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He J, Chen S, Xu R. ASO Author Reflections: A More Effective Radiotherapy Modality for Early Breast Cancer: Intraoperative Radiotherapy as a Tumour Bed Boost Combined with Whole Breast Irradiation. Ann Surg Oncol 2023; 30:8453-8454. [PMID: 37540328 DOI: 10.1245/s10434-023-14057-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 07/18/2023] [Indexed: 08/05/2023]
Affiliation(s)
- Jiafa He
- Breast Department, Guangdong Provincial Hospital of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangdong Provincial Academy of Chinese Medical Sciences, Guangzhou, Guangdong, China
| | - Shengying Chen
- Breast Department, Guangdong Provincial Hospital of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangdong Provincial Academy of Chinese Medical Sciences, Guangzhou, Guangdong, China
| | - Rui Xu
- Breast Department, Guangdong Provincial Hospital of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangdong Provincial Academy of Chinese Medical Sciences, Guangzhou, Guangdong, China.
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He J, Chen S, Ye L, Sun Y, Dai Y, Song X, Lin X, Xu R. Intraoperative Radiotherapy as a Tumour-Bed Boost Combined with Whole Breast Irradiation Versus Conventional Radiotherapy in Patients with Early-Stage Breast Cancer: A Systematic Review and Meta-analysis. Ann Surg Oncol 2023; 30:8436-8452. [PMID: 37507556 PMCID: PMC10625949 DOI: 10.1245/s10434-023-13955-w] [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: 03/28/2023] [Accepted: 07/06/2023] [Indexed: 07/30/2023]
Abstract
BACKGROUND There is no definitive answer regarding the efficacy of intraoperative radiotherapy (IORT) as a tumour bed boost for patients with early-stage breast cancer. The purpose of this meta-analysis was to summarise the available evidence and explore the efficacy and safety of IORT combined with whole breast irradiation (WBI) versus conventional radiotherapy in women with early-stage breast cancer who underwent breast-conserving surgery. METHODS The PUBMED, MEDLINE, EMBASE, Web of Science, and Cochrane Library databases were searched from inception to December 31, 2022. We collected studies on the efficacy, cosmetic outcome, and safety of IORT boost combined with WBI compared with those of conventional radiotherapy in patients with early-stage breast cancer after breast-conserving surgery. Two authors independently performed the literature selection and data extraction. The quality of the randomised, controlled trials (RCTs) was assessed according to the PEDro scale. The quality of non-RCTs was assessed according to the Methodological Index for Non-Randomised Studies. Risk ratios (RRs) for the local recurrence rate (LRR), distant metastasis rate (DMR), disease-free survival (DFS), cosmetic outcome, and toxicity were pooled using fixed or random effects models. Meta-analysis of the included studies was performed by using RevMan 5.3 software. RESULTS Nine studies, including one RCT and eight non-RCTs, with a total of 3219 patients were included. In terms of LRR, there was no significant benefit of IORT boost+WBI over conventional radiotherapy (with or without the tumour bed boost) (RR = 0.77, 95% confidence interval (CI): 0.54-1.09, P = 0.14), but a trend towards benefit could be identified. There was a significant reduction in DMR in the IORT boost+WBI group (RR = 0.63, 95% CI: 0.46-0.85, P = 0.003) and a significant improvement in DFS (RR = 0.40, 95% CI: 0.25-0.65, P = 0.0002). Exploratory subgroup analysis showed that the DMR and DFS of the electron boost group were significantly better than those of conventional radiotherapy group, and there was a tendency for LRR to improve in the electron boost group. However, the LRR, DMR, and DFS did not effectively improve in the x-ray boost group. In terms of appearance and toxicity, there were no significant differences in cosmetic outcome, fibrosis, and hyperpigmentation between the two groups (RR = 0.99, 95% CI: 0.91-1.07, P = 0.78; RR = 1.02, 95% CI: 0.41-2.56, P = 0.96; RR = 0.42, 95% CI: 0.10-1.72, P = 0.23), but the incidence of oedema was significantly reduced in the IORT boost+WBI group (RR = 0.27, 95% CI: 0.13-0.59, P = 0.0009). CONCLUSIONS IORT boost+WBI is more effective than conventional radiotherapy after breast-conserving surgery in patients with early-stage breast cancer, and electron boost exhibits better efficacy than x-ray boost. In addition, the cosmetic and safety profiles of IORT boost+WBI are not inferior to those of conventional radiotherapy.
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Affiliation(s)
- Jiafa He
- Breast Department, Guangdong Provincial Hospital of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangdong Provincial Academy of Chinese Medical Sciences, Guangzhou, Guangdong, China
| | - Shengying Chen
- Breast Department, Guangdong Provincial Hospital of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangdong Provincial Academy of Chinese Medical Sciences, Guangzhou, Guangdong, China
| | - Lingling Ye
- Breast Department, Guangdong Provincial Hospital of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangdong Provincial Academy of Chinese Medical Sciences, Guangzhou, Guangdong, China
| | - Yang Sun
- Breast Department, Guangdong Provincial Hospital of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangdong Provincial Academy of Chinese Medical Sciences, Guangzhou, Guangdong, China
| | - Yan Dai
- Breast Department, Guangdong Provincial Hospital of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangdong Provincial Academy of Chinese Medical Sciences, Guangzhou, Guangdong, China
| | - Xue Song
- Breast Department, Guangdong Provincial Hospital of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangdong Provincial Academy of Chinese Medical Sciences, Guangzhou, Guangdong, China
| | - Xiaojie Lin
- Breast Department, Guangdong Provincial Hospital of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangdong Provincial Academy of Chinese Medical Sciences, Guangzhou, Guangdong, China
| | - Rui Xu
- Breast Department, Guangdong Provincial Hospital of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangdong Provincial Academy of Chinese Medical Sciences, Guangzhou, Guangdong, China.
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Sarria GR, Ramos ML, Palacios A, Del Castillo R, Castro F, Calvo A, Cotrina JM, Heredia A, Galarreta JA, Fuentes-Rivera P, Avalos A, Martinez DA, Colqui K, Ziegler G, Schmeel LC, Pinillos LV, Wenz F, Giordano FA, Sarria GJ, Sperk E. Long-Term Outcomes of an International Cooperative Study of Intraoperative Radiotherapy Upfront Boost With Low Energy X-Rays in Breast Cancer. Front Oncol 2022; 12:850351. [PMID: 35371998 PMCID: PMC8968081 DOI: 10.3389/fonc.2022.850351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 02/18/2022] [Indexed: 11/16/2022] Open
Abstract
Purpose The purpose of this study was to assess the effectivity of upfront kilovoltage intraoperative radiotherapy (IORT) as a boost in high-risk early-stage breast cancer patients from an international pooled cohort. Materials/Methods Patients from four centers in three different countries were retrospectively screened. Those with a minimum 1-year follow-up were included. Cumulative local (LR), regional (RR), and distant metastasis rates (DM) were analyzed. Additionally, the estimated overall survival (OS) was assessed. The Cox regression analysis was performed to identify failure predicting factors. Results A total of 653 patients from centers in Peru, Spain, and Germany were included. The median follow-up was 55 (12–180) months, and age was 58 (27–86) years. Clinical tumor (T) staging was T1 65.85%, T2 30.17%, and T3 3.98%. Positive margins were found in 7.9% and in-situ component in 20.06%. The median IORT dose was 20 (6–20). The median time from IORT to EBRT was 74.5 (13-364) days. An overall 3.4% (n = 22) of patients developed local recurrence at some point during follow-up. The 12-, 60-, and 120-month cumulative LR were 0.3%, 2.3%, and 7.9%, respectively. After multivariate analysis, only age <50 remained to be a significant prognostic factor for local recurrence (HR 0.19, 95% CI 0.08–0.47; p < 0.05). The 10-year estimated OS was 81.2%. Conclusion Upfront boost with IORT yields similar local control outcomes to those EBRT-based reports. Results from prospective trials, regarding toxicity, cosmesis, and effectivity are awaited to confirm these findings.
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Affiliation(s)
- Gustavo R Sarria
- Department of Radiation Oncology, University Hospital Bonn, University of Bonn, Bonn, Germany
| | - Maria L Ramos
- Department of Mastology, Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru
| | - Amalia Palacios
- Department of Radiation Oncology, University Hospital Reina Sofia, Cordoba, Spain
| | | | - Felipe Castro
- Department of Radiotherapy, Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru
| | - Angel Calvo
- Department of Radiation Oncology, University Hospital Reina Sofia, Cordoba, Spain
| | - Jose M Cotrina
- Department of Mastology, Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru
| | - Adela Heredia
- Department of Radiotherapy, Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru
| | - Jose A Galarreta
- Department of Mastology, Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru
| | - Paola Fuentes-Rivera
- Department of Radiotherapy, Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru
| | - Alicia Avalos
- Department of Radiotherapy, Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru
| | | | - Kevin Colqui
- Department of Radiation Oncology, Oncosalud-Auna, Lima, Peru
| | - Gonzalo Ziegler
- Department of Mastology, Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru
| | | | - Luis V Pinillos
- Department of Radiation Oncology, Oncosalud-Auna, Lima, Peru
| | - Frederik Wenz
- University Hospital Freiburg, University of Freiburg, Freiburg, Germany
| | - Frank A Giordano
- Department of Radiation Oncology, University Hospital Bonn, University of Bonn, Bonn, Germany
| | - Gustavo J Sarria
- Department of Radiation Oncology, Oncosalud-Auna, Lima, Peru.,Department of Radiotherapy, Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru
| | - Elena Sperk
- Department of Radiation Oncology, Mannheim Cancer Center, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
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Leonardi MC, Kouloura A, Rojas DP, Zaffaroni M, Intra M, Veronesi P, Morra A, Gerardi MA, Fodor CI, Zerella MA, Camarda AM, Cattani F, Luraschi R, Viola A, Riva G, Miglietta E, Orecchia R, Dicuonzo S, Jereczek-Fossa BA. The POLO (Partially Omitted Lobe) approach to safely treat in-breast recurrence after intraoperative radiotherapy with electrons. Br J Radiol 2021; 95:20210405. [PMID: 34919420 DOI: 10.1259/bjr.20210405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVES The aim of this study is to evaluate feasibility of salvage 4-week hypofractionated whole breast radiotherapy (WBRT) in patients with in-breast recurrence after receiving intraoperative radiotherapy with electrons (IOERT) for primary breast cancer (BC). METHODS BC patients who had repeated quadrantectomy underwent modified WBRT with intensity-modulated radiotherapy using Helical Tomotherapy to underdose the IOERT region. This approach, called POLO (Partially Omitted Lobe), excluded the IOERT volume from receiving the full prescription dose. RESULTS Nine patients were treated with this approach, receiving 45 Gy in 20 fractions. A simultaneous integrated boost of 2.5 Gy in 20 fractions was delivered in 6/9 patients. Dose constraints and planning objectives were reported. No severe toxicity was reported while local control and overall survival were 100%. CONCLUSION The POLO approach is technically feasible and capable to achieve a significant reduction of radiation dose delivered to the previous treated IOERT area. ADVANCES IN KNOWLEDGE The study demonstrates the technical and dosimetric feasibility of conservative salvage whole breast radiotherapy, while sparing the area already treated with IORT, in patients with in-breast recurrence.
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Affiliation(s)
| | - Andriana Kouloura
- Division of Breast Surgery, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | | | - Mattia Zaffaroni
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Mattia Intra
- Division of Breast Surgery, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Paolo Veronesi
- Division of Breast Surgery, IEO, European Institute of Oncology IRCCS, Milan, Italy.,Department of Oncology and Hemato-oncology, University of Milan, Milan, Italy
| | - Anna Morra
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | | | | | - Maria Alessia Zerella
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Anna Maria Camarda
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, Milan, Italy.,Department of Oncology and Hemato-oncology, University of Milan, Milan, Italy
| | - Federica Cattani
- Unit of Medical Physics, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Rosa Luraschi
- Unit of Medical Physics, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Anna Viola
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, Milan, Italy.,Department of Oncology and Hemato-oncology, University of Milan, Milan, Italy
| | - Giulia Riva
- Clinical Department, National Center for Oncological Hadrontherapy (CNAO), Pavia, Italy
| | - Eleonora Miglietta
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Roberto Orecchia
- Scientific Direction, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Samantha Dicuonzo
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Barbara Alicja Jereczek-Fossa
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, Milan, Italy.,Department of Oncology and Hemato-oncology, University of Milan, Milan, Italy
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Wang L, Sun M, Yang S, Chen Y, Li T. Intraoperative Radiotherapy Is Not a Better Alternative to Whole Breast Radiotherapy as a Therapeutic Option for Early-Stage Breast Cancer. Front Oncol 2021; 11:737982. [PMID: 34976796 PMCID: PMC8716392 DOI: 10.3389/fonc.2021.737982] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 11/23/2021] [Indexed: 12/11/2022] Open
Abstract
Objective Intraoperative radiotherapy (IORT) in early-stage breast cancer has been studied over the years. However, it has not been demonstrated whether IORT is more suitable as a therapeutic option for early-stage breast cancer than whole breast radiotherapy (WBRT). Therefore, we performed a meta-analysis to compare the efficacy and safety of IORT to those of WBRT as therapeutic options for early-stage breast cancer patients receiving breast-conserving surgery (INPLASY2020120008). Methods PubMed, Embase, and Cochrane Library databases were searched from inception to October 2021. Computerized and manual searches were adopted to identify eligible randomized control trials from online databases. Risk ratio (RR) and 95% confidence intervals (CI) were calculated by random-effect models to assess the relative risk. Potential publication bias was quantified by Begg’s and Egger’s tests. Results Based on our inclusion criteria, 10 randomized control trials involving 5,698 patients were included in this meta-analysis. This meta-analysis showed that the IORT group was associated with a higher local recurrence risk (RR = 2.111, 95% CI, 1.130–3.943, p = 0.0191), especially in the long-term follow-up subgroup or published after 2020 subgroup or Caucasian subgroup (RR = 2.404, 95% CI, 1.183–4.885, p = 0.0154). Subgroup analysis showed that the IORT group had a higher recurrence risk than the WBRT group in the polycentric randomized controlled trial subgroup (RR = 1.213, 95% CI, 1.030–1.428, p = 0.0204). Pooled analysis showed that there was no statistically significant difference in overall survival, recurrence-free survival, distant metastasis-free survival, and cancer-specific survival between IORT and WBRT groups. Additionally, the risk of skin toxicity was reduced, but the incidences of fat toxicity, edema, and scar calcification were significantly increased in the patients who underwent IORT in comparison to those who underwent WBRT. Conclusion This meta-analysis revealed that IORT was not a better alternative to WBRT. More large-scale and well-designed clinical trials with longer follow-up periods are encouraged to further investigate the value of IORT. Systematic Review Registration https://inplasy.com/inplasy-2020-12-0008/.
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Affiliation(s)
- Linwei Wang
- Department of Radiation and Medical Oncology, Hubei Key Laboratory of Tumor Biological Behaviors/Hubei Cancer Clinical Study Center, Zhongnan Hospital, Wuhan University, Wuhan, China
| | - Min Sun
- Department of General Surgery, Taihe Hospital, Hubei University of Medicine, Shiyan, China
| | - Shuailong Yang
- Department of Radiation and Medical Oncology, The Central Hospital of Wuhan, Wuhan, China
| | - Yuanyuan Chen
- Department of Radiation and Medical Oncology, Hubei Key Laboratory of Tumor Biological Behaviors/Hubei Cancer Clinical Study Center, Zhongnan Hospital, Wuhan University, Wuhan, China
- *Correspondence: Tian Li, ; Yuanyuan Chen,
| | - Tian Li
- School of Basic Medicine, Fourth Military Medical University, Xi’an, China
- *Correspondence: Tian Li, ; Yuanyuan Chen,
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Leatherman J, Nicholas C, Cusick T, Cooke E, Ablah E, Okut H, Hunt D. Intra-operative Radiation Therapy versus Whole Breast External Beam Radiotherapy: A Comparison of Patient-Reported Outcomes. Kans J Med 2021; 14:170-175. [PMID: 34262637 PMCID: PMC8274810 DOI: 10.17161/kjm.vol1415147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 04/07/2021] [Indexed: 11/20/2022] Open
Abstract
Introduction This project sought to compare patient-reported outcomes between patients who received intra-operative radiation therapy (IORT) and those who qualified for IORT but received whole-breast external beam radiation therapy (EBRT) following breast-conserving surgery (BCS). Methods Three scales from the BREAST-Q Breast Cancer BCT Module Version 2.0 questionnaire were used to collect patient-reported outcomes regarding post-operative physical well-being of the chest, post-operative satisfaction with breast cosmesis, and post-operative adverse effects of radiation. Results Patients who received EBRT travelled farther on average than patients who received IORT to complete treatment. Respondents who received IORT reported better physical well-being of the chest than those who received EBRT. Regression revealed that the respondent’s age was the determining factor in the difference between IORT and EBRT post-operative physical well-being scores, where younger patients report poorer well-being. There was no difference in patient-reported outcomes regarding post-operative satisfaction with breast cosmesis or adverse effects of radiation. Conclusions Patients who received IORT reported better physical well-being of the chest than patients who received EBRT. There appeared to be a relationship between age and physical well-being of chest. This study suggested that there was no difference in patient-reported outcomes concerning post-operative satisfaction with breast cosmesis or post-operative adverse effects of radiation between patients who received IORT and those who received EBRT.
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Affiliation(s)
- Jo Leatherman
- University of Kansas School of Medicine-Wichita, Wichita, KS
| | - Christina Nicholas
- University of Kansas School of Medicine-Wichita, Wichita, KS.,Department of Surgery
| | - Therese Cusick
- University of Kansas School of Medicine-Wichita, Wichita, KS.,Department of Surgery
| | - Ellen Cooke
- University of Kansas School of Medicine-Wichita, Wichita, KS.,Department of Radiology
| | - Elizabeth Ablah
- University of Kansas School of Medicine-Wichita, Wichita, KS.,Department of Population Health
| | - Hayrettin Okut
- University of Kansas School of Medicine-Wichita, Wichita, KS.,Department of Population Health.,Office of Research
| | - Diane Hunt
- University of Kansas School of Medicine-Wichita, Wichita, KS.,Department of Surgery
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Health-related quality of life of early-stage breast cancer patients after different radiotherapy regimens. Breast Cancer Res Treat 2021; 189:387-398. [PMID: 34216316 PMCID: PMC8357747 DOI: 10.1007/s10549-021-06314-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 06/22/2021] [Indexed: 02/08/2023]
Abstract
Purpose To evaluate and compare health-related quality of life (HRQL) of women with early-stage breast cancer (BC) treated with different radiotherapy (RT) regimens. Methods Data were collected from five prospective cohorts of BC patients treated with breast-conserving surgery and different RT regimens: intraoperative RT (IORT, 1 × 23.3 Gy; n = 267), external beam accelerated partial breast irradiation (EB-APBI, 10 × 3.85 Gy; n = 206), hypofractionated whole breast irradiation(hypo-WBI, 16 × 2.67 Gy; n = 375), hypo-WBI + boost(hypo-WBI-B, 21–26 × 2.67 Gy; n = 189), and simultaneous WBI + boost(WBI-B, 28 × 2.3 Gy; n = 475). Women ≥ 60 years with invasive/in situ carcinoma ≤ 30 mm, cN0 and pN0-1a were included. Validated EORTC QLQ-C30/BR23 questionnaires were used to asses HRQL. Multivariable linear regression models adjusted for confounding (age, comorbidity, pT, locoregional treatment, systemic therapy) were used to compare the impact of the RT regimens on HRQL at 12 and 24 months. Differences in HRQL over time (3–24 months) were evaluated using linear mixed models. Results There were no significant differences in HRQL at 12 months between groups except for breast symptoms which were better after IORT and EB-APBI compared to hypo-WBI at 12 months (p < 0.001). Over time, breast symptoms, fatigue, global health status and role functioning were significantly better after IORT and EB-APBI than hypo-WBI. At 24 months, HRQL was comparable in all groups. Conclusion In women with early-stage breast cancer, the radiotherapy regimen did not substantially influence long-term HRQL with the exception of breast symptoms. Breast symptoms are more common after WBI than after IORT or EB-APBI and improve slowly until no significant difference remains at 2 years posttreatment. Supplementary Information The online version contains supplementary material available at 10.1007/s10549-021-06314-4.
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Guillerm SO, Bourstyn E, Itti R, Cahen-Doidy L, Quéro L, Labidi M, Marchand E, Lorphelin H, Giacchetti S, Cuvier C, Espié M, Teixeira L, Hennequin C. Intraoperative Radiotherapy for Breast Cancer in Elderly Women. Clin Breast Cancer 2021; 22:e109-e113. [PMID: 34154928 DOI: 10.1016/j.clbc.2021.05.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 04/18/2021] [Accepted: 05/06/2021] [Indexed: 11/17/2022]
Abstract
PURPOSE To evaluate outcomes and postoperative toxicities after intraoperative radiotherapy (IORT) in elderly women. POPULATION Women older than 65 years, with infiltrating ductal breast cancer ≤3 cm, expressing estrogen receptor (ER+) without Her2 overexpression, and with negative axillary nodes. TREATMENT Treatment consisted of partial mastectomy with a sentinel lymph node biopsy (SLNB) procedure; in case of positive SLNB, IORT was cancelled. IORT consisted in a total dose of 20 Gy in 1 fraction delivered at the surface of the applicator with the Intrabeam® technique. RESULTS IORT was planned to be administered to a total of 225 patients but was cancelled for 34 patients during surgery. Thus 191 patients were analyzed; mean age was 76 years, with 57 patients (30%) >80 years. Despite inclusion criteria, 15 had lobular carcinoma and 7 were triple negative. With a median follow-up of 40 months, we observed only 1 local recurrence, located in the skin over the initial tumor. The 5-year local relapse rate was 1.7%. A wound healing delay (>15 days) was observed in 21 patients (11%). Sixty-six patients (35%) had postoperative complications, mainly grade 2, resolving within a few days. Two patients needed surgical drainage for local abscesses. Long-term (>1 year) cosmetic outcome was evaluated in 120 patients and was judged excellent or good in 102 (91%). CONCLUSION IORT can be safely given to elderly women, with a good local control rate and without major toxicities.
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Affiliation(s)
- S Ophie Guillerm
- Radiation Oncology Department, Saint-Louis Hospital, Paris, France; Breast Cancer Unit, Saint-Louis Hospital, Paris, France
| | - Edwige Bourstyn
- Radiation Oncology Department, Saint-Louis Hospital, Paris, France; Breast Cancer Unit, Saint-Louis Hospital, Paris, France
| | - Ramona Itti
- Radiation Oncology Department, Saint-Louis Hospital, Paris, France; Breast Cancer Unit, Saint-Louis Hospital, Paris, France
| | - Laurence Cahen-Doidy
- Radiation Oncology Department, Saint-Louis Hospital, Paris, France; Breast Cancer Unit, Saint-Louis Hospital, Paris, France
| | - Laurent Quéro
- Radiation Oncology Department, Saint-Louis Hospital, Paris, France; Breast Cancer Unit, Saint-Louis Hospital, Paris, France
| | - Mouna Labidi
- Radiation Oncology Department, Saint-Louis Hospital, Paris, France; Breast Cancer Unit, Saint-Louis Hospital, Paris, France
| | - Eva Marchand
- Radiation Oncology Department, Saint-Louis Hospital, Paris, France; Breast Cancer Unit, Saint-Louis Hospital, Paris, France
| | - Henri Lorphelin
- Radiation Oncology Department, Saint-Louis Hospital, Paris, France; Breast Cancer Unit, Saint-Louis Hospital, Paris, France
| | - Sylvie Giacchetti
- Radiation Oncology Department, Saint-Louis Hospital, Paris, France; Breast Cancer Unit, Saint-Louis Hospital, Paris, France
| | - Caroline Cuvier
- Radiation Oncology Department, Saint-Louis Hospital, Paris, France; Breast Cancer Unit, Saint-Louis Hospital, Paris, France
| | - Marc Espié
- Radiation Oncology Department, Saint-Louis Hospital, Paris, France; Breast Cancer Unit, Saint-Louis Hospital, Paris, France
| | - Luis Teixeira
- Radiation Oncology Department, Saint-Louis Hospital, Paris, France; Breast Cancer Unit, Saint-Louis Hospital, Paris, France
| | - Christophe Hennequin
- Radiation Oncology Department, Saint-Louis Hospital, Paris, France; Breast Cancer Unit, Saint-Louis Hospital, Paris, France.
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Casey DL, Gupta GP, Ollila DW. The Role of Intraoperative Radiation in Early-stage Breast Cancer. Clin Breast Cancer 2021; 21:103-111. [PMID: 34030857 DOI: 10.1016/j.clbc.2020.12.007] [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: 10/05/2020] [Revised: 12/01/2020] [Accepted: 12/21/2020] [Indexed: 11/17/2022]
Abstract
Intraoperative radiation therapy (IORT) is a specialized form of accelerated partial breast irradiation in which a single dose of radiation is delivered to the tumor bed at the time of breast conserving surgery. With completion of radiation to the tumor bed at the time of surgery, IORT promises improved patient convenience, compliance, and quality of life. In addition, with its potentially skin-sparing properties and ability to deliver a high biologically effective dose to the tumor bed while reducing dose to nontarget tissues, IORT results in different but overall less toxicities compared with other modalities of radiation for breast cancer. However, skepticism over the role of IORT in breast cancer exists, and the 2 randomized trials that have analyzed IORT as the definitive radiation component of breast conservation therapy have shown an increase in local recurrence rates with IORT compared with whole breast irradiation, but similar rates of overall survival. In this review, we discuss the practicalities of IORT, the prospective data supporting and negating the role of IORT in lieu of whole breast irradiation, and the toxicity after IORT in early-stage breast cancer. We also review the role of IORT as a radiation boost and specific strategies for successful implementation of IORT in breast cancer.
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Affiliation(s)
- Dana L Casey
- Department of Radiation Oncology, University of North Carolina School of Medicine, Chapel Hill, NC.
| | - Gaorav P Gupta
- Department of Radiation Oncology, University of North Carolina School of Medicine, Chapel Hill, NC
| | - David W Ollila
- Division of Surgical Oncology, Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, NC
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10
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Jacobs DHM, Horeweg N, Straver M, Roeloffzen EMA, Speijer G, Merkus J, van der Sijp J, Mast ME, Fisscher U, Petoukhova AL, Zwanenburg AG, Marijnen CAM, Koper PCM. Health-related quality of life of breast cancer patients after accelerated partial breast irradiation using intraoperative or external beam radiotherapy technique. Breast 2019; 46:32-39. [PMID: 31075670 DOI: 10.1016/j.breast.2019.04.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2018] [Revised: 03/13/2019] [Accepted: 04/23/2019] [Indexed: 11/26/2022] Open
Abstract
PURPOSE To compare health-related quality of life (HRQL) in elderly breast cancer patients between two types of Accelerated Partial Breast Irradiation: intraoperative radiotherapy (IORT) and external beam APBI (EB-APBI). METHODS Between 2011 and 2016 women ≥60 years undergoing breast conserving therapy for early stage breast cancer were included in a prospective multi-centre cohort study. Patients were treated with electron IORT (1 × 23.3 Gy) or photon EB-APBI (10 × 3.85 Gy daily). HRQL was measured by the EORTC-QLQ C30 and BR23 questionnaires before surgery and at several time points until 1 year. RESULTS HRQoL data was available of 204 IORT and 158 EB-APBI patients. In longitudinal analyses emotional functioning and future perspective were significantly, but not clinically relevantly, worse in IORT-treated patients, and improved significantly during follow-up in both groups. All other aspects of HRQL slightly worsened after treatment and recovered within 3 months with an improvement until 1 year. Cross-sectional analysis showed that postoperatively fatigue and role functioning were significantly worse in IORT patients compared to EB-APBI patients who were not yet irradiated, but the difference was not clinically relevant. At other timepoints there were no significant differences. Multivariable analysis at 1 year identified comorbidity and systemic therapy as risk factors for a worse global health score (GHS). CONCLUSIONS EB-APBI and IORT were well tolerated. Despite a temporary deterioration after treatment, all HRQL scales recovered within 3 months resulting in no clinically relevant differences until 1 year between groups nor compared to baseline levels.
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Affiliation(s)
- D H M Jacobs
- Department of Radiation Oncology, Haaglanden Medical Centre, The Hague, the Netherlands; Department of Radiation Oncology, Leiden University Medical Centre, Leiden, the Netherlands.
| | - N Horeweg
- Department of Radiation Oncology, Leiden University Medical Centre, Leiden, the Netherlands
| | - M Straver
- Department of Surgery, Haaglanden Medical Centre, The Hague, the Netherlands
| | - E M A Roeloffzen
- Department of Radiation Oncology, Isala, Zwolle, the Netherlands
| | - G Speijer
- Department of Radiation Oncology, Haga Hospital, The Hague, the Netherlands
| | - J Merkus
- Department of Surgery, Haga Hospital, The Hague, the Netherlands
| | - J van der Sijp
- Department of Surgery, Haaglanden Medical Centre, The Hague, the Netherlands
| | - M E Mast
- Department of Radiation Oncology, Haaglanden Medical Centre, The Hague, the Netherlands
| | - U Fisscher
- Department of Radiation Oncology, Haaglanden Medical Centre, The Hague, the Netherlands
| | - A L Petoukhova
- Department of Radiation Oncology, Haaglanden Medical Centre, The Hague, the Netherlands
| | - A G Zwanenburg
- Department of Radiation Oncology, Isala, Zwolle, the Netherlands
| | - C A M Marijnen
- Department of Radiation Oncology, Leiden University Medical Centre, Leiden, the Netherlands
| | - P C M Koper
- Department of Radiation Oncology, Haaglanden Medical Centre, The Hague, the Netherlands
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11
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Sosin M, Gupta SS, Wang JS, Costellic CD, Gulla A, Bartholomew AJ, O'Neill SC, Hechenbleikner EM, Collins BT, Rudra S, Collins SP, Chaldekas KM, Seevaratnam S, Langan RC, Willey SC, Tousimis EA. A Prospective Analysis of Quality of Life and Toxicity Outcomes in Treating Early Breast Cancer With Breast Conservation Therapy and Intraoperative Radiation Therapy. Front Oncol 2018; 8:545. [PMID: 30560085 PMCID: PMC6287037 DOI: 10.3389/fonc.2018.00545] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2018] [Accepted: 11/05/2018] [Indexed: 12/13/2022] Open
Abstract
Introduction: Intraoperative radiation therapy (IORT) is a minimally invasive radiation option for select patients with early stage breast cancer. This prospective, single institution, pilot study summarizes patient-reported quality of life (QoL) outcomes and clinician-reported toxicity following IORT following breast conservation therapy. Methods: Forty-nine patients were enrolled in a prospective study from 2013 until 2015 to assess QoL and toxicity following breast conservation therapy and IORT. Nine patients did not meet criteria for IORT alone on final pathology and required whole breast irradiation afterwards. These patients were evaluated separately. Validated QoL questionnaires were provided to patients at 1-week, 1-month, and subsequent 6-month intervals for 2 years. Radiation-related toxicity symptoms were evaluated by clinicians at the same time intervals. Likert scale responses were converted to continuous variables to depict patient-reported and clinician-reported outcomes. Results: Outcomes were analyzed as weighted averages of the Likert scale for each symptom. Responses for negative QoL symptoms ranged largely from 0 (none) to 2 (moderate). Responses for positive QoL symptoms ranged largely from 3 (quite a bit) to 4 (very much). Seventy-five percent of patients developed a toxicity; however, 99% of the toxicities were grades 1 and 2. All toxicities demonstrated a downward trend over time, with the exception of breast fibrosis and nodularity, which increased over time. There were no local recurrences upon 2-year follow up. Conclusion: Early stage breast cancer treated with IORT yields favorable QoL outcomes and minimal toxicity profiles with adequate short-term local control.
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Affiliation(s)
- Michael Sosin
- Department of Surgery, Division of Breast Surgery, Medstar Georgetown University Hospital, Washington, DC, United States
| | - Surupa Sen Gupta
- Department of Surgery, Division of Breast Surgery, Medstar Georgetown University Hospital, Washington, DC, United States
| | - Jessica S Wang
- Department of Plastic Surgery, Medstar Georgetown University Hospital, Washington, DC, United States
| | - Corinne D Costellic
- Department of Surgery, Division of Breast Surgery, Medstar Georgetown University Hospital, Washington, DC, United States
| | - Aiste Gulla
- Department of Surgery, Division of Breast Surgery, Medstar Georgetown University Hospital, Washington, DC, United States
| | - Alex J Bartholomew
- Department of Surgery, Division of Breast Surgery, Medstar Georgetown University Hospital, Washington, DC, United States
| | - Suzanne C O'Neill
- Georgetown Lombardi Comprehensive Cancer Center, Washington, DC, United States
| | - Elizabeth M Hechenbleikner
- Department of Surgery, Division of Breast Surgery, Medstar Georgetown University Hospital, Washington, DC, United States
| | - Brian T Collins
- Department of Radiation Medicine, Medstar Georgetown University Hospital, Washington, DC, United States
| | - Sonali Rudra
- Department of Radiation Medicine, Medstar Georgetown University Hospital, Washington, DC, United States
| | - Sean P Collins
- Department of Radiation Medicine, Medstar Georgetown University Hospital, Washington, DC, United States
| | - Krysta M Chaldekas
- Georgetown Lombardi Comprehensive Cancer Center, Washington, DC, United States
| | - Sulakshana Seevaratnam
- Department of Surgery, Division of Breast Surgery, Medstar Georgetown University Hospital, Washington, DC, United States
| | - Russell C Langan
- Department of Surgery, Division of Breast Surgery, Medstar Georgetown University Hospital, Washington, DC, United States
| | - Shawna C Willey
- Department of Surgery, Division of Breast Surgery, Medstar Georgetown University Hospital, Washington, DC, United States
| | - Eleni A Tousimis
- Department of Surgery, Division of Breast Surgery, Medstar Georgetown University Hospital, Washington, DC, United States
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12
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Bradley JA. The current status of intraoperative radiation therapy in breast cancer: Challenges and promises. Breast J 2018; 24:713-714. [PMID: 30221437 DOI: 10.1111/tbj.13071] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Accepted: 05/02/2018] [Indexed: 11/28/2022]
Affiliation(s)
- Julie A Bradley
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
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13
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Harris EER, Small W. Intraoperative Radiotherapy for Breast Cancer. Front Oncol 2017; 7:317. [PMID: 29312887 PMCID: PMC5743678 DOI: 10.3389/fonc.2017.00317] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Accepted: 12/06/2017] [Indexed: 01/15/2023] Open
Abstract
Intraoperative radiotherapy (IORT) for early stage breast cancer is a technique for partial breast irradiation. There are several technologies in clinical use to perform breast IORT. Regardless of technique, IORT generally refers to the delivery of a single dose of radiation to the periphery of the tumor bed in the immediate intraoperative time frame, although some protocols have performed IORT as a second procedure. There are two large prospective randomized trials establishing the safety and efficacy of breast IORT in early stage breast cancer patients with sufficient follow-up time on thousands of women. The advantages of IORT for partial breast irradiation include: direct visualization of the target tissue ensuring treatment of the high-risk tissue and eliminating the risk of marginal miss; the use of a single dose coordinated with the necessary surgical excision thereby reducing omission of radiation and the selection of mastectomy for women without access to a radiotherapy facility or unable to undergo several weeks of daily radiation; favorable toxicity profiles; patient convenience and cost savings; radiobiological and tumor microenvironment conditions which lead to enhanced tumor control. The main disadvantage of IORT is the lack of final pathologic information on the tumor size, histology, margins, and nodal status. When unexpected findings on final pathology such as positive margins or positive sentinel nodes predict a higher risk of local or regional recurrence, additional whole breast radiation may be indicated, thereby reducing some of the convenience and low-toxicity advantages of sole IORT. However, IORT as a tumor bed boost has also been studied and appears to be safe with acceptable toxicity. IORT has potential efficacy advantages related to overall survival related to reduced cardiopulmonary radiation doses. It may also be very useful in specific situations, such as prior to oncoplastic reconstruction to improve accuracy of adjuvant radiation delivery, or when used as a boost in higher risk patients to improve tumor control. Ongoing international clinical trials are studying these uses and follow-up data are accumulating on completed studies.
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Affiliation(s)
- Eleanor E R Harris
- Department of Radiation Oncology, Brody School of Medicine, East Carolina University, Greenville, NC, United States
| | - William Small
- Department of Radiation Oncology, Stritch School of Medicine, Loyola University, Chicago, IL, United States
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14
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Valente SA, Fanning A, Stewart RA, Grundfest S, Tendulkar RD, Cherian S, Shah C, Tu C, Yanda C, Radford D, Al-Hilli Z, Grobmyer SR. Intraoperative Radiation for Breast Cancer with Intrabeam™: Factors Associated with Decreased Operative Times in Patients Having IORT for Breast Cancer. Front Oncol 2017; 7:237. [PMID: 29124038 PMCID: PMC5662891 DOI: 10.3389/fonc.2017.00237] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Accepted: 09/14/2017] [Indexed: 11/14/2022] Open
Abstract
Introduction Intraoperative radiation with Intrabeam™ (IORT) for breast cancer is a newer technology recently implemented into the operating room (OR). This procedure requires time and coordination between the surgeon and radiation oncologist, who both perform their treatments in a single operative setting. We evaluated the surgeons at our center, who perform IORT and their OR times to examine changes in OR times following implementation of this new surgical procedure. We hypothesized that IORT is a technique for which timing could be improved with the increasing number of cases performed. Methods A prospectively maintained IRB approved database was queried for OR times (incision and close) in patients who underwent breast conserving surgery (BCS), sentinel lymph node biopsy with and without IORT using the Intrabeam™ system at our institution from 2011 to 2015. The total OR times were compared for each surgeon individually and over time. Next, the OR times of each surgeon were compared to each other. Continuous variables were summarized and then a prediction model was created using IORT time, OR time, surgeon, and number of cases performed. Results There were five surgeons performing IORT at our institution during this time period with a total of 96 cases performed. There was a significant difference observed in baseline surgeon-specific OR time for BSC (p = 0.03) as well as for BCS with IORT (p < 0.05), attributable to surgeon experience. The average BCS times were faster than the BCS plus IORT procedure times for all surgeons. The overall mean OR time for the entire combined surgical and radiation procedure was 135.5 min. The most common applicator sizes used were the 3.5 and 4 cm, yielding an average 21 min IORT time. Applicator choice did not differ over time (p = 0.189). After adjusting for IORT time and surgeon, the prediction model estimated that surgeons decreased the total BCS plus IORT OR time at a rate of −4.5 min per each additional 10 cases performed. Conclusion Surgeon experience and applicator size are related to OR times for performing IORT for breast cancer. OR time for IORT in breast cancer treatment can be improved over time, even among experienced surgeons.
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Affiliation(s)
- Stephanie A Valente
- Division of Breast Services, Department of General Surgery, Cleveland Clinic, Cleveland, OH, United States
| | - Alicia Fanning
- Division of Breast Services, Department of General Surgery, Cleveland Clinic, Cleveland, OH, United States
| | - Robyn A Stewart
- Division of Breast Services, Department of General Surgery, Cleveland Clinic, Cleveland, OH, United States
| | - Sharon Grundfest
- Division of Breast Services, Department of General Surgery, Cleveland Clinic, Cleveland, OH, United States
| | - Rahul D Tendulkar
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, OH, United States
| | - Sheen Cherian
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, OH, United States
| | - Chirag Shah
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, OH, United States
| | - Chao Tu
- Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, United States
| | - Courtney Yanda
- Division of Breast Services, Department of General Surgery, Cleveland Clinic, Cleveland, OH, United States
| | - Diane Radford
- Division of Breast Services, Department of General Surgery, Cleveland Clinic, Cleveland, OH, United States
| | - Zahraa Al-Hilli
- Division of Breast Services, Department of General Surgery, Cleveland Clinic, Cleveland, OH, United States
| | - Stephen R Grobmyer
- Division of Breast Services, Department of General Surgery, Cleveland Clinic, Cleveland, OH, United States
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15
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Abbott AM, Valente SA, Loftus L, Tendulkar RD, Greif JM, Bethke KP, Donnelly ED, Lottich C, Ross DL, Friedman NB, Bedi CG, Joh JE, Kelemen P, Hoefer RA, Kang SK, Ruffer J, Police A, Fyles A, Graves GM, Willey SC, Tousimis EA, Small W, Lyons J, Grobmyer S, Laronga C. A multi-institutional analysis of intraoperative radiotherapy for early breast cancer: Does age matter? Am J Surg 2017; 214:629-633. [PMID: 28918848 DOI: 10.1016/j.amjsurg.2017.06.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Revised: 06/19/2017] [Accepted: 06/20/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Single-session intraoperative radiation therapy (IORT) minimizes treatment demands associated with traditional whole breast radiation therapy (WBRT) but outcomes on local disease control and morbidity among the elderly is limited. METHODS A multi-institutional retrospective registry was established from 19 centers utilizing IORT from 2007 to 2013. Patient, tumor, and treatment variables were analyzed for ages <70 and ≥70. RESULTS We evaluated 686 patients (<70 = 424; ≥70 = 262) who were margin and lymph node negative. Patients <70 were more likely to have longer operative time, oncoplastic closure, higher rates of IORT used as planned boost, and receive chemotherapy and post-operative WBRT. Wound complication rates were low and not significantly different between age groups. Median follow-up was 1.06 (range 0.51-1.9) years for < 70 and 1.01 (range 0.5-1.68) years for ≥ 70. There were 5 (0.73%) breast recurrences (4 in <70 and 1 ≥ 70, p = 0.65) and no axillary recurrences during follow-up. CONCLUSIONS IORT was associated with a low rate of wound complication and local recurrence on short-term follow-up in this cohort.
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Affiliation(s)
| | | | - L Loftus
- Moffitt Cancer Center, Tampa, USA
| | | | - J M Greif
- Alta Bates Summit Medical Center, Oakland, CA, USA
| | | | | | - C Lottich
- Community Physician Network Breast Care, Community Health Network, Indianapolis, IN, USA
| | - D L Ross
- Community Physician Network Breast Care, Community Health Network, Indianapolis, IN, USA
| | | | - C G Bedi
- Mercy Medical Center, Baltimore, MD, USA
| | - J E Joh
- Mercy Medical Center, Baltimore, MD, USA
| | - P Kelemen
- Ashikari Breast Center, Dobbs Ferry, NY, USA
| | - R A Hoefer
- The Sentara Dorothy G. Hoefer Comprehensive Breast Center, Newport News, VA, USA
| | - S K Kang
- The Sentara Dorothy G. Hoefer Comprehensive Breast Center, Newport News, VA, USA
| | - J Ruffer
- Advocate Good Shepherd Hospital, Barrington, IL, USA
| | - A Police
- University of California Irvine Medical Center, Irvine, CA, USA
| | - A Fyles
- Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - G M Graves
- Sutter Cancer Center, Sacramento, CA, USA
| | - S C Willey
- MedStar Georgetown University Hospital, Washington, DC, USA
| | - E A Tousimis
- MedStar Georgetown University Hospital, Washington, DC, USA
| | - W Small
- Loyola University, Maywood, IL, USA
| | - J Lyons
- The Cleveland Clinic, Cleveland, OH, USA
| | - S Grobmyer
- The Cleveland Clinic, Cleveland, OH, USA
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16
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Key S, Miglierini P, Dupré PF, Guilbert S, Lucia AS, Abgral R, Conan-Charlet V, Uguen A, Pradier O, Schick U. Cosmetic Outcome and Chronic Breast Toxicity After Intraoperative Radiation Therapy (IORT) as a Single Modality or as a Boost Using the Intrabeam® Device: A Prospective Study. Ann Surg Oncol 2017; 24:2547-2555. [DOI: 10.1245/s10434-017-5920-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Indexed: 11/18/2022]
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17
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In Reply to Park et al. Int J Radiat Oncol Biol Phys 2016; 96:707-8. [PMID: 27681769 DOI: 10.1016/j.ijrobp.2016.06.2461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Accepted: 06/26/2016] [Indexed: 11/24/2022]
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18
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Correa C, Harris EE, Leonardi MC, Smith BD, Taghian AG, Thompson AM, White J, Harris JR. Accelerated Partial Breast Irradiation: Executive summary for the update of an ASTRO Evidence-Based Consensus Statement. Pract Radiat Oncol 2016; 7:73-79. [PMID: 27866865 DOI: 10.1016/j.prro.2016.09.007] [Citation(s) in RCA: 427] [Impact Index Per Article: 53.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2016] [Accepted: 09/12/2016] [Indexed: 11/28/2022]
Abstract
PURPOSE To update the accelerated partial breast irradiation Consensus Statement published in 2009 and provide guidance on use of intraoperative radiation therapy (IORT) for partial breast irradiation in early-stage breast cancer, based on published evidence complemented by expert opinion. METHODS AND MATERIALS A systematic PubMed search using the same terms as the original Consensus Statement yielded 419 articles; 44 articles were selected. The authors synthesized the published evidence and, through a series of conference calls and e-mails, reached consensus regarding the recommendations. RESULTS The new recommendations include lowering the age in the "suitability group" from 60 to 50 years and in the "cautionary group" to 40 years for patients who meet all other elements of suitability (Table 1). Patients with low-risk ductal carcinoma in situ, as per Radiation Therapy Oncology Group 9804 criteria, were categorized in the "suitable" group. The task force agreed to maintain the current criteria based on margin status. Recommendations for the use of IORT for breast cancer patients include: counseling patients regarding the higher risk of ipsilateral breast tumor recurrence with IORT compared with whole breast irradiation; the need for prospective monitoring of long-term local control and toxicity with low-energy radiograph IORT given limited follow-up; and restriction of IORT to women with invasive cancer considered "suitable." CONCLUSION These recommendations will provide updated clinical guidance regarding use of accelerated partial breast irradiation for radiation oncologists and other specialists participating in the care of breast cancer patients.
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Affiliation(s)
- Candace Correa
- Department of Radiation Oncology, Faxton St. Luke's Healthcare, Utica, New York
| | - Eleanor E Harris
- Department of Radiation Oncology, East Carolina University, Greenville, North Carolina
| | | | - Benjamin D Smith
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Alphonse G Taghian
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Alastair M Thompson
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Julia White
- Department of Radiation Oncology, Ohio State University Cancer Center, Columbus, Ohio
| | - Jay R Harris
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Boston, Massachusetts.
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19
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Cosmesis and Breast-Related Quality of Life Outcomes After Intraoperative Radiation Therapy for Early Breast Cancer: A Substudy of the TARGIT-A Trial. Int J Radiat Oncol Biol Phys 2016; 96:55-64. [DOI: 10.1016/j.ijrobp.2016.04.024] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Revised: 04/05/2016] [Accepted: 04/17/2016] [Indexed: 11/20/2022]
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20
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Massa M, Franchelli S, Panizza R, Massa T. Is current clinical practice modified about intraoperative breast irradiation? Chin J Cancer Res 2016; 28:146-9. [PMID: 27199511 PMCID: PMC4865606 DOI: 10.21147/j.issn.1000-9604.2016.02.01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
After the results obtained in the two randomized clinical trial, the ELIOT trial and the TARGIT-A trial, a heated debate is going on concerning the question of applying intraoperative radiotherapy (IORT) instead of postoperative whole breast irradiation (WBI) after breast conservative treatment. Currently, many centers are applying the IORT following the strict selection criteria dictated by the working groups American Society for Radiation Oncology (ASTRO) and Groupe Européen de Curiethérapie-European Society for Therapeutic Radiology and Oncology (GEC-ESTRO) and monitoring the oncological outcome together with radiation toxicity on breast tissue. The clinical experience of the Geneva University Hospital regarding the use of the Intrabeam system is evaluated and compared with current evidences.
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Affiliation(s)
- Michela Massa
- 1Plastic and Reconstructive Surgery, SS. Antonio e Biagio e Cesare Arrigo Hospital, Alessandria, Italy
| | - Simonetta Franchelli
- 2Plastic and Reconstructive Surgery, IRCCS AOU San Martino-IST, National Institute of Cancer Research, L.go Rosanna Benzi 10, 16132, Genoa, Italy
| | - Renzo Panizza
- 1Plastic and Reconstructive Surgery, SS. Antonio e Biagio e Cesare Arrigo Hospital, Alessandria, Italy
| | - Tiberio Massa
- 3Diagnostic Mammography Department, IRCCS AOU San Martino-IST, National Institute of Cancer Research, L.go Rosanna Benzi 10, 16132, Genoa, Italy
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21
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Abbott AM, Dossett LA, Loftus L, Sun W, Fulp W, Sokol GH, Laronga C. Intraoperative radiotherapy for early breast cancer and age: clinical characteristics and outcomes. Am J Surg 2015; 210:624-8. [DOI: 10.1016/j.amjsurg.2015.05.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2015] [Revised: 04/30/2015] [Accepted: 05/21/2015] [Indexed: 11/28/2022]
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22
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Harris EE, Small W, Holmes D, Grobmyer S, Pavord D, Rice JS, Alvarado M. In Regard to Hepel and Wazer. Int J Radiat Oncol Biol Phys 2015; 92:955-957. [DOI: 10.1016/j.ijrobp.2015.05.034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2015] [Revised: 04/28/2015] [Accepted: 05/18/2015] [Indexed: 10/23/2022]
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23
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Intraoperative radiotherapy for breast cancer: the lasting effects of a fleeting treatment. Int J Breast Cancer 2014; 2014:214325. [PMID: 25180098 PMCID: PMC4142745 DOI: 10.1155/2014/214325] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2014] [Accepted: 07/20/2014] [Indexed: 11/24/2022] Open
Abstract
In well-selected patients who choose to pursue breast conservation therapy (BCT) for early-stage breast cancer, partial breast irradiation (PBI) delivered externally or intraoperatively, may be a viable alternative to conventional whole breast irradiation. Two large, contemporary randomized trials have demonstrated breast intraoperative radiotherapy (IORT) to be noninferior to whole breast external beam radiotherapy (EBRT) when assessing for ipsilateral breast tumor recurrence in select patients. Additionally, IORT and other PBI techniques are likely to be more widely adopted in the future because they improve patient convenience by offering an accelerated course of treatment. Coupled with these novel techniques for breast radiotherapy (RT) are distinct toxicity profiles and unique cosmetic alterations that differ from conventional breast EBRT and have the potential to impact disease surveillance and patient satisfaction. This paper will review the level-one evidence for treatment efficacy as well as important secondary endpoints like RT toxicity, breast cosmesis, quality of life, patient satisfaction, and surveillance mammography following BCT with IORT.
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Sperk E, Astor D, Keller A, Welzel G, Gerhardt A, Tuschy B, Sütterlin M, Wenz F. A cohort analysis to identify eligible patients for intraoperative radiotherapy (IORT) of early breast cancer. Radiat Oncol 2014; 9:154. [PMID: 25015740 PMCID: PMC4105865 DOI: 10.1186/1748-717x-9-154] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Accepted: 07/07/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Since the results from the randomized TARGIT A trial were published, intraoperative radiotherapy (IORT) is used more often. IORT can be provided as accelerated partial breast irradiation (APBI) or as a boost. The definition of suitable patients for IORT as APBI differs between different national societies (e.g. ESTRO and ASTRO) and different inclusion criteria of trials and so does the eligibility of patients. This analysis identifies eligible patients for IORT according to available consensus statements and inclusion criteria of the ongoing TARGIT trials. METHODS Between 01/03 - 12/09, 1505 breast cancer cases were treated at the breast cancer center at the University Medical Center Mannheim. Complete data sets for age, stage (T, N, and M), histology and hormone receptor status were available in 1108 cases. Parameters to identify eligible patients are as follows: ESTRO: >50 years, invasive ductal carcinoma/other favorable histology (IDC), T1-2 (≤3 cm), N0, any hormone receptor status, M0; ASTRO: ≥60 years, IDC, T1, N0, positive estrogen hormone receptor status, M0; TARGIT E "elderly", risk adapted radiotherapy with IORT followed by external beam radiotherapy in case of risk factors in final histopathology, phase II: ≥70 years, IDC, T1, N0, any hormone receptor status, M0; TARGIT C "consolidation", risk adapted radiotherapy, phase IV: ≥50 years, IDC, T1, N0, positive hormone receptor status, M0; TARGIT BQR "boost quality registry": every age, every histology, T1-2 (max. 3.5 cm), any hormone receptor status, N0/+, M0/+. RESULTS Out of the 1108 cases, 379 cases (34.2%) were suitable for IORT as APBI regarding the ESTRO and 175 (15.8%) regarding the ASTRO consensus statements. 82 (7.4%) patients were eligible for the TARGIT E trial, 258 (23.3%) for the TARGIT C trial and 671 (60.6%) for the TARGIT BQR registry. According to the consensus statements of ASTRO (45.1%) and ESTRO (41.4%) about half of the eligible patients were treated with IORT as APBI. From the eligible patients fulfilling the criteria for IORT boost (35%) about one third was eventually treated. CONCLUSIONS Patient selection for IORT should be restrictive. For IORT as APBI the TARGIT trials are even more restrictive including patients than the ESTRO and ASTRO consensus statements.
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Affiliation(s)
- Elena Sperk
- Department of Radiation Oncology, University Medical Center Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, Mannheim, 68167, Germany.
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Prospective study of local control and late radiation toxicity after intraoperative radiation therapy boost for early breast cancer. Int J Radiat Oncol Biol Phys 2014; 88:73-9. [PMID: 24331652 DOI: 10.1016/j.ijrobp.2013.09.049] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2013] [Revised: 09/21/2013] [Accepted: 09/27/2013] [Indexed: 11/20/2022]
Abstract
PURPOSE To report the local recurrence rate and late toxicity of intraoperative radiation therapy (IORT) boost to the tumor bed using the Intrabeam System followed by external-beam whole-breast irradiation (WBI) in women with early-stage breast cancer in a prospective single-institution study. METHODS AND MATERIALS Women with breast cancer≤3 cm were recruited between February 2003 and May 2005. After breast-conserving surgery, a single dose of 5 Gy IORT boost was delivered using 50-kV x-rays to a depth of 10 mm from the applicator surface. This was followed by WBI to a total dose of 50 Gy in 25 fractions. Patients were reviewed at regular, predefined intervals. Late toxicities were recorded using the Radiation Therapy Oncology Group/European Organization for Research and Treatment of Cancer Late Radiation Morbidity Scoring systems. RESULTS Fifty-five patients completed both IORT boost and external-beam WBI. Median follow-up was 3.3 years (range, 1.4-4.1 years). There was no reported locoregional recurrence or death. One patient developed distant metastases. Grade 2 and 3 subcutaneous fibrosis was detected in 29 (53%) and 8 patients (15%), respectively. CONCLUSIONS The use of IORT as a tumor bed boost using kV x-rays in breast-conserving therapy was associated with good local control but a clinically significant rate of grade 2 and 3 subcutaneous fibrosis.
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Alvarado MD, Mohan AJ, Esserman LJ, Park CC, Harrison BL, Howe RJ, Thorsen C, Ozanne EM. Cost-effectiveness analysis of intraoperative radiation therapy for early-stage breast cancer. Ann Surg Oncol 2013; 20:2873-80. [PMID: 23812769 DOI: 10.1245/s10434-013-2997-3] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2012] [Indexed: 11/18/2022]
Abstract
BACKGROUND Shortened courses of radiation therapy have been shown to be similarly effective to whole-breast external-beam radiation therapy (WB-EBRT) in terms of local control. We sought to analyze, from a societal perspective, the cost-effectiveness of two radiation strategies for early-stage invasive breast cancer: single-dose intraoperative radiation therapy (IORT) and the standard 6-week course of WB-EBRT. METHODS We developed a Markov decision-analytic model to evaluate these treatment strategies in terms of life expectancy, quality-adjusted life years (QALYs), costs, and the incremental cost-effectiveness ratio over 10 years. RESULTS IORT single-dose intraoperative radiation therapy was the dominant, more cost-effective strategy, providing greater quality-adjusted life years at a decreased cost compared with 6-week WB-EBRT. The model was sensitive to health state utilities and recurrence rates, but not costs. IORT was either the preferred or dominant strategy across all sensitivity analyses. The two-way sensitivity analyses demonstrate the need to accurately determine utility values for the two forms of radiation treatment and to avoid indiscriminate use of IORT. CONCLUSIONS With less cost and greater QALYs than WB-EBRT, IORT is the more valuable strategy. IORT offers a unique example of new technology that is less costly than the current standard of care option but offers similar efficacy. Even when considering the capital investment for the equipment ($425 K, low when compared with the investments required for robotic surgery or high-dose-rate brachytherapy), which could be recouped after 3-4 years conservatively, these results support IORT as a change in practice for treating early-stage invasive breast cancer.
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Affiliation(s)
- Michael D Alvarado
- Department of Surgery, UCSF Comprehensive Cancer Center, San Francisco, CA, USA.
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Tuschy B, Berlit S, Romero S, Sperk E, Wenz F, Kehl S, Sütterlin M. Clinical aspects of intraoperative radiotherapy in early breast cancer: short-term complications after IORT in women treated with low energy x-rays. Radiat Oncol 2013; 8:95. [PMID: 23607703 PMCID: PMC3643839 DOI: 10.1186/1748-717x-8-95] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2012] [Accepted: 04/18/2013] [Indexed: 11/18/2022] Open
Abstract
Background To assess postoperative complications, clinical outcome and histological findings in patients undergoing intraoperative radiotherapy with low energy x-rays for early breast cancer. Methods We retrospectively analysed data of 208 women who underwent intraoperative irradiation during breast conserving surgery (BCS) between 2002 and 2007. Demographic, clinical and surgical parameters as well as short-term complications within the first postoperative week and histological findings were evaluated. Toxicities were assessed using the CTC/EORTC Score. Results Postoperative complications were rare and the immediate toxicity low, without any grade 3/4 acute toxicity. The most frequent postoperative side effects were suggillation (24%) and palpable seroma (17.3%). In 78.6% of the axillary seroma and in 25% of the breast seroma a needle aspiration was inevitable. Erythema grade I-II of the breast was found in 27 women (13%); whereas in 7 patients (3.4%), mastitis was confirmed. In 57.7% of the cases, the pathological assessment revealed ductal invasive breast cancer and tumour size ranged between 0.1 and 4.5 cm (mean = 1.6 cm). Conclusion IORT using Intrabeam® during BCS is safe, although it is associated with postoperative adverse events such as seroma. These should be mentioned and explained to women in detail during the preoperative discussion. This explicitly clinical description is useful for daily clinical practice; especially for giving a detailed analysis of the postoperative side effects during preoperative counselling.
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Affiliation(s)
- Benjamin Tuschy
- Department of Gynaecology and Obstetrics, University Medical Centre Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.
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Grobmyer SR, Lightsey JL, Bryant CM, Shaw C, Yeung A, Bhandare N, Hitchingham B, Copeland EM. Low-Kilovoltage, Single-Dose Intraoperative Radiation Therapy for Breast Cancer: Results and Impact on a Multidisciplinary Breast Cancer Program. J Am Coll Surg 2013; 216:617-23; discussion 623-4. [DOI: 10.1016/j.jamcollsurg.2012.12.038] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2012] [Accepted: 12/12/2012] [Indexed: 01/19/2023]
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Welzel G, Boch A, Sperk E, Hofmann F, Kraus-Tiefenbacher U, Gerhardt A, Suetterlin M, Wenz F. Radiation-related quality of life parameters after targeted intraoperative radiotherapy versus whole breast radiotherapy in patients with breast cancer: results from the randomized phase III trial TARGIT-A. Radiat Oncol 2013; 8:9. [PMID: 23294485 PMCID: PMC3896671 DOI: 10.1186/1748-717x-8-9] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2012] [Accepted: 01/01/2013] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Intraoperative radiotherapy (IORT) is a new treatment approach for early stage breast cancer. This study reports on the effects of IORT on radiation-related quality of life (QoL) parameters. METHODS Two hundred and thirty women with stage I-III breast cancer (age, 31 to 84 years) were entered into the study. A single-center subgroup of 87 women from the two arms of the randomized phase III trial TARGIT-A (TARGeted Intra-operative radioTherapy versus whole breast radiotherapy for breast cancer) was analyzed. Furthermore, results were compared to non-randomized control groups: n = 90 receiving IORT as a tumor bed boost followed by external beam whole breast radiotherapy (EBRT) outside of TARGIT-A (IORT-boost), and n = 53 treated with EBRT followed by an external-beam boost (EBRT-boost). QoL was collected using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaires C30 (QLQ-C30) and BR23 (QLQ-BR23). The mean follow-up period in the TARGIT-A groups was 32 versus 39 months in the non-randomized control groups. RESULTS Patients receiving IORT alone reported less general pain (21.3 points), breast (7.0 points) and arm (15.1 points) symptoms, and better role functioning (78.7 points) as patients receiving EBRT (40.9; 19.0; 32.8; and 60.5 points, respectively, P < 0.01). Patients receiving IORT alone also had fewer breast symptoms than TARGIT-A patients receiving IORT followed by EBRT for high risk features on final pathology (IORT-EBRT; 7.0 versus 29.7 points, P < 0.01). There were no significant differences between TARGIT-A patients receiving IORT-EBRT compared to non-randomized IORT-boost or EBRT-boost patients and patients receiving EBRT without a boost. CONCLUSIONS In the randomized setting, important radiation-related QoL parameters after IORT were superior to EBRT. Non-randomized comparisons showed equivalent parameters in the IORT-EBRT group and the control groups.
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Affiliation(s)
- Grit Welzel
- Department of Radiation Oncology, University Medical Centre Mannheim, University of Heidelberg, Mannheim, 68167, Germany
| | - Angela Boch
- Department of Radiation Oncology, University Medical Centre Mannheim, University of Heidelberg, Mannheim, 68167, Germany
| | - Elena Sperk
- Department of Radiation Oncology, University Medical Centre Mannheim, University of Heidelberg, Mannheim, 68167, Germany
| | - Frank Hofmann
- Department of Radiation Oncology, University Medical Centre Mannheim, University of Heidelberg, Mannheim, 68167, Germany
| | - Uta Kraus-Tiefenbacher
- Department of Radiation Oncology, University Medical Centre Mannheim, University of Heidelberg, Mannheim, 68167, Germany
| | - Axel Gerhardt
- Department of Gynecology, University Medical Centre Mannheim, University of Heidelberg, Mannheim, 68167, Germany
| | - Marc Suetterlin
- Department of Gynecology, University Medical Centre Mannheim, University of Heidelberg, Mannheim, 68167, Germany
| | - Frederik Wenz
- Department of Radiation Oncology, University Medical Centre Mannheim, University of Heidelberg, Mannheim, 68167, Germany
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Engel D, Schnitzer A, Brade J, Blank E, Wenz F, Suetterlin M, Schoenberg S, Wasser K. Are mammographic changes in the tumor bed more pronounced after intraoperative radiotherapy for breast cancer? Subgroup analysis from a randomized trial (TARGIT-A). Breast J 2012; 19:92-5. [PMID: 23173717 DOI: 10.1111/tbj.12049] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Intraoperative radiotherapy (IORT) with low-energy x-rays is increasingly used in breast-conserving therapy (BCT). Previous non-randomized studies have observed mammographic changes in the tumor bed to be more pronounced after IORT. The purpose of this study was to reassess the postoperative changes in a randomized single-center subgroup of patients from a multicenter trial (TARGIT-A). In this subgroup (n = 48) 27 patients received BCT with IORT, 21 patients had BCT with standard whole-breast radiotherapy serving as controls. Overall 258 postoperative mammograms (median follow-up 4.3 years, range 3-8) were retrospectively evaluated by two radiologists in consensus focusing on changes in the tumor bed. Fat necroses showed to be significantly more frequent (56% versus 24%) and larger (8.7 versus 1.6 sq cm, median) after IORT than those in controls. Scar calcifications were also significantly more frequent after IORT (63% versus 19%). The high incidence of large fat necroses in our study confirms previous study findings. However, the overall higher incidence of calcifications in the tumor bed after IORT represents a new finding, requiring further attention.
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Affiliation(s)
- Dorothee Engel
- Institute of Clinical Radiology and Nuclear Medicine, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
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Sperk E, Welzel G, Keller A, Kraus-Tiefenbacher U, Gerhardt A, Sütterlin M, Wenz F. Late radiation toxicity after intraoperative radiotherapy (IORT) for breast cancer: results from the randomized phase III trial TARGIT A. Breast Cancer Res Treat 2012; 135:253-60. [PMID: 22842984 DOI: 10.1007/s10549-012-2168-4] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2012] [Accepted: 07/10/2012] [Indexed: 10/28/2022]
Abstract
The randomized phase III trial TARGIT A showed non-inferiority regarding local control after intraoperative radiotherapy (IORT 20 Gy which was followed by whole breast radiotherapy (WBRT) in patients with risk factors only) in comparison to standard WBRT (50-56 Gy) after breast-conserving surgery in selected patients. This is the first analysis of long-term toxicities in the setting of TARGIT. Between 02/2002 and 12/2008, 305 patients were treated within TARGIT A (Arm A: n = 34 IORT, n = 20 IORT + WBRT for risk factors; Arm B WBRT: n = 55) or received IORT as a planned boost (control group: n = 196) at a single center. Toxicity was assessed according to the LENT SOMA scales. No significant differences were seen between Arm A and Arm B regarding fibrosis, breast edema, retraction, ulceration, lymphedema, hyperpigmentation, and pain. Arm A had significantly less telangiectases compared to Arm B (p = 0.049). In the subanalysis (Arm A IORT vs. Arm A IORT + WBRT vs. Arm B), fibrosis had a cumulative rate of 5.9 versus 37.5 versus 18.4 %, respectively (38.2 % IORT boost control group), at 3 years. No telangiectases were seen after IORT alone (0 % Arm A IORT vs. 17.5 % Arm A IORT + WBRT vs. 17.7 % Arm B). The hazard ratio of higher grade toxicity as first event was 0.46 (95 % CI, 0.26-0.83) for Arm A IORT as compared to Arm B (p = 0.010). No recurrences were seen after a median follow-up of 40 months (Arm A) and 42 months (Arm B). With its very low chronic skin toxicity rates and outstanding long-term results regarding toxicity and local control, IORT with 50 kV X-rays is a safe and effective method for treatment of selected breast cancer patients.
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Affiliation(s)
- Elena Sperk
- Department of Radiation Oncology, University Medical Center Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany.
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Wenz F, Blank E, Welzel G, Hofmann F, Astor D, Neumaier C, Herskind C, Gerhardt A, Suetterlin M, Kraus-Tiefenbacher U. Intraoperative radiotherapy during breast-conserving surgery using a miniature x-ray generator (Intrabeam®): theoretical and experimental background and clinical experience. ACTA ACUST UNITED AC 2012; 8:39-47. [PMID: 22171773 DOI: 10.2217/whe.11.82] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Breast cancer is currently the most frequent indication for intraoperative radiotherapy with increasing numbers worldwide. Intraoperative radiotherapy can be used as a tumor bed boost followed by whole breast radiotherapy, or as a distinct form of accelerated partial breast irradiation in selected patients. This article summarizes the theoretical background including pattern of recurrence and distribution of tumor cell foci in the breast and discusses the rationale for intraoperative radiotherapy, especially using a miniature x-ray generator (Intrabeam(®)). The concepts of how to avoid geographic and temporal miss by giving radiotherapy during surgery to the open wound cavity are described. Experimental and clinical experience is presented based on in vitro experiments and more than 300 treated patients in a single department with mature follow-up.
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Affiliation(s)
- Frederik Wenz
- Department of Radiation Oncology, University Medical Centre Mannheim, University of Heidelberg, 68167 Mannheim, Germany.
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Schootman M, Deshpande AD, Pruitt S, Aft R, Jeffe DB. Estimated effects of potential interventions to prevent decreases in self-rated health among breast cancer survivors. Ann Epidemiol 2012; 22:79-86. [PMID: 22226030 DOI: 10.1016/j.annepidem.2011.10.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2011] [Revised: 10/21/2011] [Accepted: 10/27/2011] [Indexed: 11/30/2022]
Abstract
PURPOSE To estimate the effect of hypothetical changes in modifiable predictors on the incidence of fair-to-poor self-rated health (SRH) in breast cancer survivors. METHODS In 2007-2008, we interviewed 832 breast cancer survivors 1 year after diagnosis (baseline) and 1 year later. First, multivariable logistic regression models estimated the association between the predictors (sociodemographic factors, access to medical care, comorbid conditions, psychosocial factors, perceived neighborhood conditions, cancer-related behaviors, clinical factors) and SRH. Second, we estimated the probabilities of fair-to-poor SRH for values of the predictors for each breast cancer survivor. Third, we estimated the population-wide effect of potential changes in modifiable predictors on the incidence of fair-to-poor SRH. RESULTS A total of 7.6% of participants (92.4% white; mean age, 58.0 years) whose SRH was rated good-to-excellent at baseline reported fair-to-poor SRH 1 year later. The largest potential reduction in incidence of fair-to-poor SRH could be obtained by eliminating surgical side effects (27.8% reduction) and comorbidity (21.8% reduction) and by engaging in any physical activity (19.6% reduction). CONCLUSIONS A significant portion of the decline in SRH can be avoided by reducing surgical side effects, preventing comorbidity, and improving physical activity with the use of evidence-based strategies.
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Affiliation(s)
- Mario Schootman
- Departments of Medicine and Pediatrics, Division of Health Behavior Research, Washington University School of Medicine, Saint Louis, MO 63108, USA.
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Female plastic and reconstructive surgeons’ personal decision making for breast cancer treatment and reconstruction. Arch Gynecol Obstet 2010; 284:737-41. [DOI: 10.1007/s00404-010-1721-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2010] [Accepted: 10/13/2010] [Indexed: 11/26/2022]
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