Oncoplastic reconstruction with breast-conserving treatment versus breast-conserving treatment alone in the elderly

BACKGROUND/OBJECTIVES

Oncoplastic reconstruction (IOR) performed in conjunction with breast conserving therapy (BCT) has been found to improve psychosocial well-being, reduce hospitalization time, and reduce cost burden. Few studies have looked at the safety profile, complication rates, and overall outcomes in patients ages 65 years and older undergoing IOR versus BCT alone.

METHODS

A retrospective, cross-sectional, single-institution medical record review was conducted of women diagnosed with breast cancer age 65 years or older who received IOR or BCT alone. Demographics, clinical data, and major and minor complication profiles were compared between cohorts.

RESULTS

A total of 310 patients were included. Of these, 126 received IOR, while 184 received BCT alone. Age >85 was found to have a significantly higher risk for any complication and was an independent predictor for experiencing any complication (OR: 8.5, p = 0.015; OR: 1.06, p = 0.029). Major complication rates were significantly higher in the BCT cohort (16.9% vs. 7.9%, p = 0.023).

CONCLUSION

IOR in the elderly is a safe option and was not found to be a predictor of experiencing higher complications. Patients who are 85 years and older had a higher risk of complications, and future studies may explore risk-benefit in that particular cohort of patients in which BCT is planned.

Extreme oncoplasty: past, present and future

Breast surgery has evolved from mastectomy to breast-conserving surgery (BCS). Breast oncoplastic surgery later emerged with the inclusion and development of techniques used in plastic surgery for breast neoplasms. Recently, a new paradigm has been considered for mastectomy candidates with large multifocal and multicentric tumours, designated extreme oncoplasty (EO), which has allowed new techniques to be applied to tumours that would have been ineligible for BCS before. There are few publications and no uniform descriptions grouping all the technical possibilities and new indications together. We performed this a review with the objective of evaluating the indications and surgeries performed in the EO context, representing a new perspective for BCS. We observed new indications as extensive microcalcifications, locally advanced breast carcinoma with partial response to chemotherapy, small to moderate-sized non-ptotic central tumours and extreme ptosis. Small breasts are able for EO since the presence of ptosis. New surgeries are reported as disguised geometric compensation, perforators flaps, local/regional flaps, latissimus dorsi miniflap and partial breast amputation. It is important to decrease barriers to oncoplastic surgery if we want to increase the use of EO and BCS rates.

Outcomes of breast conserving therapy: Recurrence, imaging findings and histological correlation

Background

Breast conserving therapy (BCT) is the mainstay therapy in patients with early breast cancer and selected patients with locally advanced breast cancer. No formal audit has been performed on BCT at our institution.

Objectives

To determine the incidence and risk factors for ipsilateral breast tumour recurrence (IBTR). Study the imaging features of IBTR. Determine adherence to the proposed annual mammographic surveillance schedule.

Method

Clinical, radiological and histopathological records of patients who underwent BCT from 01 January 2011 to 31 December 2015 were reviewed. Patients were followed up for at least 5 years.

Results

Ninety-two patients were included in the study with a mean age of 54.3 years. Eighty of the 92 (87.0%) patients were imaged within 1-year post-BCT. Ipsilateral breast tumour recurrence was 6/92 (6.5%) with mean time to IBTR of 34.4 months. One of the 92 (1.0%) patients had a contralateral metachronous recurrence with no IBTR and 11/92 (12.0%) had distant metastases only. Pathological tumour size and extent (pT2) (68.5%) and pathological lymph node (pN0) (65.2%) were the most common locoregional staging. Infiltrating ductal carcinoma was the most common histological type (88%). Age < 35 years was associated with breast cancer recurrence (p < 0.01). Imaging findings of recurrence were microcalcification (odds ratio [OR]: 4), asymmetric density (OR: 4) and skin thickening (OR: 2.5).

Conclusion

The occurrence of IBTR following BCT in our unit is acceptable and comparable to local and international units. The accuracy of assessing the post-BCT breast for IBTR is in keeping with international standards.

Contribution

Improved radiological imaging interpretation of the post-BCT breast.

Epigenetic drugs induce the potency of classic chemotherapy, suppress post-treatment re-growth of breast cancer, but preserve the wound healing ability of stem cells

Epigenetic therapy augments neoadjuvant chemotherapy (NACT) in breast cancer and may aid post-surgical wound healing affected by NACT. Our study investigates: (1) The cytotoxicity of classic paclitaxel chemotherapy on triple negative breast cancer (TNBC) independently and in combination with epigenetic drugs. (2) The sustainable inhibition of breast cancer regrowth following paclitaxel and epigenetic therapies. (3) The effects of paclitaxel with and without epigenetic therapy on the post-treatment viability and wound healing potential of adipose stem cells (ASCs). Cytotoxicity assays were performed on TNBC and ASCs. Cells were treated and recovered in drug-free medium. Cell viability was measured via cell counts and MTT assays. W -ound healing was tested with scratch assays. The combination of epigenetic drugs shows increased toxicity against TNBC cells compared to standard chemotherapy alone. Moreover, the combination of paclitaxel with epigenetic treatments causes cancer toxicity that is sustainable to TNBC cells after the drugs' removal with minimal effect on ASCs wound healing ability. The use of epigenetic drugs in addition to standard chemotherapy is cytotoxic to TNBC cells and prevents post-treatment recovery of TNBC while maintaining ASC wound healing ability. This strategy may be useful in maximizing post-surgical wound healing following NACT in TNBC.

Comparing oncoplastic breast reduction with immediate symmetry surgery to standard breast reduction surgery: Are postoperative complications worse?

INTRODUCTION

Oncoplastic breast reduction mammoplasty (ORM) is an excellent treatment option for women with breast cancer and macromastia undergoing breast conservation therapy. Here, we aim to better understand the risks associated with ORM compared to standard reduction mammoplasty (SRM).

METHODS

A retrospective chart review was performed of patients undergoing ORM or SRM from 2015 to 2021. Primary outcomes included the occurrence of major or minor postoperative complications in the two groups and delays to adjuvant therapy (>90 days) among the women undergoing ORM.

RESULTS

Women in the ORM group (n = 198) were significantly older (p < 0.001) with a higher prevalence of smoking (p < 0.001), diabetes mellitus (p < 0.01), and a Charlson comorbidity index ≥ 3 (p < 0.001) compared to women undergoing SRM (n = 177). After controlling for potential confounders, there were no significant between-group differences in the odds of developing postoperative complications (odds ratio = 0.80, 95% confidence interval: 0.36-1.69). Only 3% (n = 4) of the 150 women undergoing adjuvant radiation or chemotherapy experienced delays related to postoperative complications.

CONCLUSION

ORM has a similar safety profile as SRM, despite the older age and higher number of comorbidities often seen in patients undergoing ORM, and is a safe option for achieving contralateral symmetry at the time of partial mastectomy without delays to adjuvant therapy.

Evolving Trends in Surgical Management of Breast Cancer: An Analysis of 30 Years of Practice Changing Papers

The management of breast cancer has evolved into a multidisciplinary evidence-based surgical speciality, with emphasis on conservative surgery. A number of landmark trials have established lumpectomy followed by radiation as the standard of care for many patients. The aim of this study is to construct a narrative review of recent developments in the surgical management of breast cancer and how such developments have impacted surgical practice. A comprehensive literature search of Pubmed was conducted. The latest search was performed on October 31^st, 2020. Search terms “breast cancer” were used in combinations with specific key words and Boolean operators relating to surgical management. The reference lists of retrieved articles were comprehensively screened for additional eligible publications. Articles were selected and reviewed based on relevance. We selected publications in the past 10 years but did not exclude commonly referenced and highly regarded previous publications. Review articles and book chapters were also cited to provide reference on details not discussed in the academic literature. This article reviews the current evidence in surgical management of early-stage breast cancer, discusses recent trends in surgical practice for therapeutic and prophylactic procedures and provides commentary on implications and factors associated with these trends.

Associated Factors and Survival Outcomes for Breast Conserving Surgery versus Mastectomy among New Zealand Women with Early-Stage Breast Cancer

This study aimed to investigate type of loco-regional treatment received, associated treatment factors and mortality outcomes in New Zealand women with early-stage breast cancer who were eligible for breast conserving surgery (BCS). This is a retrospective analysis of prospectively collected data from the Auckland and Waikato Breast Cancer Registers and involves 6972 women who were diagnosed with early-stage primary breast cancer (I-IIIa) between 1 January 2000 and 31 July 2015, were eligible for BCS and had received one of four loco-regional treatments: breast conserving surgery (BCS), BCS followed by radiotherapy (BCS + RT), mastectomy (MTX) or MTX followed by radiotherapy (MTX + RT), as their primary cancer treatment. About 66.1% of women received BCS + RT, 8.4% received BCS only, 21.6% received MTX alone and 3.9% received MTX + RT. Logistic regression analysis was used to identify demographic and clinical factors associated with the receipt of the BCS + RT (standard treatment). Differences in the uptake of BCS + RT were present across patient demographic and clinical factors. BCS + RT was less likely amongst patients who were older (75+ years old), were of Asian ethnicity, resided in impoverished areas or areas within the Auckland region and were treated in a public healthcare facility. Additionally, BCS + RT was less likely among patients diagnosed symptomatically, diagnosed during 2000–2004, had an unknown tumour grade, negative/unknown oestrogen and progesterone receptor status or tumour sizes ≥ 20 mm, ≤50 mm and had nodal involvement. Competing risk regression analysis was undertaken to estimate the breast cancer-specific mortality associated with each of the four loco-regional treatments received. Over a median follow-up of 8.8 years, women who received MTX alone had a higher risk of breast cancer-specific mortality (adjusted hazard ratio: 1.38, 95% confidence interval (CI): 1.05–1.82) compared to women who received BCS + RT. MTX + RT and BCS alone did not have any statistically different risk of mortality when compared to BCS + RT. Further inquiry is needed as to any advantages BCS + RT may have over MTX alternatives.

Post-lumpectomy radiation therapy boost in breast cancer patients: evidence revisited

Purpose

Radiation therapy is an integral part in the management of breast cancer after breast conservative surgery. In selected patients at high risk for local recurrence (LR), a boost radiation dose is commonly applied to the tumour bed.

Methods

We performed a review of the English literature using PubMed, Medline and Google Scholar for published manuscripts addressing the effect of boost radiation in breast cancer patients, focusing mainly on LR and overall survival (OS).

Results

A total of seven studies were included in our review. Most studies (6/7, 85.7%) showed a significant improvement in local control independent of age (hazard ratios ranging between 0.34 and 0.73), with the largest absolute benefit in younger patients. None of the studies, however, was able to demonstrate an improvement in OS.

Conclusions

With lack of sufficient studies addressing the role of boost radiation, individualised treatment decisions are recommended, taking into account the risk factors for LR, including tumour biology. Real-life data are sorely needed to better assess the role of tumour bed boost in the contemporary era.

A German Study Comparing Standard Wire Localization With Magnetic Seed Localization of Non-palpable Breast Lesions

BACKGROUND

Exact localization of non-palpable breast lesions is necessary to ensure that the correct lesion is removed. Conventional methods come with several disadvantages.

PATIENTS AND METHODS

We compared 28 patients who underwent breast-conserving surgery for a non-palpable lesion. By surgeon choice, 14 patients were assigned to undergo magnetic seed localization and 14 underwent standard wire localization. The primary outcome was the operative time, and secondary outcome was the patient pain level.

RESULTS

The mean age was 52±10 (SD) years in the seed arm, and 55±13 years in the wire arm. The median time from skin incision to tumor extraction was not significantly different between the two groups. Patients in the wire localized group significantly more often reported pain during coughing/breathing, movement, and sleep.

CONCLUSION

Using seed localization at Charité Breast Center did not lead to a significant decrease in operative time but might allow time savings once established, while increasing patient comfort and reducing organizational burden.

Who are the optimal candidates for partial breast irradiation?

At the 2017 St. Gallen International Expert Consensus Conference on the Primary Therapy for Early Breast Cancer, the consensus panel recognized "partial breast irradiation as an option for women meeting the low-risk criteria put forward by the American Society for Radiation Oncology/European Society for Radiotherapy and Oncology (ASTRO/ESTRO) guideline," although acknowledging that there was less evidence for this approach. Partial breast irradiation is defined as irradiation localized to the surgical resection cavity only as opposed to the entire breast. Accelerated partial breast irradiation (APBI) involves intensive treatment in a short time period. The methods vary, and three available APBI options are brachytherapy, external beam and intra-operative irradiation. The long-term follow-up results from two large-scale, well-designed phase III randomized clinical trials have been released. However, further discussion of the optimal treatment candidates and delivery method is needed before the clinical application of APBI as a mainstream breast conservation treatment.

Feasibility, Image Quality and Clinical Evaluation of Contrast-Enhanced Breast MRI Performed in a Supine Position Compared to the Standard Prone Position

Background: To assess the feasibility, image quality and diagnostic value of contrast-enhanced breast magnetic resonance imaging (MRI) performed in a supine compared to a prone position. Methods: One hundred and fifty-one patients who had undergone a breast MRI in both the standard prone and supine position were evaluated retrospectively. Two 1.5 T MR scanners were used with the same image resolution, sequences and contrast medium in all examinations. The image quality and the number and dimensions of lesions were assessed by two expert radiologists in an independent and randomized fashion. Two different classification systems were used. Histopathology was the standard of reference. Results: Two hundred and forty MRIs from 120 patients were compared. The analysis revealed 134 MRIs with monofocal (U), 68 with multifocal (M) and 38 with multicentric (C) lesions. There was no difference between the image quality and number of lesions in the prone and supine examinations. A significant difference in the lesion extension was observed between the prone and supine position. No significant differences emerged in the classification of the lesions detected in the prone compared to the supine position. Conclusions: It is possible to perform breast MRI in a supine position with the same image quality, resolution and diagnostic value as in a prone position. In the prone position, the lesion dimensions are overestimated with a higher wash-in peak than in the supine position.

Web-Based Medical Information Searching by Chinese Patients With Breast Cancer and its Influence on Survival: Observational Study

Background

The internet allows patients to easily look for health information. However, how Chinese patients with breast cancer use the internet has rarely been investigated, and there is a scarcity of information about the influence of internet use on survival.

Objective

This observational study aimed to investigate the details of online medical information searching by Chinese patients with breast cancer and to determine whether internet use has any survival benefits.

Methods

Patients who were diagnosed with invasive breast cancer at Peking Union Medical College Hospital between January 2014 and December 2015 were enrolled. We obtained information on their internet-searching behavior and gathered data from the patients’ medical and follow-up records. The associations between internet use and other clinic-pathological factors were analyzed. A Cox proportional-hazards model and the Kaplan-Meier method were used for disease-free survival (DFS) analyses.

Results

A total of 973 patients with invasive breast cancer who underwent definitive surgery took part in the study. Among them, 477 cases (49.0%) performed web-based breast cancer information searching before the initial treatment. A multivariate logistic regression analysis suggested that web-based breast cancer information searching was significantly associated with younger age (odds ratio [OR] 0.95, 95% CI 0.94-0.97, P<.001), higher education level (OR 1.37, 95% CI 1.01–1.86, P=.04), and breast conserving surgery (OR 1.35, 95% CI 1.04-1.77, P=.03). Baidu (73.4%, 350/477) and WeChat (66.7%, 318/477) were the two most popular online information sources for breast cancer; however, only 44.9% (214/477) felt satisfied with the online information. In contrast to the nonweb searching group, the web-using patients who were satisfied with online information showed significantly improved DFS (hazard ratio 0.26; 95% CI 0.08-0.88, P=.03).

Conclusions

The patients who were most likely to search the internet for breast cancer information were younger and well-educated, and they were more likely to have breast conserving therapy. Web-using patients who were satisfied with the internet information showed significantly improved DFS. Patients should browse credible websites offering accurate and updated information, and website developers should provide high-quality and easy-to-understand information to better meet the needs of patients with breast cancer.

Do early HER2-overexpression breast cancer patients benefit from undergoing neoadjuvant trastuzumab and mastectomy? A meta-analysis

Purpose

To assess the overall survival (OS) of early human epidermal growth factor receptor 2 (HER2)-enriched breast cancer patients after receiving neoadjuvant trastuzumab (NAT) compared to adjuvant trastuzumab (AT) treatment and the difference in local-regional relapse (LRR) rate with this tumor and treatment between women after mastectomy and women after breast-conserving therapy (BCT).

Methods

Articles were retrieved from PubMed, Embase, Web of Science, and Cochrane Library. A pooled odds ratio (OR) with a 95% confidential interval (CI) was calculated. The StataSE version 12.0 software was employed for meta-analysis.

Results

Twelve available clinical studies containing 2366 subjects were included. The OS of NAT compared with that of AT was not significantly different (pooled OR=1.04; 95% CI, 0.47–2.33). There was a significantly lower LRR rate for patients with mastectomy compared to those with BCT (pooled OR=0.58; 95% CI, 0.38–0.89); however, subgroup analysis revealed that the significant advantage of LRR for mastectomy compared to BCT was only represented in women without trastuzumab treatment (pooled OR=0.52; 95% CI, 0.31–0.88) compared to those who received trastuzumab treatment (pooled OR=0.71; 95% CI, 0.34–1.49).

Conclusion

Early stage HER2-overexpression breast cancer patients benefit with an equivalent OS from NAT treatment compared to AT. Patients who underwent mastectomy and BCT experienced a similar LRR rate if they received anti-HER2 targeted therapy of trastuzumab, but the LRR rate was discernibly reduced in patients who received mastectomy compared to BCT if they did not also receive trastuzumab treatment.

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Accelerated partial breast irradiation-Redefining the treatment target for women with early stage breast cancer

Following breast conserving surgery, the standard of care has been to deliver adjuvant radiation therapy directed to the whole breast (WBI) over a period of 3-7 weeks. Over the past decade, increasing data have supported the concept that treatment to the whole breast may not be required in selected patients, allowing for the emergence of partial breast irradiation (PBI). Multiple randomized trials with 5-10 years of follow-up have been published documenting the safety and efficacy associated with PBI using multiple techniques. Questions that remain to be answered include (a) what is the optimal PBI technique for each clinical scenario, (b) are there additional patients that can be effectively managed with PBI approaches, and (c) are there different techniques/dose schedules that allow for further reduction in treatment duration and/or toxicities? Partial breast irradiation represents a standard approach for appropriately selected patients. PBI provides comparable clinical outcomes to WBI while allowing for a reduction in the duration treatment and the potential for reduced toxicities. Future studies may also help to better define which patients require no radiation, PBI, hypofractionated WBI or conventional WBI, based upon patient, clinical, pathologic features as well as potentially using tumor genetics.

Evaluation of distant sequelae of breast cancer treatment among patients after breast-conserving surgery depending on the type of intervention in the axillary fossa

Aim of the study

The goal of this work was to assess upper-limb sequelae among patients undergoing breast-conserving therapy (BCT) for breast cancer 5-6 years after the surgical procedure.

Material and methods

A controlled clinical study was conducted on 128 patients who had undergone surgery 5-6 years prior. BCT + ALND (axillary lymph node dissection) was performed in 58 patients and 69 underwent BCT + SLND (sentinel lymph node dissection). Patients declared active participation in physiotherapy. The following parameters were assessed in studied subjects: range of motion in the shoulder joint, superficial sensation, upper limb circumference, skin sensation, and presence of winged scapula sign.

Results

Five to six years after BCT, patients who had undergone BCT + ALND presented with significantly poorer outcomes concerning upper limb range of motion on the operated side compared to the BCT + SLND group with regard to the following features: flexion (p = 0.00004), external rotation (p = 0.0292), and internal rotation (p = 0.0448). However, no statistically significant differences were noted between compared groups with regard to upper limb circumference and sensation disturbances. Statistically significant differences between limb on the operated side (operated limb - OL) vs. contralateral limb (healthy limb - HL) were noted in the BCT + SLND group with regard to the range of motion in extension (p = 0.0004), external rotation (p = 0.0055), and internal rotation (p < 0.0001), as well as the occurrence of winged scapula sign (p < 0.0001) and sensation disturbances (p < 0.0001).

Conclusions

Our study demonstrated that both procedures are not free of distant sequelae, although the BCT + ALND group is more frequently affected.

Enhancing patterns of breast cancer on preoperative dynamic contrast-enhanced magnetic resonance imaging and resection margin in breast conserving therapy

BACKGROUND

The association between enhancing patterns of preoperative dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) and resection margins after BCS has not been studied in detail before.

OBJECTIVE

We investigated the association between surgical outcomes and enhancing patterns observed on DCE-MRI.

METHODS

269 enhancing patterns on DCE-MRI scans were selected, and subdivided into the following groups: (1) a single mass-like enhancement, (2) a single non-mass-like enhancement (NME), (3) mass-like enhancing breast cancer with other mass-like enhancing lesions, and (4) mass-like enhancing breast cancer with additional NMEs. Associations between enhancing patterns on DCE-MRI and re-excision rate, size of specimen, and ratio of tumor/specimen were evaluated retrospectively.

RESULTS

The conversion rate from breast conserving therapy (BCT) to mastectomy as a result of MRI findings was 13.4%, re-excision rate during BCT was 8.2% and excision rate of another suspicious lesion was 7.4%. The single NME group had the highest re-excision rate after BCT (22.2%) (p = 0.02). The ratio of tumor/specimen (p = 0.61) and mean specimen size (p = 0.38) were not influenced by enhancement patterns. The false positive rate and positive predictive values of using DCE-MRI for defining the extension of breast cancer was 22.2% and 71.4%, respectively.

CONCLUSION

Enhancement patterns on DCE- MRI, especially NME, could increase re-excision rates.

Pulsed-dose-rate peri-operative brachytherapy as an interstitial boost in organ-sparing treatment of breast cancer

Purpose

To evaluate peri-operative multicatheter interstitial pulsed-dose-rate brachytherapy (PDR-BT) with an intra-operative catheter placement to boost the tumor excision site in breast cancer patients treated conservatively.

Material and methods

Between May 2002 and October 2008, 96 consecutive T1-3N0-2M0 breast cancer patients underwent breast-conserving therapy (BCT) including peri-operative PDR-BT boost, followed by whole breast external beam radiotherapy (WBRT). The BT dose of 15 Gy (1 Gy/pulse/h) was given on the following day after surgery.

Results

No increased bleeding or delayed wound healing related to the implants were observed. The only side effects included one case of temporary peri-operative breast infection and 3 cases of fat necrosis, both early and late. In 11 patients (11.4%), subsequent WBRT was omitted owing to the final pathology findings. These included eight patients who underwent mastectomy due to multiple adverse prognostic pathological features, one case of lobular carcinoma in situ, and two cases with no malignant tumor. With a median follow-up of 12 years (range: 7-14 years), among 85 patients who completed BCT, there was one ipsilateral breast tumor and one locoregional nodal recurrence. Six patients developed distant metastases and one was diagnosed with angiosarcoma within irradiated breast. The actuarial 5- and 10-year disease free survival was 90% (95% CI: 84-96%) and 87% (95% CI: 80-94%), respectively, for the patients with invasive breast cancer, and 91% (95% CI: 84-97%) and 89% (95% CI: 82-96%), respectively, for patients who completed BCT. Good cosmetic outcome by self-assessment was achieved in 58 out of 64 (91%) evaluable patients.

Conclusions

Peri-operative PDR-BT boost with intra-operative tube placement followed by EBRT is feasible and devoid of considerable toxicity, and provides excellent long-term local control. However, this strategy necessitates careful patient selection and histological confirmation of primary diagnosis.

Accelerated partial breast irradiation utilizing brachytherapy: patient selection and workflow

Accelerated partial breast irradiation (APBI) represents an evolving technique that is a standard of care option in appropriately selected woman following breast conserving surgery. While multiple techniques now exist to deliver APBI, interstitial brachytherapy represents the technique used in several randomized trials (National Institute of Oncology, GEC-ESTRO). More recently, many centers have adopted applicator-based brachytherapy to deliver APBI due to the technical complexities of interstitial brachytherapy. The purpose of this article is to review methods to evaluate and select patients for APBI, as well as to define potential workflow mechanisms that allow for the safe and effective delivery of APBI. Multiple consensus statements have been developed to guide clinicians on determining appropriate candidates for APBI. However, recent studies have demonstrated that these guidelines fail to stratify patients according to the risk of local recurrence, and updated guidelines are expected in the years to come. Critical elements of workflow to ensure safe and effective delivery of APBI include a multidisciplinary approach and evaluation, optimization of target coverage and adherence to normal tissue guideline constraints, and proper quality assurance methods.

The importance of surgical margins in breast cancer

Achieving negative margins with "no tumor on ink" is an appropriate goal in breast conserving therapy (BCT). Wider margins do not decrease recurrence rates, and re-excision in patients with microscopic positive margins is warranted. Several strategies exist to increase rates of negative margins, including techniques to improve tumor localization, intraoperative assessment of margins and oncoplastic techniques. Negative margins should be the goal of BCT, as this will improve both local control and long-term survival.

The use of an interstitial boost in the conservative treatment of breast cancer: how to perform it routinely in a radiotherapy department

Purpose

To demonstrate the utility of a boost with interstitial brachytherapy (BT) in breast-conserving therapy (BCT) by doing a thorough review of the literature and describing in detail our technique for delivering this boost.

Material and methods

Our department has been delivering the boost with interstitial BT since 1989, in most cases with rigid needles and a theoretical dosimetry. In the early years, we used low-dose-rate (LDR) with iridium-192 wires. The dose administered was 15 Gy if there were no risk factors for local relapse or 20-25 Gy in the presence of risk factors. The risk factors considered were the presence of a close margin (less than 10 mm) and an extensive intraductal component (more than 25%). After 2002, we switched to high-dose-rate (HDR); using the linear quadratic model we changed the low dose to 3 fractions of 4.5 Gy in the case of no risk factors for local relapse or to 3 fractions of 5 Gy in the presence of risk factors.

Results

In 79 consecutive boost patients treated in our department between 2010 and 2011, with a median follow-up of 46 months, the local control rate was 97.47%. With respect to cosmesis, fibrosis occurred in 17 cases (21.5%) and hyperpigmentation in 26 cases (32.9%). Our hospital's results are comparable in terms of local control and cosmesis to those of other authors.

Conclusions

This educational article describes our department's boost technique with rigid needles and comments briefly on our results using this technique in a group of consecutively treated patients in our department. A review of the literature and the published results on local control and cosmesis is also described.

Outcome of Breast Cancer Patients Treated outside of Clinical Trials

Background: Information on outcome of breast cancer patients treated in the community is scarce. Data on outcome of patients treated in real-life clinical practice may provide useful information for performance improvement.

Methods: Study population is from a single institution practice at the American University of Beirut Medical Center. Demographics, clinical characteristics and survival data on patients diagnosed 1997-2010 in two IRB-approved studies were entered and analyzed on SPSS program. Survival was estimated using Kaplan Meier Method.

Findings: Total was 519 patients. 23.9% had stage I, 39.7% stage II, 30.4% Stage III and 6% stage IV. ER positive in 74.4% of patients. 30.6% of patients <35 had TNBC compared to 12.3% for the whole group. 45.9% of non-metastatic patients had breast-conserving therapy (BCT). BCT rates increased to 64% during the second half of the study, coinciding with increasing awareness and changing cultural mores. 5-year and 10-year overall survivals for stage I were 98.9% and 80.5%, 89.2% and 70.7% for stage II, 67.6% and 35.5% for stage III, and 39.1% and 26.1% for stage IV respectively.

Interpretation: Patients treated outside clinical trials in a multidisciplinary fashion according to guidelines have comparable, and at times better, survival compared to data from trials or population statistics. Locally generated outcome data could be valuable for evaluating results of treatment at individual practices for the purpose of quality assessment and improvement. Our data also provides report of increased rate of breast conserving surgery from Middle East.

Landmark trials affecting the surgical management of invasive breast cancer

Significant progress has been made in the surgical management of breast cancer. Most women diagnosed with early stage invasive breast cancer can now be managed with breast-conserving therapy to include a segmental mastectomy followed by radiation. Axillary lymph nodes are routinely assessed by sentinel lymph node biopsy. Axillary lymph node dissection is reserved for patients with documented nodal metastasis; however, here too progress has been made because a population of low-risk patients has been identified in whom a complete dissection is not required even in the setting of a positive sentinel lymph node. This article details the landmark clinical trials that have guided the surgical management of breast cancer.

Dosimetric Improvements in Balloon Based Brachytherapy Using the Contura® Multi-Lumen Balloon (MLB) Catheter to Deliver Accelerated Partial Breast Irradiation

Purpose

Preliminary dosimetric findings in patients managed with the Contura^® Multi-Lumen Balloon (MLB) breast brachytherapy catheter to deliver accelerated partial breast irradiation (APBI) on a multi-institutional phase IV registry trial were reviewed.

Material and methods

CT-based 3D planning with dose optimization was performed for all patients. For the study, new ideal dosimetric goals were developed: 1) ≥ 95% of the prescribed dose (PD) covering ≥ 90% of the target volume (TV), 2) a maximum skin dose ≤ 125% of the PD, 3) maximum rib dose ≤ 145% of the PD, and 4) the V150 ≤ 50 cc and V200 ≤ 10 cc. The frequency of concurrently achieving these dosimetric goals using the Contura^® MLB was investigated.

Results

194 cases were evaluable. Employing the MLB, all ideal dosimetric criteria were achieved in 76% of cases. Evaluating dosimetric criteria separately, 90% and 89% of cases met the new ideal skin and rib dose criteria, respectively. In 96%, ideal TV coverage goals were achieved and in 96%, dose homogeneity criteria (V150 and V200) were met. For skin spacing ≥ 5-7 mm, the median skin dose was 121% of the PD and when < 5 mm, the median skin dose was 124.4%. For rib distancees < 5 mm, the median rib dose was reduced to 136.4% of the PD. For skin spacing < 7 mm and distance to rib < 5 mm, the median skin and rib doses were concurrently limited to 121% and 142.8% of the PD, respectively.

Conclusions

The Contura^® MLB catheter provides potential improvements in dosimetric capabilities (i.e., reduced skin and rib doses and improved TV coverage) in many clinical scenarios.