, concurrent therapies, and even omission to further improve oncologic outcomes and reduce risks of toxicities. Here, we review existing evidence from laboratory, pre-clinical, and clinical studies with regard to how genetic alterations may affect radiosensitivity. We also summarize recent data from clinical trials and explore potential future directions to utilize genetic data to support clinical decision-making in developing a pathway toward personalized RT.
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Affiliation(s)
- Andrew Tam
- Department of Radiation Oncology, City of Hope Comprehensive Cancer Center, 1500 E Duarte Rd., Duarte, CA 91010, USA; (A.T.); (B.D.M.); (R.M.T.); (E.T.); (I.G.W.); (J.S.); (R.G.); (T.W.)
| | - Benjamin D. Mercier
- Department of Radiation Oncology, City of Hope Comprehensive Cancer Center, 1500 E Duarte Rd., Duarte, CA 91010, USA; (A.T.); (B.D.M.); (R.M.T.); (E.T.); (I.G.W.); (J.S.); (R.G.); (T.W.)
- Department of Medical Oncology & Therapeutics Research, City of Hope Comprehensive Cancer Center, 1500 E Duarte Rd., Duarte, CA 91010, USA; (H.H.); (S.W.G.)
| | - Reeny M. Thomas
- Department of Radiation Oncology, City of Hope Comprehensive Cancer Center, 1500 E Duarte Rd., Duarte, CA 91010, USA; (A.T.); (B.D.M.); (R.M.T.); (E.T.); (I.G.W.); (J.S.); (R.G.); (T.W.)
| | - Eemon Tizpa
- Department of Radiation Oncology, City of Hope Comprehensive Cancer Center, 1500 E Duarte Rd., Duarte, CA 91010, USA; (A.T.); (B.D.M.); (R.M.T.); (E.T.); (I.G.W.); (J.S.); (R.G.); (T.W.)
| | - Irene G. Wong
- Department of Radiation Oncology, City of Hope Comprehensive Cancer Center, 1500 E Duarte Rd., Duarte, CA 91010, USA; (A.T.); (B.D.M.); (R.M.T.); (E.T.); (I.G.W.); (J.S.); (R.G.); (T.W.)
| | - Juncong Shi
- Department of Radiation Oncology, City of Hope Comprehensive Cancer Center, 1500 E Duarte Rd., Duarte, CA 91010, USA; (A.T.); (B.D.M.); (R.M.T.); (E.T.); (I.G.W.); (J.S.); (R.G.); (T.W.)
| | - Rishabh Garg
- Department of Radiation Oncology, City of Hope Comprehensive Cancer Center, 1500 E Duarte Rd., Duarte, CA 91010, USA; (A.T.); (B.D.M.); (R.M.T.); (E.T.); (I.G.W.); (J.S.); (R.G.); (T.W.)
| | - Heather Hampel
- Department of Medical Oncology & Therapeutics Research, City of Hope Comprehensive Cancer Center, 1500 E Duarte Rd., Duarte, CA 91010, USA; (H.H.); (S.W.G.)
| | - Stacy W. Gray
- Department of Medical Oncology & Therapeutics Research, City of Hope Comprehensive Cancer Center, 1500 E Duarte Rd., Duarte, CA 91010, USA; (H.H.); (S.W.G.)
| | - Terence Williams
- Department of Radiation Oncology, City of Hope Comprehensive Cancer Center, 1500 E Duarte Rd., Duarte, CA 91010, USA; (A.T.); (B.D.M.); (R.M.T.); (E.T.); (I.G.W.); (J.S.); (R.G.); (T.W.)
| | - Jose G. Bazan
- Department of Radiation Oncology, City of Hope Comprehensive Cancer Center, 1500 E Duarte Rd., Duarte, CA 91010, USA; (A.T.); (B.D.M.); (R.M.T.); (E.T.); (I.G.W.); (J.S.); (R.G.); (T.W.)
| | - Yun R. Li
- Department of Radiation Oncology, City of Hope Comprehensive Cancer Center, 1500 E Duarte Rd., Duarte, CA 91010, USA; (A.T.); (B.D.M.); (R.M.T.); (E.T.); (I.G.W.); (J.S.); (R.G.); (T.W.)
- Department of Cancer Genetics and Epigenetics, City of Hope National Medical Center, Duarte, CA 91010, USA
- Division of Quantitative Medicine & Systems Biology, Translational Genomics Research Institute, 445 N. Fifth Street, Phoenix, AZ 85022, USA
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16
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Machiels M, Oulkadi R, Tramm T, Stecklein SR, Somaiah N, De Caluwé A, Klein J, Tran WT, Salgado R. Individualising radiation therapy decisions in breast cancer patients based on tumour infiltrating lymphocytes and genomic biomarkers. Breast 2023; 71:13-21. [PMID: 37437386 PMCID: PMC10512095 DOI: 10.1016/j.breast.2023.06.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 06/12/2023] [Accepted: 06/27/2023] [Indexed: 07/14/2023] Open
Abstract
Radiation therapy (RT) has long been fundamental for the curative treatment of breast cancer. While substantial progress has been made in the anatomical and technological precision of RT delivery, and some approaches to de-escalate or omit RT based on clinicopathologic features have been successful, there remain substantial opportunities to refine individualised RT based on tumour biology. A major area of clinical and research interest is to ascertain the individualised risk of loco-regional recurrence to direct treatment decisions regarding escalation and de-escalation of RT. Patient-tailored treatment with RT is considerably lagging behind compared with the massive progress made in the field of personalised medicine that currently mainly applies to decisions on the use of systemic therapy or targeted agents. Herein we review select literature surrounding the use of tumour genomic biomarkers and biomarkers of the immune system, including tumour infiltrating lymphocytes (TILs), within the management of breast cancer, specifically as they relate to progress in moving toward analytically validated and clinically tested biomarkers utilized in RT.
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Affiliation(s)
- Melanie Machiels
- Department of Radiation Oncology, Iridium Netwerk, University of Antwerp, Health & Sciences, Antwerp, Belgium.
| | - Redouane Oulkadi
- Department of Radiation Oncology, Iridium Netwerk, University of Antwerp, Health & Sciences, Antwerp, Belgium
| | - Trine Tramm
- Department of Pathology, Aarhus University Hospital, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Shane R Stecklein
- Departments of Radiation Oncology, Pathology & Laboratory Medicine, And Cancer Biology, The University of Kansas Medical Center, KS, USA
| | - Navita Somaiah
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, Breast Unit, The Royal Marsden NHS Foundation Trust, UK
| | - Alex De Caluwé
- Université Libre de Bruxelles (ULB), Hôpitaux Universitaires de Bruxelles (H.U.B), Institut Jules Bordet, Brussels, Belgium
| | - Jonathan Klein
- State University of New York (SUNY) Downstate Health Sciences University and Maimonides Medical Center, NY, United States
| | - William T Tran
- Department of Radiation Oncology, University of Toronto & Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Roberto Salgado
- Division of Research, Peter MacCallum Cancer Centre, Melbourne, Australia; Department of Pathology, GZA - ZNA Hospitals, Antwerp, Belgium
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17
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Alkner S, de Boniface J, Lundstedt D, Mjaaland I, Ryden L, Vikstrom J, Bendahl PO, Holmberg E, Sackey H, Wieslander E, Karlsson P. Protocol for the T-REX-trial: tailored regional external beam radiotherapy in clinically node-negative breast cancer patients with 1-2 sentinel node macrometastases - an open, multicentre, randomised non-inferiority phase 3 trial. BMJ Open 2023; 13:e075543. [PMID: 37751948 PMCID: PMC10533703 DOI: 10.1136/bmjopen-2023-075543] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 09/07/2023] [Indexed: 09/30/2023] Open
Abstract
INTRODUCTION Modern systemic treatment has reduced incidence of regional recurrences and improved survival in breast cancer (BC). It is thus questionable whether regional radiotherapy (RT) is still beneficial in patients with sentinel lymph node (SLN) macrometastasis. Postoperative regional RT is associated with an increased risk of arm morbidity, pneumonitis, cardiac disease and secondary cancer. Therefore, there is a need to individualise regional RT in relation to the risk of recurrence. METHODS AND ANALYSIS In this multicentre, prospective randomised trial, clinically node-negative patients with oestrogen receptor-positive, HER2-negative BC and 1-2 SLN macrometastases are eligible. Participants are randomly assigned to receive regional RT (standard arm) or not (intervention arm). Regional RT includes the axilla level I-III, the supraclavicular fossa and in selected patients the internal mammary nodes. Both groups receive RT to the remaining breast. Chest-wall RT after mastectomy is given in the standard arm, but in the intervention arm only in cases of widespread multifocality according to national guidelines. RT quality assurance is an integral part of the trial.The trial aims to include 1350 patients between March 2023 and December 2028 in Sweden and Norway. Primary outcome is recurrence-free survival (RFS) at 5 years. Non-inferiority will be declared if outcome in the de-escalation arm is not >4.5 percentage units below that with regional RT, corresponding to an HR of 1.41 assuming 88% 5-year RFS with standard treatment. Secondary outcomes include locoregional recurrence, overall survival, patient-reported arm morbidity and health-related quality of life. Gene expression analysis and tumour tissue-based studies to identify prognostic and predictive markers for benefit of regional RT are included. ETHICS AND DISSEMINATION The trial protocol is approved by the Swedish Ethics Authority (Dnr-2022-02178-01, 2022-05093-02, 2023-00826-02, 2023-03035-02). Results will be presented at scientific conferences and in peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT05634889.
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Affiliation(s)
- Sara Alkner
- Department of Oncology, Institute of Clinical Sciences, Lund University Faculty of Medicine, Lund, Sweden
- Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital Lund, Lund, Sweden
| | - Jana de Boniface
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
- Department of Surgery, Capio St Göran's Hospital, Stockholm, Sweden
| | - Dan Lundstedt
- Department of Oncology, Institute of Clinical Sciences, University of Gothenburg Sahlgrenska Academy, Göteborg, Sweden
| | - Ingvil Mjaaland
- Department of Radiotherapy, Stavanger University Hospital, Stavanger, Norway
| | - Lisa Ryden
- Department of Oncology, Institute of Clinical Sciences, Lund University Faculty of Medicine, Lund, Sweden
| | - Johan Vikstrom
- Department of Radiotherapy, Stavanger University Hospital, Stavanger, Norway
| | - Pär-Ola Bendahl
- Department of Oncology, Institute of Clinical Sciences, Lund University Faculty of Medicine, Lund, Sweden
| | - Erik Holmberg
- Department of Oncology, Institute of Clinical Sciences, University of Gothenburg Sahlgrenska Academy, Göteborg, Sweden
| | - Helena Sackey
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
- Department of Breast, Endocrine Tumors and Sarcoma, Karolinska University Hospital, Stockholm, Sweden
| | - Elinore Wieslander
- Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital Lund, Lund, Sweden
| | - Per Karlsson
- Department of Oncology, Institute of Clinical Sciences, University of Gothenburg Sahlgrenska Academy, Göteborg, Sweden
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18
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Narayanan S, Rao R. To Radiate or Not to Radiate After Breast-Conserving Surgery-Endocrine Therapy is the Question. Ann Surg Oncol 2023; 30:5309-5311. [PMID: 37219655 DOI: 10.1245/s10434-023-13665-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 05/08/2023] [Indexed: 05/24/2023]
Affiliation(s)
- Sumana Narayanan
- Division of Surgical Oncology at Mount Sinai Medical Center, Columbia University, Miami Beach, FL, USA
| | - Roshni Rao
- Department of Surgery, Columbia University Medical Center, New York, NY, USA.
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19
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Haussmann J, Budach W, Corradini S, Krug D, Bölke E, Tamaskovics B, Jazmati D, Haussmann A, Matuschek C. Whole Breast Irradiation in Comparison to Endocrine Therapy in Early Stage Breast Cancer-A Direct and Network Meta-Analysis of Published Randomized Trials. Cancers (Basel) 2023; 15:4343. [PMID: 37686620 PMCID: PMC10487067 DOI: 10.3390/cancers15174343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 08/09/2023] [Accepted: 08/15/2023] [Indexed: 09/10/2023] Open
Abstract
BACKGROUND Multiple randomized trials have established adjuvant endocrine therapy (ET) and whole breast irradiation (WBI) as the standard approach after breast-conserving surgery (BCS) in early-stage breast cancer. The omission of WBI has been studied in multiple trials and resulted in reduced local control with maintained survival rates and has therefore been adapted as a treatment option in selected patients in several guidelines. Omitting ET instead of WBI might also be a valuable option as both treatments have distinctly different side effect profiles. However, the clinical outcomes of BCS + ET vs. BCS + WBI have not been formally analyzed. METHODS We performed a systematic literature review searching for randomized trials comparing BCS + ET vs. BCS + WBI in low-risk breast cancer patients with publication dates after 2000. We excluded trials using any form of chemotherapy, regional nodal radiation and mastectomy. The meta-analysis was performed using a two-step process. First, we extracted all available published event rates and the effect sizes for overall and breast-cancer-specific survival (OS, BCSS), local (LR) and regional recurrence, disease-free survival, distant metastases-free interval, contralateral breast cancer, second cancer other than breast cancer and mastectomy-free interval as investigated endpoints and compared them in a network meta-analysis. Second, the published individual patient data from the Early Breast Cancer Trialists' Collaborative Group (EBCTCG) publications were used to allow a comparison of OS and BCSS. RESULTS We identified three studies, including a direct comparison of BCS + ET vs. BCS + WBI (n = 1059) and nine studies randomizing overall 7207 patients additionally to BCS only and BCS + WBI + ET resulting in a four-arm comparison. In the network analysis, LR was significantly lower in the BCS + WBI group in comparison with the BCS + ET group (HR = 0.62; CI-95%: 0.42-0.92; p = 0.019). We did not find any differences in OS (HR = 0.93; CI-95%: 0.53-1.62; p = 0.785) and BCSS (OR = 1.04; CI-95%: 0.45-2.41; p = 0.928). Further, we found a lower distant metastasis-free interval, a higher rate of contralateral breast cancer and a reduced mastectomy-free interval in the BCS + WBI-arm. Using the EBCTCG data, OS and BCSS were not significantly different between BCS + ET and BCS + WBI after 10 years (OS: OR = 0.85; CI-95%: 0.59-1.22; p = 0.369) (BCSS: OR = 0.72; CI-95%: 0.38-1.36; p = 0.305). CONCLUSION Evidence from direct and indirect comparison suggests that BCS + WBI might be an equivalent de-escalation strategy to BCS + ET in low-risk breast cancer. Adverse events and quality of life measures have to be further compared between these approaches.
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Affiliation(s)
- Jan Haussmann
- Department of Radiation Oncology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University, 40225 Düsseldorf, Germany; (J.H.); (W.B.); (B.T.); (D.J.); (C.M.)
| | - Wilfried Budach
- Department of Radiation Oncology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University, 40225 Düsseldorf, Germany; (J.H.); (W.B.); (B.T.); (D.J.); (C.M.)
| | - Stefanie Corradini
- Department of Radiation Oncology, University Hospital, Ludwig-Maximilians-University (LMU), 81377 Munich, Germany;
| | - David Krug
- Department of Radiation Oncology, University Hospital Schleswig-Holstein, 24105 Kiel, Germany;
| | - Edwin Bölke
- Department of Radiation Oncology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University, 40225 Düsseldorf, Germany; (J.H.); (W.B.); (B.T.); (D.J.); (C.M.)
| | - Balint Tamaskovics
- Department of Radiation Oncology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University, 40225 Düsseldorf, Germany; (J.H.); (W.B.); (B.T.); (D.J.); (C.M.)
| | - Danny Jazmati
- Department of Radiation Oncology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University, 40225 Düsseldorf, Germany; (J.H.); (W.B.); (B.T.); (D.J.); (C.M.)
| | - Alexander Haussmann
- Division of Physical Activity, Prevention and Cancer, German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany;
| | - Christiane Matuschek
- Department of Radiation Oncology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University, 40225 Düsseldorf, Germany; (J.H.); (W.B.); (B.T.); (D.J.); (C.M.)
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20
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Lavasani S, Healy E, Kansal K. Locoregional Treatment for Early-Stage Breast Cancer: Current Status and Future Perspectives. Curr Oncol 2023; 30:7520-7531. [PMID: 37623026 PMCID: PMC10453608 DOI: 10.3390/curroncol30080545] [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: 05/26/2023] [Revised: 08/08/2023] [Accepted: 08/09/2023] [Indexed: 08/26/2023] Open
Abstract
BACKGROUND The locoregional recurrence of breast cancer has been reduced due to the multidisciplinary approach of breast surgery, systemic therapy and radiation. Early detection and better surgical techniques contribute to an improvement in breast cancer outcomes. PURPOSE OF REVIEW The purpose of this review is to have an overview and summary of the current evidence behind the current approaches to the locoregional treatment of breast cancer and to discuss its future direction. SUMMARY With improved surgical techniques and the use of a more effective neoadjuvant systemic therapy, including checkpoint inhibitors and dual HER2-directed therapies that lead to a higher frequency of pathologic complete responses and advances in adjuvant radiation therapy, breast cancer patients are experiencing better locoregional control and reduced local and systemic recurrence. De-escalation in surgery has not only improved the quality of life in the majority of breast cancer patients, but also maintained the low risk of recurrence. There are ongoing clinical trials to optimize radiation therapy in breast cancer. More modern radiation technologies are evolving to improve the patient outcome and reduce radiation toxicities.
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Affiliation(s)
- Sayeh Lavasani
- Division of Hematology and Medical Oncology, UC Irvine, Orange, CA 92868, USA
| | - Erin Healy
- Department of Radiation Oncology, UC Irvine, Orange, CA 92868, USA
| | - Kari Kansal
- Division of Breast Surgery, UC Irvine, Orange, CA 92868, USA
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21
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Nardone V, Meirson T, De Felice F, Meattini I. Genomic Profiling: Can We Rely on Retrospective Analysis to Drive Changes in Clinical Practice? J Clin Oncol 2023; 41:3957-3958. [PMID: 37279433 DOI: 10.1200/jco.23.00334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Accepted: 03/31/2023] [Indexed: 06/08/2023] Open
Affiliation(s)
- Valerio Nardone
- Valerio Nardone, MD, Department of Precision Oncology, University Hospital of Campania "L. Vanvitelli," Naples, Italy; Tomer Meirson, MD, Davidoff Cancer Center, Rabin Medical Center-Beilinson Hospital, Petah Tikva, Israel; Francesca De Felice, MD, Department of Radiotherapy, Policlinico Umberto I "Sapienza," University of Rome, Rome, Italy; and Icro Meattini, MD, Department of Experimental and Clinical Biomedical Sciences "M. Serio," University of Florence, Florence, Italy
| | - Tomer Meirson
- Valerio Nardone, MD, Department of Precision Oncology, University Hospital of Campania "L. Vanvitelli," Naples, Italy; Tomer Meirson, MD, Davidoff Cancer Center, Rabin Medical Center-Beilinson Hospital, Petah Tikva, Israel; Francesca De Felice, MD, Department of Radiotherapy, Policlinico Umberto I "Sapienza," University of Rome, Rome, Italy; and Icro Meattini, MD, Department of Experimental and Clinical Biomedical Sciences "M. Serio," University of Florence, Florence, Italy
| | - Francesca De Felice
- Valerio Nardone, MD, Department of Precision Oncology, University Hospital of Campania "L. Vanvitelli," Naples, Italy; Tomer Meirson, MD, Davidoff Cancer Center, Rabin Medical Center-Beilinson Hospital, Petah Tikva, Israel; Francesca De Felice, MD, Department of Radiotherapy, Policlinico Umberto I "Sapienza," University of Rome, Rome, Italy; and Icro Meattini, MD, Department of Experimental and Clinical Biomedical Sciences "M. Serio," University of Florence, Florence, Italy
| | - Icro Meattini
- Valerio Nardone, MD, Department of Precision Oncology, University Hospital of Campania "L. Vanvitelli," Naples, Italy; Tomer Meirson, MD, Davidoff Cancer Center, Rabin Medical Center-Beilinson Hospital, Petah Tikva, Israel; Francesca De Felice, MD, Department of Radiotherapy, Policlinico Umberto I "Sapienza," University of Rome, Rome, Italy; and Icro Meattini, MD, Department of Experimental and Clinical Biomedical Sciences "M. Serio," University of Florence, Florence, Italy
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22
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Sjöström M, Fyles A, Liu FF, McCready D, Feng FY, Speers CW, Pierce LJ, Holmberg E, Fernö M, Malmström P, Karlsson P. Reply to V. Nardone et al. J Clin Oncol 2023; 41:3959-3960. [PMID: 37279434 DOI: 10.1200/jco.23.00566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 03/24/2023] [Indexed: 06/08/2023] Open
Affiliation(s)
- Martin Sjöström
- Martin Sjöström, PhD, Division of Oncology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden; Anthony Fyles, MD; Fei-Fei Liu, MD; and David McCready, MD, Princess Margaret Cancer Centre and University of Toronto, Toronto, Ontario, Canada; Felix Y. Feng, MD, Department of Radiation Oncology, University of California San Francisco, San Francisco, CA; Corey W. Speers, MD, PhD and Lori J. Pierce, MD, Department of Radiation Oncology, University of Michigan, Ann Arbor, MI; Erik Holmberg, PhD, Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Mårten Fernö, PhD, Division of Oncology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden; Per Malmström, MD, PhD, Division of Oncology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden, Department of Haematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden; and Per Karlsson, MD, PhD, Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Anthony Fyles
- Martin Sjöström, PhD, Division of Oncology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden; Anthony Fyles, MD; Fei-Fei Liu, MD; and David McCready, MD, Princess Margaret Cancer Centre and University of Toronto, Toronto, Ontario, Canada; Felix Y. Feng, MD, Department of Radiation Oncology, University of California San Francisco, San Francisco, CA; Corey W. Speers, MD, PhD and Lori J. Pierce, MD, Department of Radiation Oncology, University of Michigan, Ann Arbor, MI; Erik Holmberg, PhD, Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Mårten Fernö, PhD, Division of Oncology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden; Per Malmström, MD, PhD, Division of Oncology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden, Department of Haematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden; and Per Karlsson, MD, PhD, Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Fei-Fei Liu
- Martin Sjöström, PhD, Division of Oncology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden; Anthony Fyles, MD; Fei-Fei Liu, MD; and David McCready, MD, Princess Margaret Cancer Centre and University of Toronto, Toronto, Ontario, Canada; Felix Y. Feng, MD, Department of Radiation Oncology, University of California San Francisco, San Francisco, CA; Corey W. Speers, MD, PhD and Lori J. Pierce, MD, Department of Radiation Oncology, University of Michigan, Ann Arbor, MI; Erik Holmberg, PhD, Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Mårten Fernö, PhD, Division of Oncology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden; Per Malmström, MD, PhD, Division of Oncology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden, Department of Haematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden; and Per Karlsson, MD, PhD, Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - David McCready
- Martin Sjöström, PhD, Division of Oncology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden; Anthony Fyles, MD; Fei-Fei Liu, MD; and David McCready, MD, Princess Margaret Cancer Centre and University of Toronto, Toronto, Ontario, Canada; Felix Y. Feng, MD, Department of Radiation Oncology, University of California San Francisco, San Francisco, CA; Corey W. Speers, MD, PhD and Lori J. Pierce, MD, Department of Radiation Oncology, University of Michigan, Ann Arbor, MI; Erik Holmberg, PhD, Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Mårten Fernö, PhD, Division of Oncology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden; Per Malmström, MD, PhD, Division of Oncology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden, Department of Haematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden; and Per Karlsson, MD, PhD, Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Felix Y Feng
- Martin Sjöström, PhD, Division of Oncology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden; Anthony Fyles, MD; Fei-Fei Liu, MD; and David McCready, MD, Princess Margaret Cancer Centre and University of Toronto, Toronto, Ontario, Canada; Felix Y. Feng, MD, Department of Radiation Oncology, University of California San Francisco, San Francisco, CA; Corey W. Speers, MD, PhD and Lori J. Pierce, MD, Department of Radiation Oncology, University of Michigan, Ann Arbor, MI; Erik Holmberg, PhD, Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Mårten Fernö, PhD, Division of Oncology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden; Per Malmström, MD, PhD, Division of Oncology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden, Department of Haematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden; and Per Karlsson, MD, PhD, Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Corey W Speers
- Martin Sjöström, PhD, Division of Oncology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden; Anthony Fyles, MD; Fei-Fei Liu, MD; and David McCready, MD, Princess Margaret Cancer Centre and University of Toronto, Toronto, Ontario, Canada; Felix Y. Feng, MD, Department of Radiation Oncology, University of California San Francisco, San Francisco, CA; Corey W. Speers, MD, PhD and Lori J. Pierce, MD, Department of Radiation Oncology, University of Michigan, Ann Arbor, MI; Erik Holmberg, PhD, Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Mårten Fernö, PhD, Division of Oncology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden; Per Malmström, MD, PhD, Division of Oncology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden, Department of Haematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden; and Per Karlsson, MD, PhD, Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Lori J Pierce
- Martin Sjöström, PhD, Division of Oncology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden; Anthony Fyles, MD; Fei-Fei Liu, MD; and David McCready, MD, Princess Margaret Cancer Centre and University of Toronto, Toronto, Ontario, Canada; Felix Y. Feng, MD, Department of Radiation Oncology, University of California San Francisco, San Francisco, CA; Corey W. Speers, MD, PhD and Lori J. Pierce, MD, Department of Radiation Oncology, University of Michigan, Ann Arbor, MI; Erik Holmberg, PhD, Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Mårten Fernö, PhD, Division of Oncology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden; Per Malmström, MD, PhD, Division of Oncology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden, Department of Haematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden; and Per Karlsson, MD, PhD, Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Erik Holmberg
- Martin Sjöström, PhD, Division of Oncology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden; Anthony Fyles, MD; Fei-Fei Liu, MD; and David McCready, MD, Princess Margaret Cancer Centre and University of Toronto, Toronto, Ontario, Canada; Felix Y. Feng, MD, Department of Radiation Oncology, University of California San Francisco, San Francisco, CA; Corey W. Speers, MD, PhD and Lori J. Pierce, MD, Department of Radiation Oncology, University of Michigan, Ann Arbor, MI; Erik Holmberg, PhD, Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Mårten Fernö, PhD, Division of Oncology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden; Per Malmström, MD, PhD, Division of Oncology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden, Department of Haematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden; and Per Karlsson, MD, PhD, Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Mårten Fernö
- Martin Sjöström, PhD, Division of Oncology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden; Anthony Fyles, MD; Fei-Fei Liu, MD; and David McCready, MD, Princess Margaret Cancer Centre and University of Toronto, Toronto, Ontario, Canada; Felix Y. Feng, MD, Department of Radiation Oncology, University of California San Francisco, San Francisco, CA; Corey W. Speers, MD, PhD and Lori J. Pierce, MD, Department of Radiation Oncology, University of Michigan, Ann Arbor, MI; Erik Holmberg, PhD, Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Mårten Fernö, PhD, Division of Oncology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden; Per Malmström, MD, PhD, Division of Oncology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden, Department of Haematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden; and Per Karlsson, MD, PhD, Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Per Malmström
- Martin Sjöström, PhD, Division of Oncology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden; Anthony Fyles, MD; Fei-Fei Liu, MD; and David McCready, MD, Princess Margaret Cancer Centre and University of Toronto, Toronto, Ontario, Canada; Felix Y. Feng, MD, Department of Radiation Oncology, University of California San Francisco, San Francisco, CA; Corey W. Speers, MD, PhD and Lori J. Pierce, MD, Department of Radiation Oncology, University of Michigan, Ann Arbor, MI; Erik Holmberg, PhD, Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Mårten Fernö, PhD, Division of Oncology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden; Per Malmström, MD, PhD, Division of Oncology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden, Department of Haematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden; and Per Karlsson, MD, PhD, Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Per Karlsson
- Martin Sjöström, PhD, Division of Oncology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden; Anthony Fyles, MD; Fei-Fei Liu, MD; and David McCready, MD, Princess Margaret Cancer Centre and University of Toronto, Toronto, Ontario, Canada; Felix Y. Feng, MD, Department of Radiation Oncology, University of California San Francisco, San Francisco, CA; Corey W. Speers, MD, PhD and Lori J. Pierce, MD, Department of Radiation Oncology, University of Michigan, Ann Arbor, MI; Erik Holmberg, PhD, Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Mårten Fernö, PhD, Division of Oncology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden; Per Malmström, MD, PhD, Division of Oncology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden, Department of Haematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden; and Per Karlsson, MD, PhD, Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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23
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Speers CW, Barlow WE, Symmans WF. Reply to Y. Wang et al and Q. Sui et al. J Clin Oncol 2023; 41:3763-3764. [PMID: 37262407 PMCID: PMC10351949 DOI: 10.1200/jco.23.00722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 04/03/2023] [Indexed: 06/03/2023] Open
Affiliation(s)
- Corey W. Speers
- Corey W. Speers, MD, PhD, University Hospitals Seidman Cancer Center and Case Western Reserve Medical School, Cleveland, OH; William E. Barlow, PhD, SWOG Statistics and Data Management Center, Seattle, WA; and W. Fraser Symmans, MD, University of Texas MD Anderson Cancer Center, Houston, TX
| | - William E. Barlow
- Corey W. Speers, MD, PhD, University Hospitals Seidman Cancer Center and Case Western Reserve Medical School, Cleveland, OH; William E. Barlow, PhD, SWOG Statistics and Data Management Center, Seattle, WA; and W. Fraser Symmans, MD, University of Texas MD Anderson Cancer Center, Houston, TX
| | - W. Fraser Symmans
- Corey W. Speers, MD, PhD, University Hospitals Seidman Cancer Center and Case Western Reserve Medical School, Cleveland, OH; William E. Barlow, PhD, SWOG Statistics and Data Management Center, Seattle, WA; and W. Fraser Symmans, MD, University of Texas MD Anderson Cancer Center, Houston, TX
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Stenmark Tullberg A, Sjöström M, Tran L, Niméus E, Killander F, Kovács A, Lundstedt D, Holmberg E, Karlsson P. Combining histological grade, TILs, and the PD-1/PD-L1 pathway to identify immunogenic tumors and de-escalate radiotherapy in early breast cancer: a secondary analysis of a randomized clinical trial. J Immunother Cancer 2023; 11:e006618. [PMID: 37208129 PMCID: PMC10201214 DOI: 10.1136/jitc-2022-006618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/17/2023] [Indexed: 05/21/2023] Open
Abstract
BACKGROUND The implementation of immunological biomarkers for radiotherapy (RT) individualization in breast cancer requires consideration of tumor-intrinsic factors. This study aimed to investigate whether the integration of histological grade, tumor-infiltrating lymphocytes (TILs), programmed cell death protein-1 (PD-1), and programmed death ligand-1 (PD-L1) can identify tumors with aggressive characteristics that can be downgraded regarding the need for RT. METHODS The SweBCG91RT trial included 1178 patients with stage I-IIA breast cancer, randomized to breast-conserving surgery with or without adjuvant RT, and followed for a median time of 15.2 years. Immunohistochemical analyses of TILs, PD-1, and PD-L1 were performed. An activated immune response was defined as stromal TILs ≥10% and PD-1 and/or PD-L1 expression in ≥1% of lymphocytes. Tumors were categorized as high-risk or low-risk using assessments of histological grade and proliferation as measured by gene expression. The risk of ipsilateral breast tumor recurrence (IBTR) and benefit of RT were then analyzed with 10 years follow-up based on the integration of immune activation and tumor-intrinsic risk group. RESULTS Among high-risk tumors, an activated immune infiltrate was associated with a reduced risk of IBTR (HR 0.34, 95% CI 0.16 to 0.73, p=0.006). The incidence of IBTR in this group was 12.1% (5.6-25.0) without RT and 4.4% (1.1-16.3) with RT. In contrast, the incidence of IBTR in the high-risk group without an activated immune infiltrate was 29.6% (21.4-40.2) without RT and 12.8% (6.6-23.9) with RT. Among low-risk tumors, no evidence of a favorable prognostic effect of an activated immune infiltrate was seen (HR 2.0, 95% CI 0.87 to 4.6, p=0.100). CONCLUSIONS Integrating histological grade and immunological biomarkers can identify tumors with aggressive characteristics but a low risk of IBTR despite a lack of RT boost and systemic therapy. Among high-risk tumors, the risk reduction of IBTR conferred by an activated immune infiltrate is comparable to treatment with RT. These findings may apply to cohorts dominated by estrogen receptor-positive tumors.
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Affiliation(s)
- Axel Stenmark Tullberg
- Department of Oncology, University of Gothenburg Institute of Clinical Sciences, Goteborg, Sweden
| | - Martin Sjöström
- Department of Radiation Oncology, UCSF, San Francisco, California, USA
- Department of Clinical Sciences Lund, Oncology/Pathology and Surgery, Lund University, Lund, Sweden
| | - Lena Tran
- Department of Clinical Sciences Lund, Oncology/Pathology and Surgery, Lund University, Lund, Sweden
| | - Emma Niméus
- Department of Clinical Sciences Lund, Oncology/Pathology and Surgery, Lund University, Lund, Sweden
- Department of Surgery, Skåne University Hospital, Lund, Sweden
| | - Fredrika Killander
- Department of Clinical Sciences Lund, Oncology/Pathology and Surgery, Lund University, Lund, Sweden
- Department of Oncology, Skåne University Hospital, Lund, Sweden
| | - Anikó Kovács
- Department of Clinical Pathology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Dan Lundstedt
- Department of Oncology, University of Gothenburg Institute of Clinical Sciences, Goteborg, Sweden
| | - Erik Holmberg
- Department of Oncology, University of Gothenburg Institute of Clinical Sciences, Goteborg, Sweden
| | - Per Karlsson
- Department of Oncology, University of Gothenburg Institute of Clinical Sciences, Goteborg, Sweden
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Dover L, Dulaney C. PROshot: Mepitel Film, Daily Versus Twice-Daily Radiation Therapy for Small Cell Lung Cancer, POLAR, Decipher, and Patterns of Failure After Magnetic Resonance Imaging-Guided Brachytherapy for Cervical Cancer. Pract Radiat Oncol 2023; 13:167-171. [PMID: 37080639 DOI: 10.1016/j.prro.2023.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 02/21/2023] [Indexed: 04/22/2023]
Affiliation(s)
- Laura Dover
- Department of Radiation Oncology, Ascension St. Vincent's East, Birmingham, Alabama.
| | - Caleb Dulaney
- Department of Radiation Oncology, Anderson Regional Health System, Meridian, Mississippi
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Recent Advances in Optimizing Radiation Therapy Decisions in Early Invasive Breast Cancer. Cancers (Basel) 2023; 15:cancers15041260. [PMID: 36831598 PMCID: PMC9954587 DOI: 10.3390/cancers15041260] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 02/07/2023] [Accepted: 02/10/2023] [Indexed: 02/18/2023] Open
Abstract
Adjuvant whole breast irradiation after breast-conserving surgery is a well-established treatment standard for early invasive breast cancer. Screening, early diagnosis, refinement in surgical techniques, the knowledge of new and specific molecular prognostic factors, and now the standard use of more effective neo/adjuvant systemic therapies have proven instrumental in reducing the rates of locoregional relapses. This underscores the need for reliably identifying women with such low-risk disease burdens in whom elimination of radiation from the treatment plan would not compromise oncological safety. This review summarizes the current evidence for radiation de-intensification strategies and details ongoing prospective clinical trials investigating the omission of adjuvant whole breast irradiation in molecularly defined low-risk breast cancers and related evidence supporting the potential for radiation de-escalation in HER2+ and triple-negative clinical subtypes. Furthermore, we discuss the current evidence for the de-escalation of regional nodal irradiation after neoadjuvant chemotherapy. Finally, we also detail the current knowledge of the clinical value of stromal tumor-infiltrating lymphocytes and liquid-based biomarkers as prognostic factors for locoregional relapse.
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