Adjuvant Radiotherapy For Breast Cancer Research Articles

The Effect of Hormonotherapy on the Development of Lung Fibrosis after Radiotherapy in Breast Cancer Patients

This study aimed to investigate the effects of hormonotherapy on lung fibrosis in patients receiving adjuvant conformal radiotherapy with the diagnosis of breast cancer. Data of 876 patients were examined.469 patients who underwent computed tomography (CT) for any reason after radiotherapy and whose CT images were available at 6th month and 2nd years were included in the study. CT sections were evaluated by a radiologist blindly. Pulmonary fibrosis was graded according to RTOG/EORTC toxicity criteria. The effect of hormonotherapy (tamoxifen and aromatase inhibitors), age, menopause status, radiotherapy, lung volume receiving ipsilateral 5 Gy (V5), lung volume receiving ipsilateral 20 Gy (V20), ipsilateral mean lung dose (MLD) and taxane group chemotherapy on pulmonary fibrosis were investigated. The median age in the study group was 51 (27-83). 239 patients (51%) were premenopausal. As hormonotherapy, 159 patients (33.9%) used tamoxifen and 253 patients used aromatase inhibitors (53.9%). Hormonotherapy was not used in 57 patients (12.2%-control group). Grade 1 fibrosis developed in 273 (53.9%) patients and grade 2 in 18 (3.8%) patients at the 6th month.304 patients (64.8%) developed grade 1, and 37 (7.9%) developed grade 2 fibrosis in the second year. Grade 3 and grade 4 fibrosis were not detected. When early and late lung fibrosis was examined, there was an increase in grade 2 lung fibrosis at the end of the 2nd year (p<0,001). A significant relationship was found between 6th month lung fibrosis and V20 (p = 0.019), MLD (p = 0.020) and regional lymphatic irradiation (p = 0.030). V20 (p<0,001), MLD (p<0,001), regional lymphatic irradiation (p = 0,030) and use of hormonotherapy (p<0,001) were effective in the formation of lung fibrosis in the 2nd year. Patients who received tamoxifen had more grade 2 fibrosis at the end of the second year than the patients who received control and aromatase inhibitors evaluated of hormone therapy(p<0,001). No relation was found between menopause status, age and taxane group chemotherapy and lung fibrosis development. The use of tamoxifen in patients receiving adjuvant radiotherapy for breast cancer increases the early and late lung fibrosis more than the aromatase inhibitors. However, V20, MLD, and regional lymph node irradiation also contribute to the frequency of fibrosis.Abstract 2112; TableLung fibrosis (No) n (%)Lung fibrosis (Yes) n (%)p valueAge (y-median)50 (28-74)52(27-83)0,257V5 (%-median)33,31 (4,83-94,0)36,59(16,55-96,69)0,095V20 (%-median)20,47(1,46-35,78)23,43(6,5-35,98)<0,001MLD(Gy-median)11,24(1,73-18,62)12,34(4,87-23,28)<0,001Hormonotherapy No Aromatase Inhibitors Tamoxifen29(22,7) 66(25,8) 33(25,8)28(8,2) 187(54,8) 126(37)<0,001Menopausal status Premenopause Postmenopause71(55,5) 57(44,5)168(49,3) 173(50,7)0,255Irradiation of the regional lymph nodes No Yes53(41,4) 75(58,6)92(27) 249(73)0,030Taxane chemotherapy No Yes68(53,1) 60(46,9)161(47,2) 180(52,8)0,257 Open table in a new tab

Postmastectomy Radiotherapy Using 5040 cGy in 28 Fractions for Patients with Immediate Breast Reconstruction: Institutional Outcomes

For patients planned to undergo adjuvant postmastectomy radiotherapy (PMRT) for breast cancer, immediate breast reconstruction (IBR) has been considered a relative contraindication. Delayed wound healing, increased risk of capsular contracture, fat necrosis, poor cosmesis, and rates of reoperation are of concern. Patients who have undergone IBR at our institution with an indication for PMRT are prescribed extended fractionation as per institutional policy. The aim of this quality assurance project is to review rates of reoperation for patients who received PMRT after IBR with autologous tissue (AT), tissue expanders (TE), or permanent implants (PI). Using a patient information system, patients were identified who underwent adjuvant PMRT to the chest wall and regional nodes to a total dose of 5040 cGy in 28 fractions between January 1, 2013 and January 31, 2019. Radiotherapy plans were reviewed. Medical records were reviewed for patient and treatment characteristics, and unexpected reoperation rate. Seventy-three patients underwent IBR and PMRT. Eleven (15.1%) patients had AT, 24 (32.9%) had TE, and 38 (52.1%) had PI. Twenty-four patients (32.9%) had documented cosmetic complications (including capsular contracture and asymmetry) after PMRT requiring reoperation. Cosmetic complications (CC) leading to reoperation were documented in 45.5% of patients with AT, 37.5% of patients with TE, and 26.3% of patients with PI. The mean elapsed time from PMRT completion to reoperation for cosmetic complications was 12.3 months (range = 2.3-33.1 months). Most patients received either adjuvant or neoadjuvant chemotherapy (97.3%). Of the patients having CC leading to reoperation compared to those without complication, a higher proportion received neoadjuvant chemotherapy, but this difference was not statistically significant (39.1% vs 19.4%, p = 0.135). For patients with CC leading to reoperation, there was a significantly higher volume of chest wall receiving ≥5040 cGy (851cc vs 680 cc, p = 0.023). Bolus was slightly more common in patients with CC but this difference was not statistically significant (91.7% vs 81.5, p = 0.461). For our cohort of patients receiving PMRT after IBR, the rate of CC is comparable to those quoted elsewhere. Interestingly, for our cohort, patients having PI had the lowest rate of CC leading to reoperation compared those with AT and TE. Patients with CC had a higher volume of chest wall receiving ≥ 5040 cGy. Further dosimetric analysis is needed to determine if there is a correlation with capsule dose and cosmetic outcomes.

Acute toxicity of normofractionated intensity modulated radiotherapy with simultaneous integrated boost compared to three-dimensional conformal radiotherapy with sequential boost in the adjuvant treatment of breast cancer

BackgroundIntensity-modulated radiotherapy (IMRT) improves dose homogeneity and late toxicity compared to simple tangential techniques in adjuvant whole-breast radiotherapy for patients with breast cancer. Simultaneous-integrated boost (SIB) radiotherapy shortens the overall treatment time and improves dose homogeneity. However, prospective randomized trials regarding IMRT with SIB for adjuvant radiotherapy in breast cancer are lacking.MethodsThe IMRT-MC2 (MINT) trial is a phase III prospective randomized controlled trial comparing IMRT with SIB (Arm A: whole breast 28 × 1.8 Gy, Boost 28 × 2.3 Gy) to 3D-conformal radiotherapy with a sequential boost (Arm B: whole breast 28 × 1.8 Gy, boost 8 × 2 Gy) in patients with breast cancer after BCS. Indication for boost radiotherapy was defined as age < 70 years or age > 70 years with presence of additional risk factors. This is a retrospective analysis of acute toxicity at one of two trial sites.ResultsFive hundred two patients were randomized, of which 446 patients were eligible for this analysis. There was no statistically significant difference in terms of any grade radiation dermatitis between the two treatment arms at the end of treatment (p = 0.26). However, radiation dermatitis grade 2/3 (29.1% vs. 20.1 and 3.5% vs. 2.3%) occurred significantly more often in Arm A (p = 0.02). Breast/chest wall pain at the first follow-up visit was significantly more common in patients treated on Arm B (p = 0.02).ConclusionsTreatment on both arms was well tolerated, however there were some differences regarding radiodermatitis and breast pain. Further analyses are ongoing.Trial registrationclinicaltrials.gov, NCT01322854, registered 24th March 2011.

Adjuvant Trastuzumab Emtansine (T-DM1) and Concurrent Radiotherapy for Residual Invasive HER2-positive Breast Cancer: Single-center Preliminary Results.

The treatment of nonmetastatic HER2-positive breast cancer with residual invasive disease using concurrent Trastuzumab emtansine (T-DM1) and radiotherapy appears to be an effective option. Our aim was to evaluate the acute side effects of this treatment regime. Fourteen patients were treated between March 2019 and April 2020 concurrent T-DM1 and radiotherapy. Left ventricular ejection fraction was assessed at baseline, before and after radiotherapy. All toxicities were evaluated using Common Terminology Criteria of Adverse Events (CTCAE) version 3.0. The median age was 55 years (range 36 to 72). All patients received total dose of 50 Gy for the breast/ chest wall, 10 patients got lymph node irradiation, 4 patients received an additional tumor bed boost. The most common side effect was grade 1 radiodermatitis. A reversible grade 2 left ventricular ejection fraction decrease occurred in 2 patients. During our examination 3 patients showed alanine aminotransferases increase after the cycle 4 of T-DM1, 1 patient had grade 1, 1 patient grade 2, and 1 patient grade 3 alanine aminotransferase increases. The acute toxicity rate especially focusing on skin and cardiac toxicity were assumed acceptable in our cohort. To safely administer this concomitant treatment, further examination and prospective data are needed.

Expression of HGF, pMet, and pAkt is related to benefit of radiotherapy after breast-conserving surgery: a long-term follow-up of the SweBCG91-RT randomised trial.

Experimental studies suggest that hepatocyte growth factor (HGF) and its transmembrane tyrosine kinase receptor, Met, in part also relying on Akt kinase activity, mediate radioresistance. We investigated the importance of these biomarkers for the risk of ipsilateral breast tumour recurrence (IBTR) after adjuvant radiotherapy (RT) in primary breast cancer. HGF, phosphorylated Met (pMet) and phosphorylated Akt (pAkt) were evaluated immunohistochemically on tissue microarrays from 1004 patients in the SweBCG91-RT trial, which randomly assigned patients to breast-conserving therapy, with or without adjuvant RT. HGF was evaluated in the stroma (HGFstr ); pMet in the membrane (pMetmem ); HGF, pMet and pAkt in the cytoplasm (HGFcyt , pMetcyt , pAktcyt ); and pAkt in the nucleus (pAktnuc ). The prognostic and treatment predictive effects were evaluated to primary endpoint IBTR as first event during the first 5years. Patients with tumours expressing low levels of HGFcyt and pMetcyt and high levels of pAktnuc derived a larger benefit from RT [hazard ratio (HR): 0.11 (0.037-0.30), 0.066 (0.016-0.28) and 0.094 (0.028-0.31), respectively] compared to patients with high expression of HGFcyt and pMetcyt , and low pAktnuc [HR: 0.36 (0.19-0.67), 0.35 (0.20-0.64) and 0.47 (0.32-0.71), respectively; interaction analyses: P=0.052, 0.035 and 0.013, respectively]. These differences remained in multivariable analysis when adjusting for patient age, tumour size, histological grade, St Gallen subtype and systemic treatment (interaction analysis, P-values: 0.085, 0.027, and 0.023, respectively). This study suggests that patients with immunohistochemically low HGFcyt , low pMetcyt and high pAktnuc may derive an increased benefit from RT after breast-conserving surgery concerning the risk of developing IBTR.

Abstract CT271: PRECISION (Profiling early breast cancer for radiotherapy omission): A phase II study of breast-conserving surgery without adjuvant radiotherapy for favorable-risk breast cancer

Abstract Background: Radiation therapy (RT) following breast conserving surgery (BCS) is known to improve locoregional and distant control in women with invasive breast cancer; however, RT does pose significant cost and potential risk, including concern for cardiopulmonary toxicity and secondary malignancy. Randomized trials show that the omission of RT among older women with otherwise favorable-risk breast cancer does not affect overall survival (OS) at 10 years, and modestly increases the risk of local recurrence (LR). Nevertheless, there is little prospective support for RT omission in younger women. Moreover, risk stratification in the randomized prospective studies to date relies on limited methods with potentially low fidelity at distinguishing luminal subtypes. Enhanced molecular profiling techniques could better discern tumor biology and, in turn, more precisely assess risk. PAM-50 is an expression profile of 50 genes used to classify breast cancer intrinsic subtype with consequent prognostic implications. The goal of this study is to identify low-risk breast cancer patients with luminal A subtype who may feasibly omit RT from their therapeutic regimen. Methods: This is a phase II prospective cohort study (NCT02653755) designed to assess the safety of treatment de-escalation (omission of RT) in women with favorable-risk invasive breast cancer following BCS. Eligibility criteria include female patients with invasive breast cancer, age 50-75, with tumors less than or equal to 2cm, negative surgical margins, ER+ or PR+ and HER2- disease, grade 1 or 2, no lymph node involvement, and no plans for chemotherapy or biologic therapy, who are eligible for and willing to receive endocrine therapy. Tumor samples from eligible patients will undergo PAM-50 transcriptional profiling using the Nanostring Prosigna assay. A low Risk of Recurrence (ROR) score, corresponding to the luminal A subtype, will permit patients to forego radiotherapy should they so choose. The primary endpoint is 5-year risk of local or regional recurrence of invasive or in situ breast carcinoma within the ipsilateral breast or regional lymph nodes. Study enrollment began in May 2016. Citation Format: Mira A. Patel, Deborah A. Dillon, Giulia Digiovanni, Yu-Hui Chen, Paul Catalano, Carmen Perez, David Wazer, Jean Wright, Rachel Jimenez, Eric Winer, Julia Wong, Jennifer Bellon, Lior Z. Braunstein. PRECISION (Profiling early breast cancer for radiotherapy omission): A phase II study of breast-conserving surgery without adjuvant radiotherapy for favorable-risk breast cancer [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr CT271.

A Single-centre, Retrospective Audit of Adherence to the Updated Royal College of Radiology (RCR) Guidelines for the Treatment Duration of Adjuvant Breast Radiotherapy

Purpose: Adjuvant breast cancer radiotherapy forms a vital part of breast cancer management. This is delivered as 40.05 Gy/15 fractions and should complete within 19 days. Cancer cells can repopulate between treatments and overall treatment time should be minimised. Gaps in treatment can facilitate repopulation, potentially leading to lower cure rates [1]. Radical radiotherapy courses should not be interrupted; if unavoidable, these delays should be compensated for. In January 2019, the Royal College of Radiologists (RCR) published updated guidance on the recommended treatment duration for adjuvant breast cancer radiotherapy, stipulating a prolongation of treatment duration by no more than 2 days [2].

Delays to Adjuvant Breast Cancer Radiotherapy Resulting from Oncotype Dx Testing in Patients with Low/Intermediate Recurrence Risk Scores

Purpose: Oncotype Dx is a 21 gene recurrence score assay that risk stratifies patients who have completed primary surgical treatment for breast cancer to low or intermediate (adjuvant chemotherapy not routinely recommended) versus high risk of recurrence (adjuvant chemotherapy recommended). 73% of patients tested are stratified to the low/intermediate risk of recurrence group [1]. However, a proportion of these patients may have delays to commencing adjuvant radiotherapy. The current median time to adjuvant radiotherapy following surgery is recorded as 60 days [2].

Effect of Delayed Targeted Intraoperative Radiotherapy vs Whole-Breast Radiotherapy on Local Recurrence and Survival

Conventional adjuvant radiotherapy for breast cancer given daily for several weeks is onerous and expensive. Some patients may be obliged to choose a mastectomy instead, and some may forgo radiotherapy altogether. We proposed a clinical trial to test whether radiotherapy could be safely limited to the tumor bed. To determine whether delayed second-procedure targeted intraoperative radiotherapy (TARGIT-IORT) is noninferior to whole-breast external beam radiotherapy (EBRT) in terms of local control. In this prospective, randomized (1:1 ratio) noninferiority trial, 1153 patients aged 45 years or older with invasive ductal breast carcinoma smaller than 3.5 cm treated with breast conservation were enrolled from 28 centers in 9 countries. Data were locked in on July 3, 2019. The TARGIT-A trial was started in March 2000; patients were randomized after needle biopsy to receive TARGIT-IORT immediately after lumpectomy under the same anesthetic vs EBRT and results have been shown to be noninferior. A parallel study, described in this article, was initiated in 2004; patients who had their cancer excised were randomly allocated using separate randomization tables to receive EBRT or delayed TARGIT-IORT given as a second procedure by reopening the lumpectomy wound. A noninferiority margin for local recurrence rate of 2.5% at 5 years, and long-term survival outcomes. Overall, 581 women (mean [SD] age, 63 [7] years) were randomized to delayed TARGIT-IORT and 572 patients (mean [SD] age, 63 [8] years) were randomized to EBRT. Sixty patients (5%) had tumors larger than 2 cm, or had positive nodes and only 32 (2.7%) were younger than 50 years. Delayed TARGIT-IORT was not noninferior to EBRT. The local recurrence rates at 5-year complete follow-up were: delayed TARGIT-IORT vs EBRT (23/581 [3.96%] vs 6/572 [1.05%], respectively; difference, 2.91%; upper 90% CI, 4.4%). With long-term follow-up (median [IQR], 9.0 [7.5-10.5] years), there was no statistically significant difference in local recurrence-free survival (HR, 0.75; 95% CI, 0.57-1.003; P = .052), mastectomy-free survival (HR, 0.88; 95% CI, 0.65-1.18; P = .38), distant disease-free survival (HR, 1.00; 95% CI, 0.72-1.39; P = .98), or overall survival (HR, 0.96; 95% CI, 0.68-1.35; P = .80). These long-term data show that despite an increase in the number of local recurrences with delayed TARGIT-IORT, there was no statistically significant decrease in mastectomy-free survival, distant disease-free survival, or overall survival. ISRCTN34086741, ClinicalTrials.gov Identifier: NCT00983684.

Dosimetric Correlation Between The Depth of Chest Wall Expansion and Heart Dose in Left Breast Cancer Irradiation Using Deep Inspiratory Breath Hold Technique

Introduction and Objective: In adjuvant radiotherapy for left breast cancer, a significant heart volume may be included in the radiation field leading to long-term cardiac toxicities. Deep inspiratory breath hold technique (DIBH) leads to chest wall separation away from the heart and thus can reduce the heart dose compared to free breathing technique. The aim of this study is to correlate dosimetrically the degree of chest wall expansion measured on planning 4D-CT scan to the heart dose in left breast cancer irradiation using DIBH technique. Materials and Methods: Thirty four patients with left breast cancer planned for adjuvant radiotherapy were included. All patients were scanned by Varian RPM (Real Time Position Managment) respiratory gating system using infrared reflecting markers and a video camera to detect the respiratory motion. IMRT or VMAT plans were done for all patients with a prescribed dose 50Gy/25fr/5w with or without operative bed boost dose 10Gy/5fr/1w. The degree of chest wall expansion was identified by measuring the amplitude of DIBH breathing curve from baseline in planning 4D-CT scan in centimeters. The depth of expansion was correlated dosimetrically with the heart V20, V30, and mean heartdose. Results: The mean distance of chest wall expansion was 2.9cm. The mean left lung dose was 8.6Gy. The mean left lung V20 was 13.8%. The mean heart dose was 1.8Gy. The mean heart V30 was 0.6%. A statistically significant reduction of the mean heart dose and V30 was observed with chest wall expansion of 1.4cm or higher (p&lt;0.05). Conclusion: In DIBH technique, the depth of chest wall expansion in 4DCT planning is dosimetrically correlated with the cardiac dose reduction during adjuvant irradiation of left breast cancer. Further clinical studies are needed to translate this dosimetric advantage into clinical benefit.

Do patients enrolled in observational studies have better outcomes than non-participants? A retrospective analysis

Patients are commonly enrolled into clinical trials. It has been reported that these patients may have better outcomes than those not enrolled into the study. The reasoning from these improvements could be attributable to closer follow-up, better patient adherence, more health aware patients have, or reaction to observation such as the Hawthorne effect. Three hundred forty-six patients were approached for a prospective skin toxicity study in adjuvant breast cancer radiotherapy (RT) but declined participation between January 2018 and July 2019 (non-trial group). They were retrospectively reviewed and patient, treatment and RT-related characteristics, as well as the occurrence of skin reactions, and the usage of topical treatments were collected. This was compared with a comparison cohort of 349 patients who were enrolled into a previously conducted prospective study (trial group). More patients in the trial group had conventional RT (CFRT) versus hypofractionated RT (HFRT). Data was further stratified and there was no significant difference in moist desquamation, topical antibiotic usage, dressing application, home care use, topical corticoid steroid use, and oral analgesic use. There was a significantly lower pain score in the group compared with the non-trial group in both HFRT and CFRT (OR = 0.091 and OR = 0.348, p < 0.0001). Our results demonstrated no differences other than pain between the trial group and non-trial group. Therefore, in this cohort, patients enrolled into an observational trial while undergoing adjuvant breast RT demonstrated similar experiences of skin reactions. There are challenges to assessing differences between these groups, as confounding is likely. Therefore, it is recommended for future studies to additionally assess the impact of study participation on outcomes such as quality of life, quality of care received, and/or anxiety levels.

Time to Adjuvant Radiotherapy in Breast Cancer Affects Survival: Implications for the American College of Surgeons Commission on Cancer Quality Metrics.

To optimize breast cancer care, the American College of Surgeons Commission on Cancer developed quality measures regarding receipt and timing of adjuvant radiotherapy (RT). Nationwide compliance with these measures and its impact on overall survival (OS) are evaluated herein. Patients (n = 285,291) diagnosed with invasive breast cancer from 2004 to 2012 were identified from the National Cancer Database. Compliance with RT administration within 365days from diagnosis was determined for patients with stage III disease with ≥ 4 positive lymph nodes post mastectomy and stage I-III disease post breast-conserving surgery (BCS). Univariate and multivariate logistic regression and Cox proportional hazard models were used to assess factors associated with compliance and OS, respectively. In the mastectomy cohort, 66.9% received timely RT, showing improved OS versus no RT patients (HR 0.70, 95% CI 0.67-0.73). Delayed RT patients (≥ 365days) achieved equivalent OS to those receiving timely RT (HR 1.07, 95% CI 0.93-1.23) and superior OS to no RT patients (HR 0.74, 95% CI 0.65-0.85). In the BCS cohort, 89.4% received timely RT, showing improved OS versus no RT patients (HR 0.47, 95% CI 0.45-0.49). Delayed RT was associated with improved OS versus no RT (HR 0.64, 95% CI 0.56-0.74) and decreased OS versus timely RT (HR 1.37, 95% CI 1.19-1.58). Factors associated with noncompliance included insurance type and distance to hospital. Quality measure compliance with adjuvant RT improves OS, regardless of timing after mastectomy. However, timeliness does impact OS after BCS. Focus on modifiable factors to improve compliance such as access to care may lead to improved compliance and OS.

A retrospective analysis on metastatic rate of the internal mammary lymph node and its clinical significance in adjuvant radiotherapy of breast cancer patients

BackgroundThere is a discrepancy about the metastatic rate of internal mammary lymph nodes (IMNs) between clinical and pathologic findings. We aimed to investigate the metastatic rate of IMNs and to provide recommendations on target volume delineation of IMNs for adjuvant radiotherapy in breast cancer patients.MethodsWe retrospectively analyzed data from 114 breast cancer patients treated with surgery without adjuvant radiotherapy who developed local and/or regional lymph node recurrence/metastasis at our institute from January 2015 to January 2019. Patients with widely lung or pleural metastases were excluded. We first analyzed the recurrence rate with the chest wall, the metastatic rate of internal mammary/anterior mediastinal, ipsilateral axillary and supraclavicular lymph nodes, and then investigated the distribution of the IMNs.ResultsAmong the 114 included patients, the recurrence rate with the chest wall, metastatic rate of IMNs, IMNs/anterior mediastinal lymph nodes, ipsilateral axillary lymph nodes, and the ipsilateral supraclavicular lymph nodes was 43, 37.7, 59.6, 12.3, and 22.8%, respectively. The metastatic IMNs were mainly located from the first to the second intercostal space. However, metastatic lymph nodes could also be observed above the upper edge of the first rib.ConclusionsThe metastatic rate is high in the IMNs and irradiation of the internal mammary lymphatic chain is required. It is suggested that the upper bound of the internal mammary lymphatic chain should be up to the subclavian vein with a 5-mm margin, thus connecting to the caudal border of supraclavicular clinical target volume in breast cancer patients at high risk of recurrence.

An Evaluation of Rates of Breast Re-Excision in Patients Undergoing Breast Conserving Surgery with Adjuvant Radiotherapy for Breast Cancer

Background: Most women diagnosed with early stage breast cancer have the option of receiving either mastectomy or breast conserving surgery (BCS) plus adjuvant radiotherapy as randomized clinical trials have reported equivalent outcomes in terms of mortality. BCS followed by radiotherapy is generally the preferred treatment option for early stage breast cancer as BCS is less invasive, associated with less morbidity and a superior cosmetic outcome than mastectomy. Primary disadvantages of this treatment include the risk of positive resection margins that necessitate additional surgery by either further BCS or mastectomy. Re-excision is associated with greater morbidity, patient anxiety, inferior cosmetic outcome, delayed initiation of adjuvant therapies, and increased medical cost. Our aim was to evaluate re-excisions rates at our hospital and assess the impact of gaining a radiologist opinion on the specimen x-ray makes on re-excision rates. Furthermore, we aimed to confirm that all breast conservation procedures including non-image guided WLE’s (palpable lesions) need specimen x-rays.

Long-term risk of ischemic heart disease after adjuvant radiotherapy in breast cancer: results from a large population-based cohort

BackgroundAdjuvant radiotherapy (RT) for breast cancer (BC) has been associated with an increased risk of ischemic heart disease (IHD). We examined the incidence of IHD in a large population-based cohort of women with BC.MethodsThe Breast Cancer DataBase Sweden (BCBaSe) includes all women diagnosed with BC from 1992 to 2012 (n = 60,217) and age-matched women without a history of BC (n = 300,791) in three Swedish health care regions. Information on comorbidity, educational level, and incidence of IHD was obtained through linkage with population-based registries. The risk of IHD was estimated by Cox proportional hazard regression analyses and cumulative incidence by the Kaplan-Meier method.ResultsWomen with BC had a lower risk of IHD compared to women without BC with a hazard ratio (HR) of 0.91 (95% CI 0.88–0.95). When women with left-sided BC were compared to right-sided BC, an increased HR for IHD of 1.09 (95% CI 1.01–1.17) was seen. In women receiving RT, a HR of 1.18 (95% CI 1.06–1.31) was seen in left-sided compared to right-sided BC, and the HRs increased with more extensive lymph node involvement and with the addition of systemic therapy. The cumulative IHD incidence was increased in women receiving left-sided RT compared to right-sided RT, starting from the first years after RT and sustained with longer follow-up.ConclusionsWomen given RT for left-sided BC during 1992 to 2012 had an increased risk of IHD compared to women treated for right-sided BC. These women were treated in the era of three-dimensional conformal RT (3DCRT), and the results emphasize the importance of further developing and implementing RT techniques that lower the cardiac doses, without compromising the beneficial effects of RT.

Adjuvant radiotherapy for low-risk early breast cancer in elderly women: evidence from randomized trials.

Breast cancer is the most common cancer pathology in women in the Western world. The median age at diagnosis is 60 years and in the coming decades it is estimated that the number of elderly women affected reaches an important percentage. This aging of the cancer population, associated with its inherent comorbidities and aggravated by the lack of consensus about the most appropriate treatment, make it difficult to administer an effective postoperative treatment in elderly women with a low-risk profile. An exhaustive geriatric evaluation is a sine qua non condition to opt for a specific type of treatment. To date, several options are available such as endocrine therapy (ET) alone, moderate/high hypofractionation and various accelerated partial breast irradiation (APBI) techniques. In this article, we provide information about each of them.

Late locoregional complications associated with adjuvant radiotherapy in the treatment of breast cancer: Systematic review and meta-analysis.

This systematic review with meta-analysis addressed late locoregional complications associated with adjuvant radiotherapy (RT) in breast cancer. Among 2120 titles, ten comparative studies in patients undergoing surgery vs surgery and radiotherapy reporting complications were evaluated. RT was associated with an increased risk of capsular contracture and decreased the mobility of the upper limb. A borderline association of lymphedema risk using RT was noted in the random-effects model but was significant in the fixed-effects model.

ST2 levels increased and were associated with changes in left ventricular systolic function during a three-year follow-up after adjuvant radiotherapy for breast cancer

ObjectivesTo search for biomarkers of RT-induced cardiotoxicity, we studied the behavior of ST2 during RT and three years after RT, and the associations with echocardiographic changes. Materials and methodsWe measured soluble ST2 (ng/ml) in serum samples from 63 patients receiving RT for early breast cancer. Sampling and echocardiography were performed at baseline, after RT and at the three-year follow-up. Patients were grouped by >15% (group 1) and ≤15% (group 2) relative worsening in global longitudinal strain (GLS). ResultsST2 levels tended to increase during RT, from a median (interquartile range; IQR) of 17.9 (12.4–22.4) at baseline to 18.2 (14.1–23.5) after RT (p = 0.075). By the three-year follow up, ST2 levels increased to 18.7 (15.8–24.2), p = 0.018. The increase in ST2 level was associated with worsening cardiac systolic function at three-year follow-up, GLS (rho = 0.272, p = 0.034) and left ventricular ejection fraction (LVEF) (rho = ─0.343, p = 0.006). Group 1 (n = 14) had a significant increase in ST2 levels from 17.8 (12.3–22.5) at baseline to 18.4 (15.6–22.6) after RT, p = 0.035 and to 19.9 (16.0–25.1) three years after RT, p = 0.005. ST2 levels were stable in group 2 (n = 47): 17.8 (12.3–22.0) at baseline, 17.7 (12.6–23.5) after RT and 18.0 (15.5–22.4) at three years. ConclusionST2 may be useful for determining which patients are at risk for long-term cardiovascular toxicity following adjuvant breast cancer RT, but prospective clinical studies are needed to confirm this hypothesis.

Helical tomotherapy for patients presented with implant breast reconstruction in case of adjuvant breast cancer radiotherapy: A single center experience.

Helical tomotherapy for patients presented with implant breast reconstruction in case of adjuvant breast cancer radiotherapy: A single center experience.

Synchronous versus sequential chemo-radiotherapy in patients with early stage breast cancer (SECRAB): A randomised, phase III, trial

The optimal sequence of adjuvant chemotherapy and radiotherapy for breast cancer is unknown. SECRAB assesses whether local control can be improved without increased toxicity. SECRAB was a prospective, open-label, multi-centre, phase III trial comparing synchronous to sequential chemo-radiotherapy, conducted in 48 UK centres. Patients with invasive, early stage breast cancer were eligible. Randomisation (performed using random permuted block assignment) was stratified by centre, axillary surgery, chemotherapy, and radiotherapy boost. Permitted chemotherapy regimens included CMF and anthracycline-CMF. Synchronous radiotherapy was administered between cycles two and three for CMF or five and six for anthracycline-CMF. Sequential radiotherapy was delivered on chemotherapy completion. Radiotherapy schedules included 40 Gy/15F over three weeks, and 50 Gy/25F over five weeks. The primary outcome was local recurrence at five and ten years, defined as time to local recurrence, and analysed by intention to treat. ClinicalTrials.gov NCT00003893. Between 02-July-1998 and 25-March-2004, 2297 patients were recruited (1150 synchronous and 1146 sequential). Baseline characteristics were balanced. With 10.2 years median follow-up, the ten-year local recurrence rates were 4.6% and 7.1% in the synchronous and sequential arms respectively (hazard ratio (HR) 0.62; 95% confidence interval (CI): 0.43-0.90; p = 0.012). In a planned sub-group analysis of anthracycline-CMF, the ten-year local recurrence rates difference were 3.5% versus 6.7% respectively (HR 0.48 95% CI: 0.26-0.88; p = 0.018). There was no significant difference in overall or disease-free survival. 24% of patients on the synchronous arm suffered moderate/severe acute skin reactions compared to 15% on the sequential arm (p < 0.0001). There were no significant differences in late adverse effects apart from telangiectasia (p = 0.03). Synchronous chemo-radiotherapy significantly improved local recurrence rates. This was delivered with an acceptable increase in acute toxicity. The greatest benefit of synchronous chemo-radiation was in patients treated with anthracycline-CMF. Cancer Research UK (CR UK/98/001) and Pharmacia.