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Massaccesi M, Fontana A, Palumbo I, Argenone A, De Santis MC, Masiello V, Pontoriero A, Ciabattoni A. Pattern of practice of re-irradiation for ipsilateral breast tumor recurrence in Italy: a survey by the Italian Association of Radiotherapy and Clinical Oncology (AIRO). Clin Transl Oncol 2024; 26:644-652. [PMID: 37515701 DOI: 10.1007/s12094-023-03289-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Accepted: 07/17/2023] [Indexed: 07/31/2023]
Abstract
PURPOSE The Re-irradiation and the Breast Cancer Working Groups of the Italian Association of Radiotherapy and Clinical Oncology (AIRO) conducted a survey to provide an overview of the policies for breast cancer (BC) re-irradiation (re-RT) among the Italian radiotherapy (RT) centers. METHODS In October 2021, 183 RT centers were invited to answer a survey: after an initial section about general aspects, the questionnaire focused on radiation oncologists' (ROs) attitude toward re-RT in three different scenarios: ipsilateral breast tumor recurrence (IBTR) treated with second conservative surgery, IBTR treated with mastectomy and inoperable IBTR. Surveyed ROs were also asked to express their interest in being involved in a prospective trials. RESULTS Seventy-seven/183 (42.0%) centers answered the Survey, only one RO per center was requested to answer. In particular, 86.5% ROs declared to have performed "curative" re-RT for IBTR during the previous two years (2019-2020): 76.7% respondents administered re-RT after second BCS, 50.9% after mastectomy, and 48.1% for inoperable IBTR. Re-RT practice varied widely among centers in terms of treatment volumes, dose and fractionation schedules, techniques and dose-volume constraints for organs at risks (OARs). Forty-six participants (59.7%) expressed their interest in participating in a prospective study investigating BC re-RT. CONCLUSIONS About one out of three RT centers in Italy delivered re-RT for IBTR. Nevertheless, practice of re-RT varied widely among centers highlighting the needs for prospective studies to improve knowledge in this field.
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Affiliation(s)
- Mariangela Massaccesi
- Radiation Oncology Unit, Department of Radiology, Radiation Oncology and Hematology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Antonella Fontana
- Radiotherapy Department, Santa Maria Goretti Hospital, Latina, Italy
| | - Isabella Palumbo
- Radiation Oncology Section, Department of Medicine and Surgery, Sant'Andrea delle Fratte, University of Perugia and Perugia General Hospital, 06156, Perugia, Italy.
| | | | - Maria Carmen De Santis
- Radiation Oncology, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Milan, Italy
| | - Valeria Masiello
- Radiation Oncology Unit, Department of Radiology, Radiation Oncology and Hematology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Antonio Pontoriero
- Radiation Oncology Unit, Department of Biomedical, Dental Science and Morphological and Functional Images, University of Messina, Messina, Italy
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Lyons JA. Second Breast Conserving Therapy: Who, What, When, and How? Int J Radiat Oncol Biol Phys 2023; 117:1211-1212. [PMID: 37980142 DOI: 10.1016/j.ijrobp.2023.08.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 08/07/2023] [Accepted: 08/09/2023] [Indexed: 11/20/2023]
Affiliation(s)
- Janice A Lyons
- University Hospitals Seidman Cancer Center, Cleveland, Ohio.
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Baude J, Dendale R, Cao K, Fourquet A, Kirova Y. Tolerance and Oncological Outcomes of In-Field Reirradiation for Locally Recurrent Breast Cancer: A Long-Term Single-Center Experience. Cancers (Basel) 2023; 15:4515. [PMID: 37760484 PMCID: PMC10527329 DOI: 10.3390/cancers15184515] [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: 08/11/2023] [Revised: 09/04/2023] [Accepted: 09/07/2023] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND The management of cancer relapse in previously irradiated tissues is a challenging therapeutic issue. The aim of this work was to report our experience with breast reirradiation for locoregionally recurrent breast cancer. METHODS All patients who underwent breast or chest wall in-field reirradiation at the Institut Curie, Paris, France, between 2003 and 2019, were identified. Efficacy outcomes and physician-reported toxicities were retrospectively assessed. RESULTS A total of 21,372 patients underwent breast irradiation in our institution. Of these, 28 received a second course of radiotherapy to the homolateral breast/chest wall. A total of 18 (64%) patients were treated with a curative intent, and 10 (36%) were treated for palliative purposes. Only one acute and one late grade 3 adverse events were reported. One patient with major cardiovascular risk factors died of myocardial infarction 13 months after left breast reirradiation. The 2-year LRFS, OS, DSS, PFS and MFS were 59%, 79%, 82%, 46% and 75%, respectively, in the whole cohort. The 2-year LRFS (72% vs. 31%, p = 0.02), OS (94% vs. 50%, p < 0.01), DSS (94% vs. 56%, p < 0.01) and PFS (61% vs. 20%, p = 0.02) differed significantly between patients treated with curative or palliative intent but not the MFS (78% vs. 69%, p = 0.77). Among the patients, eight (29%) remained relapse-free 5 years after reirradiation. CONCLUSION Breast/chest wall reirradiation appears to be feasible with good disease control, especially in patients treated with a curative intent, and presents acceptable toxicity rates.
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Affiliation(s)
- Jérémy Baude
- Department of Radiation Oncology, Institut Curie, 75005 Paris, France; (J.B.); (R.D.); (K.C.); (A.F.)
| | - Rémi Dendale
- Department of Radiation Oncology, Institut Curie, 75005 Paris, France; (J.B.); (R.D.); (K.C.); (A.F.)
| | - Kim Cao
- Department of Radiation Oncology, Institut Curie, 75005 Paris, France; (J.B.); (R.D.); (K.C.); (A.F.)
| | - Alain Fourquet
- Department of Radiation Oncology, Institut Curie, 75005 Paris, France; (J.B.); (R.D.); (K.C.); (A.F.)
| | - Youlia Kirova
- Department of Radiation Oncology, Institut Curie, 75005 Paris, France; (J.B.); (R.D.); (K.C.); (A.F.)
- UFR Santé, Versailles Saint-Quentin-en-Yvelines University, 78180 Saint Quentin-en-Yvelines, France
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4
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Early effectiveness and toxicity outcomes of reirradiation after breast conserving surgery for recurrent or new primary breast cancer. Breast Cancer Res Treat 2023; 198:43-51. [PMID: 36604352 DOI: 10.1007/s10549-022-06853-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 12/28/2022] [Indexed: 01/07/2023]
Abstract
PURPOSE Breast reirradiation (reRT) after breast conserving surgery (BCS) has emerged as a viable alternative to mastectomy for women presenting with recurrent or new primary breast cancer. There are limited data on safety of different fractionation regimens. This study reports safety and efficacy among women treated with repeat BCS and reRT. METHODS AND MATERIALS Patients who underwent repeat BCS followed by RT from 2015 to 2021 at 2 institutions were analyzed. Univariate logistic regression models were used to identify predictors of acute and late toxicities. Kaplan-Meier estimates were used to evaluate overall survival (OS), distant metastasis-free survival (DMFS) and locoregional recurrence-free survival (LR-RFS). RESULTS Sixty-six patients were reviewed with median follow-up of 16 months (range: 3-60 months). At time of first recurrence, 41% had invasive carcinoma with a ductal carcinoma in situ (DCIS) component, 41% had invasive carcinoma alone and 18% had DCIS alone. All were clinically node negative. For the reirradiation course, 95% received partial breast irradiation (PBI) (57.5% with 1.5 Gy BID; 27% with 1.8 Gy daily; 10.5% with hypofractionation), and 5% received whole breast irradiation (1.8-2 Gy/fx), all of whom had received PBI for initial course. One patient experienced grade 3 fibrosis, and one patient experienced grade 3 telangiectasia. None had grade 4 or higher late adverse events. We found no association between the fractionation of the second course of RT or the cumulative dose (measured as EQD2) with acute or late toxicity. At 2 years, OS was 100%, DMFS was 91.6%, and LR-RFS was 100%. CONCLUSION In this series of patients with recurrent or new primary breast cancer, a second breast conservation surgery followed by reirradiation was effective with no local recurrences and an acceptable toxicity profile across a range of available fractionation regimens at a median follow up of 16 months. Longer follow up is required.
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Abeloos CH, Purswani JM, Galavis P, McCarthy A, Hitchen C, Choi JI, Gerber NK. Different Re-Irradiation Techniques after Breast-Conserving Surgery for Recurrent or New Primary Breast Cancer. Curr Oncol 2023; 30:1151-1163. [PMID: 36661737 PMCID: PMC9857440 DOI: 10.3390/curroncol30010088] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 01/05/2023] [Accepted: 01/12/2023] [Indexed: 01/15/2023] Open
Abstract
Breast re-irradiation (reRT) after breast-conserving surgery (BCS) using external beam radiation is an increasingly used salvage approach for women presenting with recurrent or new primary breast cancer. However, radiation technique, dose and fractionation as well as eligibility criteria differ between studies. There is also limited data on efficacy and safety of external beam hypofractionation and accelerated partial-breast irradiation (APBI) regimens. This paper reviews existing retrospective and prospective data for breast reRT after BCS, APBI reRT outcomes and delivery at our institution and the need for a randomized controlled trial using shorter courses of radiation to better define patient selection for different reRT fractionation regimens.
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Affiliation(s)
| | - Juhi M. Purswani
- Department of Radiation Oncology, NYU School of Medicine, New York, NY 10016, USA
| | - Paulina Galavis
- Department of Radiation Oncology, NYU School of Medicine, New York, NY 10016, USA
| | - Allison McCarthy
- Department of Radiation Oncology, NYU School of Medicine, New York, NY 10016, USA
| | - Christine Hitchen
- Department of Radiation Oncology, NYU School of Medicine, New York, NY 10016, USA
| | - J. Isabelle Choi
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Naamit K. Gerber
- Department of Radiation Oncology, NYU School of Medicine, New York, NY 10016, USA
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Hunte SO, Clark CH, Zyuzikov N, Nisbet A. Volumetric modulated arc therapy (VMAT): a review of clinical outcomes—what is the clinical evidence for the most effective implementation? Br J Radiol 2022; 95:20201289. [PMID: 35616646 PMCID: PMC10162061 DOI: 10.1259/bjr.20201289] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Modern conformal radiation therapy using techniques such as modulation, image guidance and motion management have changed the face of radiotherapy today offering superior conformity, efficiency, and reproducibility to clinics worldwide. This review assesses the impact of these advanced radiotherapy techniques on patient toxicity and survival rates reported from January 2017 to September 2020. The main aims are to establish if dosimetric and efficiency gains correlate with improved survival and reduced toxicities and to answer the question ‘What is the clinical evidence for the most effective implementation of VMAT?’. Compared with 3DCRT, improvements have been reported with VMAT in prostate, locally advanced cervical carcinoma and various head and neck applications, leading to the shift in technology to VMAT. Other sites such as thoracic neoplasms and nasopharyngeal carcinomas have observed some improvement with VMAT although not in line with improved dosimetric measures, and the burden of toxicity and the incidence of cancer related deaths remain high, signaling the need to further mitigate toxicity and increase survival. As technological advancement continues, large randomised long-term clinical trials are required to determine the way-forward and offer site-specific recommendations. These studies are usually expensive and time consuming, therefore utilising pooled real-world data in a prospective nature can be an alternative solution to comprehensively assess the efficacy of modern radiotherapy techniques.
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Affiliation(s)
- Sherisse Ornella Hunte
- Radiotherapy Department, Cancer Centre of Trinidad and Tobago, St James, Trinidad and Tobago
- University of the West Indies, St. Augustine, Trinidad & Tobago
| | - Catharine H Clark
- Radiotherapy Physics, UCLH NHS Foundation Trust, London, UK
- Metrology for Medical Physics National Physical Laboratory, Teddington, UK
- Department of Medical Physics & Biomedical Engineering, University College London, London, UK
| | | | - Andrew Nisbet
- Department of Medical Physics & Biomedical Engineering, University College London, London, UK
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7
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De Rose F, Meduri B, Carmen De Santis M, Ferro A, Marino L, Ray Colciago R, Gregucci F, Vanoni V, Apolone G, Di Cosimo S, Delaloge S, Cortes J, Curigliano G. Rethinking breast cancer follow-up based on individual risk and recurrence management. Cancer Treat Rev 2022; 109:102434. [DOI: 10.1016/j.ctrv.2022.102434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 06/27/2022] [Accepted: 06/28/2022] [Indexed: 12/01/2022]
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Gabrys D, Kulik R, Namysł-Kaletka A. Re-irradiation for intra-thoracic tumours and extra-thoracic breast cancer: dose accumulation, evaluation of efficacy and toxicity based on a literature review. Br J Radiol 2022; 95:20201292. [PMID: 34826226 PMCID: PMC9153724 DOI: 10.1259/bjr.20201292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
The improvement seen in the diagnostic procedures and treatment of thoracic tumours means that patients have an increased chance of longer overall survival. Nevertheless, we can still find those who have had a recurrence or developed a secondary cancer in the previously treated area. These patients require retreatment including re-irradiation. We have reviewed the published data on thoracic re-irradiation, which shows that some specific healthy tissues can tolerate a significant dose of irradiation and these patients benefit from aggressive treatment; however, there is a risk of damage to normal tissue under these circumstances. We analysed the literature data on re-irradiation in the areas of vertebral bodies, spinal cord, breast, lung and oesophagus. We evaluated the doses of primary and secondary radiotherapy, the treatment techniques, as well as the local control and median or overall survival in patients treated with re-radiation. The longest OS is reported in the case of re-irradiation after second breast-conserving therapy where the 5-year OS range is 81 to 100% and is shorter in patients with loco-reginal re-irradiation where the 5-y OS range is 18 to 60%. 2-year OS in patients re-irradiated for lung cancer and oesophagus cancer range from 13 to 74% and 18 to 42%, respectively. Majority grade ≥3 toxicity after second breast-conserving therapy was fibrosis up to 35%. For loco-regional breast cancer recurrences, early toxicity occurred in up to 33% of patients resulting in mostly desquamation, while late toxicity was recorded in up to 23% of patients and were mostly ulcerations. Early grade ≥3 lung toxicity developed in up to 39% of patients and up to 20% of Grade 5 hemoptysis. The most frequently observed early toxicity grade ≥3 in oesophageal cancer was oesophagitis recorded in up to 57% of patients, followed by hematological complications which was recorded in up to 50% of patients. The most common late complications included dysphagia, recorded in up to 16.7% of patients. We have shown that thoracic re-irradiation is feasible and effective in achieving local control in some patients. Re-irradiation should be performed with maximum accuracy and care using the best available treatment methods with a highly conformal, image-guided approach. Due to tremendous technological progress in the field of radiotherapy, we can deliver radiation precisely, shorten the overall treatment time and potentially reduce treatment-related toxicities.
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Affiliation(s)
- Dorota Gabrys
- Radiotherapy Department, Maria Sklodowska-Curie National Research and Institute of Oncology, Gliwice, Poland
| | - Roland Kulik
- Radiotherapy Planning Department, Maria Sklodowska-Curie National Research and Institute of Oncology, Gliwice, Poland
| | - Agnieszka Namysł-Kaletka
- Radiotherapy Department, Maria Sklodowska-Curie National Research and Institute of Oncology, Gliwice, Poland
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9
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Choi JI, Khan AJ, Powell SN, McCormick B, Lozano AJ, Del Rosario G, Mamary J, Liu H, Fox P, Gillespie E, Braunstein LZ, Mah D, Cahlon O. Proton reirradiation for recurrent or new primary breast cancer in the setting of prior breast irradiation. Radiother Oncol 2021; 165:142-151. [PMID: 34688807 DOI: 10.1016/j.radonc.2021.10.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 10/07/2021] [Accepted: 10/11/2021] [Indexed: 12/25/2022]
Abstract
BACKGROUND AND PURPOSE Late local recurrences and second primary breast cancers are increasingly common. Proton beam therapy (PBT) reirradiation (reRT) may allow safer delivery of a second definitive radiotherapy (RT) course. We analyzed outcomes of patients with recurrent or new primary breast cancer who underwent reRT. MATERIALS AND METHODS In an IRB-approved retrospective study, patient/tumor characteristics, treatment parameters, outcomes, and toxicities were collected for all consecutive patients with recurrent or new primary non-metastatic breast cancer previously treated with breast or chest wall RT who underwent PBT reRT. RESULTS Forty-six patients received reRT using uniform (70%) or pencil beam (30%) scanning PBT. Median first RT, reRT, and cumulative doses were 60 Gy (range 45-66 Gy), 50.4 Gy(RBE) (40-66.6 Gy(RBE)), and 110 Gy(RBE) (96.6-169.4 Gy(RBE)), respectively. Median follow-up was 21 months. There were no local or regional recurrences; 17% developed distant recurrence. Two-year DMFS and OS were 92.0% and 93.6%, respectively. Nine of 13 (69.2%) patients who underwent implant or flap reconstruction developed capsular contracture, 3 (23.1%) requiring surgical intervention. One (7.7%) patient developed grade 3 breast pain requiring mastectomy after breast conserving surgery. No acute or late grade 4-5 toxicities were seen. Increased body mass index (BMI) was protective of grade ≥ 2 acute toxicity (OR = 0.84, 95%CI = 0.70-1.00). CONCLUSION In the largest series to date of PBT reRT for breast cancer recurrence or new primary after prior definitive breast or chest wall RT, excellent locoregional control and few high-grade toxicities were encountered. PBT reRT may provide a relatively safe and highly effective salvage option. Additional patients and follow-up are needed to correlate composite normal tissue doses with toxicities and assess long-term outcomes.
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Affiliation(s)
- J Isabelle Choi
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, USA; New York Proton Center, New York, USA.
| | - Atif J Khan
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Simon N Powell
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Beryl McCormick
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, USA
| | | | | | | | - Haoyang Liu
- ProCure Proton Therapy Center, Somerset, USA
| | - Pamela Fox
- ProCure Proton Therapy Center, Somerset, USA
| | - Erin Gillespie
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Lior Z Braunstein
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Dennis Mah
- ProCure Proton Therapy Center, Somerset, USA
| | - Oren Cahlon
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, USA; New York Proton Center, New York, USA
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10
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Chatzikonstantinou G, Strouthos I, Scherf C, Köhn J, Solbach C, Rödel C, Tselis N. Interstitial multicatheter HDR-brachytherapy as accelerated partial breast irradiation after second breast-conserving surgery for locally recurrent breast cancer. JOURNAL OF RADIATION RESEARCH 2021; 62:465-472. [PMID: 33604659 PMCID: PMC8127653 DOI: 10.1093/jrr/rrab004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Revised: 11/27/2020] [Indexed: 06/12/2023]
Abstract
Our aim was to evaluate the efficacy and toxicity of interstitial multicatheter high dose rate brachytherapy (imHDR-BRT) as accelerated partial breast irradiation (APBI) after second breast-conserving surgery (BCS) in patients with ipsilateral breast tumor recurrence (IBTR). Between January 2010 and December 2019, 20 patients with IBTR who refused salvage mastectomy (sMT) were treated with second BCS and post-operative imHDR-BRT as APBI. All patients had undergone primary BCS followed by adjuvant external beam radiotherapy. Median imHDR-BRT dose was 32 Gy delivered in twice-daily fractions of 4 Gy. Five-year IBTR-free survival, distant metastasis-free survival (DMFS), overall survival (OS) as well as toxicity and cosmesis were evaluated in the present retrospective analysis. Median age at recurrence and median time from the first diagnosis to IBTR was 65.1 years and 12.2 years, respectively. After a median follow-up of 69.9 months, two patients developed a second local recurrence resulting in 5-year IBTR free-survival of 86.8%. Five-year DMFS and 5-year OS were 84.6% and 92.3%, respectively. Grade 1-2 fibrosis was noted in 60% of the patients with no grade 3 or higher toxicity. Two (10%) cases of asymptomatic fat necrosis were documented. Cosmetic outcome was classified as excellent in 6 (37.5%), good in 6 (37.5%), fair in 3 (18.75%) and poor in 1 (6.25%) patient, respectively. We conclude that imHDR-BRT as APBI re-irradiation is effective and safe for IBTR and should be considered in appropriately selected patients.
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Affiliation(s)
- Georgios Chatzikonstantinou
- Corresponding author. Department of Radiotherapy and Oncology, University Hospital Frankfurt, Goethe University Frankfurt, Theodor-Stern-Kai 7, D-60590 Frankfurt am Main, Germany. Tel: +49 69 6301 5130; Fax: +49 69 6301 5091;
| | | | - Christian Scherf
- Department of Radiotherapy and Oncology, University Hospital, Goethe University Frankfurt am Main, Frankfurt, Germany
| | - Janett Köhn
- Department of Radiotherapy and Oncology, University Hospital, Goethe University Frankfurt am Main, Frankfurt, Germany
| | - Christine Solbach
- Department of Gynecology and Obstetrics, University Hospital, Goethe University Frankfurt am Main, Frankfurt, Germany
| | - Claus Rödel
- Department of Radiotherapy and Oncology, University Hospital, Goethe University Frankfurt am Main, Frankfurt, Germany
| | - Nikolaos Tselis
- Department of Radiotherapy and Oncology, University Hospital, Goethe University Frankfurt am Main, Frankfurt, Germany
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11
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Salata C, deAlmeida CE, Ferreira-Machado SC, Barroso RC, Nogueira LP, Mantuano A, Pickler A, Mota CL, de Andrade CBV. Preliminary pre-clinical studies on the side effects of breast cancer treatment. Int J Radiat Biol 2021; 97:877-887. [PMID: 33900904 DOI: 10.1080/09553002.2021.1919782] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Purpose: Technological advancement in the treatment of cancer together with early detection and diagnosis have considerably improved the survival of breast cancer patients. On the other hand, the potential of patients developing side effects from cancer treatment are not negligible. Despite the progress that has been made in terms of early diagnosis, therapy, and survival, including improvements in the chemotherapeutic agents, radiation and molecular targeted therapies, cardiotoxicity of cancer therapy is still cause for concern. Radiation therapy for breast cancer is associated with increased risk of heart disease and myocardial infarction. Furthermore, the association of radiation therapy to chemotherapy is an important aspect to be considered in the development of cardiac disease, as this could play an additional role as a risk factor. Besides the heart effect, other side effects can be observed in the bone, ovary, uteri, and other organs. This paper aims to review the recent literature to present the current understanding of side effects associated with breast cancer treatment. The focus is on recent preclinical studies that have assessed potential changes in different organs that may be injured after breast cancer treatment, both due to both radiation and chemotherapy agents.Conclusion: Radiation-induced heart disease is one important side effect that must be considered during the treatment planning and patient follow-up. The cardiac damage can be potentialized when chemotherapy is associated to radiotherapy, and the literature findings indicate that heart fibrosis plays an important role at the radio-chemotherapy induced cardiac damage. Literature findings also showed important side effects at the bone, that can lead to ospeoporosis, due to the decrease of calcium, after radio or chemotherapy treatments. This decrease could be explained by the ovarian failure observed at rats after chemotherapy treatment. It is of great importance to acknowledge the complications originating from the treatment, so that new strategies can be developed. In this way, it will be possible to minimize side effects and improve the patients' quality of life.
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Affiliation(s)
- Camila Salata
- Department of Radiological Sciences, Rio de Janeiro State University (UERJ), Rio de Janeiro, Brazil.,Brazilian Nuclear Energy Authority (CNEN), Rio de Janeiro, Brazil
| | - Carlos E deAlmeida
- Department of Radiological Sciences, Rio de Janeiro State University (UERJ), Rio de Janeiro, Brazil
| | - Samara C Ferreira-Machado
- Department of Radiological Sciences, Rio de Janeiro State University (UERJ), Rio de Janeiro, Brazil.,Department of General Biology, Federal Fluminense University (UFF), Niterói, Brazil
| | - Regina C Barroso
- Physics Department, Rio de Janeiro State University (UERJ), Rio de Janeiro, Brazil
| | - Liebert P Nogueira
- Oral Research Laboratory (ORL), Institute of Clinical Dentistry, University of Oslo, Oslo, Norway
| | - Andrea Mantuano
- Department of Radiological Sciences, Rio de Janeiro State University (UERJ), Rio de Janeiro, Brazil.,Physics Department, Rio de Janeiro State University (UERJ), Rio de Janeiro, Brazil
| | - Arissa Pickler
- Department of Radiological Sciences, Rio de Janeiro State University (UERJ), Rio de Janeiro, Brazil
| | - Carla L Mota
- Department of Radiological Sciences, Rio de Janeiro State University (UERJ), Rio de Janeiro, Brazil.,Physics Department, Rio de Janeiro State University (UERJ), Rio de Janeiro, Brazil
| | - Cherley B V de Andrade
- Department of Histology and Embryology, Rio de Janeiro State University (UERJ), Rio de Janeiro, Brazil
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12
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Chen I, Botty Van den Bruele AM, Gillespie EF, Mueller BA, Xu AJ, Cuaron J, Khan AJ, McCormick B, Cahlon O, Powell SN, Cody H, Braunstein LZ. Salvage of locally recurrent breast cancer with repeat breast conservation using 45 Gy hyperfractionated partial breast re-irradiation. Breast Cancer Res Treat 2021; 188:409-414. [PMID: 33770311 DOI: 10.1007/s10549-021-06206-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 03/19/2021] [Indexed: 01/22/2023]
Abstract
PURPOSE Mastectomy has long been the preferred approach for local salvage of recurrent breast cancer following breast-conservation therapy (BCT). Growing interest in avoiding mastectomy prompted RTOG 1014, a landmark phase two study demonstrating the feasibility of repeat BCT using a novel radiotherapy (RT) regimen (i.e., 45 Gy administered in 30 fractions of 1.5 Gy twice-daily to the partial breast, "rePBI"). We adopted this regimen as our institutional standard and report our observations regarding the safety and efficacy of rePBI as salvage therapy. METHODS All patients at our institution who underwent repeat BCT and subsequently received rePBI from 2011 to 2019 were identified. Clinicopathologic features and treatment characteristics for both primary breast cancers and recurrences were collected, as were rates of subsequent recurrence and treatment-associated toxicities. RESULTS The cohort included 34 patients with a median age of 65.8 (46.2-78.2) at the time of rePBI. At a median follow-up of 23.5 months, there were two subsequent locoregional recurrences (2-year local control rate 97%). There was no grade ≥ 3 toxicity. The most common acute toxicity (< 3 months) was radiation dermatitis (100%), and common grade 1-2 late toxicities (> 3 months) included fibrosis in 14 (41%), breast asymmetry in 12 (35%), and chest wall pain in 11 (32%). CONCLUSIONS Repeat breast conservation using the hyperfractionated partial breast RT regimen defined by RTOG 1014 (45 Gy administered in 30 1.5 Gy twice-daily fractions) appears effective and well tolerated. No grade 3 or higher toxicities were observed and local control was excellent. Longer term follow-up among larger cohorts will define whether salvage mastectomy should remain the preferred standard.
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Affiliation(s)
- Ishita Chen
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, Box 22, New York, NY , 10044, USA
| | | | - Erin F Gillespie
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, Box 22, New York, NY , 10044, USA
| | - Boris A Mueller
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, Box 22, New York, NY , 10044, USA
| | | | - John Cuaron
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, Box 22, New York, NY , 10044, USA
| | - Atif J Khan
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, Box 22, New York, NY , 10044, USA
| | - Beryl McCormick
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, Box 22, New York, NY , 10044, USA
| | - Oren Cahlon
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, Box 22, New York, NY , 10044, USA
| | - Simon N Powell
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, Box 22, New York, NY , 10044, USA
| | - Hiram Cody
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Lior Z Braunstein
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, Box 22, New York, NY , 10044, USA.
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13
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Piras A, Sanfratello A, Boldrini L, La Vecchia M, Venuti V, Amari ML, Orlando M, Zichichi L, Angileri T, Daidone A. Paget's disease of scrotum and penis case report of a re-irradiation and review of the literature. Dermatol Ther 2020; 33:e13890. [PMID: 32584449 DOI: 10.1111/dth.13890] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 06/21/2020] [Indexed: 12/19/2022]
Abstract
Extramammary Paget's disease (EMPD) is a rare cutaneous adenocarcinoma generally arising in the anogenital region. Surgery is still considered the treatment of choice for patients with EMPD, while Radiotherapy is a common alternative for inoperable cases and it's necessary in case of lack of surgical radicality. In this article, we described our experience and a review of the literature, with a particular focus on radiation-induced toxicity and on the feasibility of re-irradiation. A 70-year-old patient with EPMD underwent adjuvant radiotherapy in 2015. After 28 months for recurrence another radiant treatment was performed. No G3 (CTCAE v4) toxicity were recorded. In the last follow-up visit at 18 months, no signs of relapse were reported. A search strategy of the bibliographic database PubMed was performed. The inclusion criteria for the articles were case report, clinical prospective, or retrospective studies with histological confirmation of EMPD of scrotum and penis; studies with patients undergoing RT; studies in the past 30 years. In most of the 14 reported studies, RT was overall well tolerated. The major observed toxicity was G3 skin toxicity in one study. To our knowledge, there are no other cases of EPMD re-irradiation in literature. Our patient showed an excellent response and tolerated very well the high doses of both the radiation treatments. This suggests that the tolerance of skin to re-irradiation following a long period between the two treatments may be comparable to the normal constraints.
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Affiliation(s)
- Antonio Piras
- Villa Santa Teresa, Radioterapia Oncologica, Palermo, Italy
| | | | - Luca Boldrini
- Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Roma, Italy
| | - Maria La Vecchia
- Radioterapia Oncologica, Università degli Studi di, Palermo, Italy
| | - Valeria Venuti
- Radioterapia Oncologica, Università degli Studi di, Palermo, Italy
| | | | - Marzia Orlando
- Villa Santa Teresa, Radioterapia Oncologica, Palermo, Italy
| | - Leonardo Zichichi
- U.O.C. Dermatologia e Venerologia, Ospedale San Antonio Abate, Trapani, Italy
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14
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Vavassori A, Riva G, Cavallo I, Spoto R, Dicuonzo S, Fodor C, Comi S, Cambria R, Cattani F, Morra A, Leonardi MC, Lazzari R, Intra M, Luini A, Galimberti VE, Veronesi P, Orecchia R, Jereczek-Fossa BA. High-dose-rate Brachytherapy as Adjuvant Local rEirradiation for Salvage Treatment of Recurrent breAst cancer (BALESTRA): a retrospective mono-institutional study. J Contemp Brachytherapy 2020; 12:207-215. [PMID: 32695191 PMCID: PMC7366017 DOI: 10.5114/jcb.2020.96860] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 04/13/2020] [Indexed: 01/06/2023] Open
Abstract
PURPOSE To evaluate clinical results of catheter-based interstitial high-dose-rate (HDR) brachytherapy (BT) as adjuvant treatment in previously irradiated recurrent breast cancer. MATERIAL AND METHODS Between January 2011 and September 2015, 31 consecutive patients with histologically confirmed recurrent breast cancer after conservative surgery and conventional whole breast radiotherapy, were retreated with a second conservative surgical resection and reirradiated with adjuvant interstitial HDR-BT. None of the brachytherapy implant was performed during the quadrantectomy procedure. A dose of 34 Gy in 10 fractions, 2 fractions per day, with a minimal interval of 6 hours was delivered. RESULTS At the time of the implant, the median age of patients was 59.7 years (range, 39.3-74.9 years). The median time from first treatment until BT for local recurrence was 11.9 years (range, 2.5-27.8 years). The median interval between salvage surgery and BT was 3.6 months (range, 1-8.2 months). No acute epidermitis or soft tissue side effects higher than grade 2 were recorded, with good cosmetic results in all patients. Most of the patients presented grade 1-2 late side effects. Only one patient developed grade 3 liponecrosis. After a median follow-up of 73.7 months (range, 28.8-102.4 months), the overall survival and cancer specific survival were 87.1% and 90.3%, respectively; 5-year local control and 5-year progression-free survival rate were 90.3% and 83.9%, respectively. CONCLUSIONS Our preliminary analysis showed that HDR-BT is a feasible treatment for partial breast reirradiation offering very low complications rate and fast procedure. Higher patients' cohort is warranted in order to define the role of this treatment modality in the breast conservative management of local recurrence.
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Affiliation(s)
- Andrea Vavassori
- Department of Radiotherapy, IEO European Institute of Oncology IRCCS, Milan, Italy
| | - Giulia Riva
- Department of Radiotherapy, IEO European Institute of Oncology IRCCS, Milan, Italy
- Clinical Department, National Center for Oncological Hadrontherapy (CNAO), Pavia, Italy
| | - Iacopo Cavallo
- Department of Radiotherapy, IEO European Institute of Oncology IRCCS, Milan, Italy
- University of Milan, Department of Oncology and Hemato-Oncology, Milan, Italy
| | - Ruggero Spoto
- Department of Radiotherapy, IEO European Institute of Oncology IRCCS, Milan, Italy
| | - Samantha Dicuonzo
- Department of Radiotherapy, IEO European Institute of Oncology IRCCS, Milan, Italy
| | - Cristiana Fodor
- Department of Radiotherapy, IEO European Institute of Oncology IRCCS, Milan, Italy
| | - Stefania Comi
- Unit of Medical Physics, IEO European Institute of Oncology IRCCS, Milan, Italy
| | - Raffaella Cambria
- Unit of Medical Physics, IEO European Institute of Oncology IRCCS, Milan, Italy
| | - Federica Cattani
- Unit of Medical Physics, IEO European Institute of Oncology IRCCS, Milan, Italy
| | - Anna Morra
- Department of Radiotherapy, IEO European Institute of Oncology IRCCS, Milan, Italy
| | | | - Roberta Lazzari
- Department of Radiotherapy, IEO European Institute of Oncology IRCCS, Milan, Italy
| | - Mattia Intra
- Department of Breast Surgery, IEO European Institute of Oncology IRCCS, Milan, Italy
| | - Alberto Luini
- Department of Breast Surgery, IEO European Institute of Oncology IRCCS, Milan, Italy
| | | | - Paolo Veronesi
- Department of Breast Surgery, IEO European Institute of Oncology IRCCS, Milan, Italy
| | - Roberto Orecchia
- Scientific Directorate, IEO European Institute of Oncology IRCCS, Milan, Italy
| | - Barbara Alicja Jereczek-Fossa
- Department of Radiotherapy, IEO European Institute of Oncology IRCCS, Milan, Italy
- University of Milan, Department of Oncology and Hemato-Oncology, Milan, Italy
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15
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Elfgen C, Güth U, Gruber G, Birrer S, Bjelic-Radisic V, Fleisch M, Tausch CJ. Breast-conserving surgery with intraoperative radiotherapy in recurrent breast cancer: the patient's perspective. Breast Cancer 2020; 27:1107-1113. [PMID: 32488732 PMCID: PMC7567708 DOI: 10.1007/s12282-020-01114-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 05/20/2020] [Indexed: 12/14/2022]
Abstract
Purpose When ipsilateral breast-tumor recurrence (IBTR) following breast-conserving surgery (BCS) occurs, the cure of a potentially life-threatening disease is the main goal. If, however, this is diagnosed early, prognosis is still good and patient-reported outcomes become more important. Despite the fact that many patients would prefer a further BCS, international breast cancer guidelines still recommend mastectomy, mainly because previous radiation implies limited options. Our comparative study evaluates the long-term quality-of-life and outcome in patients with IBTR who received BCS plus intraoperative radiotherapy (IORT) versus mastectomy. Methods Patients with IBTR were retrospectively divided into three groups according to the local treatment: group 1 (n = 26) was treated with BCS + IORT; group 2 (n = 35) received a standard mastectomy; group 3 (n = 52) had a mastectomy with subsequent reconstruction. Outcomes were analyzed after a mean follow-up of 5 years after IBTR. Quality-of-life was evaluated by the validated questionnaire BREAST-Q in 50 patients who fulfilled the inclusion criteria. Results Quality-of-life scores varied within the groups, ranging from 51.4 to 91.3 (out of 100 points). We observed satisfactory scores in all items, with no statistical difference within the groups. Disease-free survival of all groups did not statistically differ, and overall mortality was very low (0.9%). The postinterventional complication rate was lower after BCS (19.2% versus 34.3% after mastectomy and 30.8% after mastectomy with reconstruction). Conclusion For patients with previous surgery and radiation who demand a second BCS in the recurrent situation, this surgical technique can be offered in combination with IORT. Our long-term results imply oncological safety, lower complication rate, and good patient satisfaction.
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Affiliation(s)
- Constanze Elfgen
- Breast Centre Zurich, Seefeldstrasse 214, 8008, Zurich, Switzerland. .,University of Witten-Herdecke, Witten, Germany.
| | - U Güth
- Breast Centre Zurich, Seefeldstrasse 214, 8008, Zurich, Switzerland
| | - G Gruber
- Institute of Radiooncology, Hirslanden Hospital Zurich, Zurich, Switzerland
| | - S Birrer
- Faculty of Medicine, University of Zurich, Zurich, Switzerland
| | - V Bjelic-Radisic
- University of Witten-Herdecke, Witten, Germany.,Institute of Gynecology and Obstetrics, Universitätsklinikum Wuppertal, Wuppertal, Germany
| | - M Fleisch
- University of Witten-Herdecke, Witten, Germany.,Institute of Gynecology and Obstetrics, Universitätsklinikum Wuppertal, Wuppertal, Germany
| | - C J Tausch
- Breast Centre Zurich, Seefeldstrasse 214, 8008, Zurich, Switzerland
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16
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Present clinical practice of breast cancer radiotherapy in Italy: a nationwide survey by the Italian Society of Radiotherapy and Clinical Oncology (AIRO) Breast Group. Radiol Med 2020; 125:674-682. [DOI: 10.1007/s11547-020-01147-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 02/06/2020] [Indexed: 10/25/2022]
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17
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Montagne L, Hannoun A, Hannoun-Levi JM. Second conservative treatment for second ipsilateral breast tumor event: A systematic review of the different re-irradiation techniques. Breast 2020; 49:274-280. [PMID: 31945697 PMCID: PMC7375668 DOI: 10.1016/j.breast.2020.01.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 12/29/2019] [Accepted: 01/07/2020] [Indexed: 12/27/2022] Open
Abstract
AIM To address the different partial breast re-irradiation techniques available in the context of second conservative treatment (SCT), as an alternative to salvage mastectomy, for 2nd ipsilateral breast tumor event (IBTE) and summarize their respective oncological and toxicity outcomes. MATERIAL AND METHODS A literature search was made based on MeSH/PubMed, including papers from 1995 to 2019. Each article was described according to the main irradiation technique, fractionation, oncological results and grade 3 toxicities related to the salvage conservative treatment. RESULTS Twenty-two articles were identified, reporting the outcomes of over 1 000 patients. MIB Brachytherapy was the most used re-irradiation technique in case of SCT, with a median 3rdIBTE-FS rate of 88% and summed up grade 3 toxicities of 6%. As for IORT, the average rate of 3rdIBTE-FS was about Finally, external beam partial re-irradiation was recently tested in this indication with encouraging results in terms of tolerance. CONCLUSION When presenting a 2ndIBTE, a SCT can safely be proposed to carefully selected and well-informed patients, as an alternative to salvage mastectomy. MIB appears to be the first intention and most robust choice. IORT, external beam radiotherapy and balloon brachytherapy are interesting alternatives but have only been tested in small series. Further investigations are required and their use should be limited to clinical trial only.
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Affiliation(s)
- Lucile Montagne
- Department of Radiation Oncology, Antoine Lacassagne Cancer Center, University of Cote D'Azur, Nice, France
| | | | - Jean-Michel Hannoun-Levi
- Department of Radiation Oncology, Antoine Lacassagne Cancer Center, University of Cote D'Azur, Nice, France.
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18
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Clinical outcomes and toxicity of proton beam radiation therapy for re-irradiation of locally recurrent breast cancer. Clin Transl Radiat Oncol 2019; 19:116-122. [PMID: 31692702 PMCID: PMC6806378 DOI: 10.1016/j.ctro.2019.09.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Revised: 09/27/2019] [Accepted: 09/30/2019] [Indexed: 11/24/2022] Open
Abstract
Re-irradiation using proton therapy for recurrent breast cancer has excellent local control. Re-irradiation using proton beam radiation therapy increases risk of skin toxicity. There is minimal increase in the late toxicity due to re-irradiation using proton beam therapy.
Purpose Repeat radiation therapy (RT) using photons/X-rays for locally recurrent breast cancer results in increased short and long-term toxicity. Proton beam RT (PBRT) can minimize dose to surrounding organs, thereby potentially reducing toxicity. Here, we report the toxicity and clinical outcomes for women who underwent re-irradiation to the chest wall for locally recurrent breast cancer using PBRT. Materials and methods This was a retrospective study analyzing 16 consecutive patients between 2013 and 2018 with locally recurrent breast cancer who underwent re-irradiation to the chest wall with PBRT. For the recurrent disease, patients underwent maximal safe resection, including salvage mastectomy, wide local excision, or biopsy only per surgeons recommendations. Systemic therapy was used per the recommendation of the medical oncologist. Patients were treated with median dose of 50.4 Cobalt Gray Equivalent (CGyE) in 28 fractions at the time of re-irradiation. Follow-up was calculated from the start of second RT course. Acute toxicities were defined as those occurring during treatment or up to 8 weeks after treatment. Late toxicities were defined as those occurring more than 8 weeks after the completion of therapy. Toxicities were based on CTCAE 4.0. Results The median age at original diagnosis and at recurrence was 49.8 years and 60.2 years, respectively. The median time between the two RT courses was 10.2 (0.7–20.2) years. The median follow-up time was 18.7 (2.5–35.2) months. No local failures were observed after re-irradiation. One patient developed distant metastasis and ultimately died. Grade 3–4 acute skin toxicity was observed in 5 (31.2%) patients. Four (25%) patients developed chest wall infections during or shortly (2 weeks) after re-irradiation. Late grade 3–4 fibrosis was observed in only 3 (18.8%) patients. Grade 5 toxicities were not observed. Hyperpigmentation was seen in 12 (75%) patients. Pneumonitis, telangiectasia, rib fracture, and lymphedema occurred in 2 (12.5%), 4 (25%), 1 (6.3%), and 1 (6.3%) patients, respectively. Conclusions Re-irradiation with PBRT for recurrent breast cancer has acceptable toxicities. There was a high incidence of acute grade 3–4 skin toxicity and infections, which resolved, however, with skin care and antibiotics. Longer follow-up is needed to determine long-term clinical outcomes.
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19
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Second breast conserving therapy after ipsilateral breast tumor recurrence - a 10-year experience of re-irradiation. J Contemp Brachytherapy 2019; 11:312-319. [PMID: 31523231 PMCID: PMC6737570 DOI: 10.5114/jcb.2019.87001] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Accepted: 05/31/2019] [Indexed: 11/17/2022] Open
Abstract
Purpose The aim of this study is to evaluate the efficacy and toxicity of post-operative partial breast re-irradiation with multi-catheter brachytherapy after second breast conserving therapy (BCT) in patients with small, low-risk ipsilateral breast tumor recurrence (IBTR). Material and methods Between 2008 and 2018, 19 consecutive patients with low-risk IBTR (max. rpT1 cN0 cM0, Her2 negative, preferably positive hormone receptor status) who refused mastectomy were treated with salvage lumpectomy, followed by post-operative partial breast re-irradiation with multi-catheter brachytherapy. Eight patients were irradiated using PDR brachytherapy (49.8-50.4 Gy in pulses of 0.5-0.7 Gy) and 11 patients using HDR brachytherapy (34.2 Gy in fractions of 3.8 Gy or 32 Gy in fractions of 4 Gy). All patients had undergone prior BCT for their primary tumor, followed by adjuvant whole breast radiotherapy. Local control (LC), locoregional control (LRC), overall survival (OS), disease-free survival (DFS) as well as toxicity were evaluated in the present study. Results After a median follow-up of 65 months following IBTR (18-120 months), only one second IBTR in 19 patients was diagnosed 77 months after re-irradiation, resulting in a LC rate of 100% at 5 years. DFS and OS rates were both 100% at 5 years following re-irradiation. Except for the above mentioned second IBTR, no regional or distant relapse was recorded. Regarding toxicity, 63% of patients developed adverse events (CTCAE grade ≤ 2), with fibrosis detected in 37% (7/19) of patients, necrosis in 11% (2/19), hyperpigmentation in 47% (9/19), and telangiectasia in 11% (2/19), respectively. No patient showed a high-grade (CTCAE grade ≥ 3) adverse event. Conclusions In case of small, low-risk IBTR, adjuvant re-irradiation using multi-catheter brachytherapy is a feasible, safe, and effective treatment method after repeated lumpectomy, and an alternative to mastectomy.
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20
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Duma MN, Baumann R, Budach W, Dunst J, Feyer P, Fietkau R, Haase W, Harms W, Hehr T, Krug D, Piroth MD, Sedlmayer F, Souchon R, Sauer R. Heart-sparing radiotherapy techniques in breast cancer patients: a recommendation of the breast cancer expert panel of the German society of radiation oncology (DEGRO). Strahlenther Onkol 2019; 195:861-871. [PMID: 31321461 DOI: 10.1007/s00066-019-01495-w] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 06/27/2019] [Indexed: 02/08/2023]
Abstract
PURPOSE The aim of this review was to analyze the respective efficacy of various heart-sparing radiotherapy techniques. MATERIAL AND METHODS Heart-sparing can be performed in three different ways in breast cancer radiotherapy: by seeking to keep the heart out of treated volumes (i.e. by prone position or specific breathing techniques such as deep inspiration breath-hold [DIBH] and/or gating), by solely irradiating a small volume around the lumpectomy cavity (partial breast irradiation, PBI), or by using modern radiation techniques like intensity-modulated radiation therapy (IMRT), volumetric modulated arc therapy (VMAT) or protons. This overview presents the available data on these three approaches. RESULTS Studies on prone position are heterogeneous and most trials only refer to patients with large breasts; therefore, no definitive conclusion can be drawn for clinical routine. Nonetheless, there seems to be a trend toward better sparing of the left anterior descending artery in supine position even for these selected patients. The data on the use of DIBH for heart-sparing in breast cancer patients is consistent and the benefit compared to free-breathing is supported by several studies. In comparison with whole breast irradiation (WBI), PBI has an advantage in reducing the heart dose. Of note, DIBH and PBI with multicatheter brachytherapy are similar with regard to the dose reduction to heart structures. WBI by IMRT/VMAT techniques without DIBH is not an effective strategy for heart-sparing in breast cancer patients with "standard" anatomy. A combination of DIBH and IMRT may be used for internal mammary radiotherapy. CONCLUSION Based on the available findings, the DEGRO breast cancer expert panel recommends the use of DIBH as the best heart-sparing technique. Nonetheless, depending on the treatment volume and localization, other techniques may be employed or combined with DIBH when appropriate.
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Affiliation(s)
- Marciana-Nona Duma
- Department of Radiotherapy and Radiation Oncology, University Hospital, Friedrich-Schiller-University, Bachstr. 18, 07745, Jena, Germany.
| | | | - Wilfried Budach
- Heinrich-Heine-University Hospital Düsseldorf, Düsseldorf, Germany
| | - Jürgen Dunst
- University Hospital Schleswig-Holstein, Kiel, Germany
| | - Petra Feyer
- Vivantes Hospital Neukoelln, Berlin, Germany
| | | | - Wulf Haase
- St.-Vincentius-Hospital Karlsruhe, Karlsruhe, Germany
| | | | - Thomas Hehr
- Marienhospital Stuttgart, Stuttgart, Germany
| | - David Krug
- University Hospital Schleswig-Holstein, Kiel, Germany
| | - Marc D Piroth
- Helios University Hospital Wuppertal, Witten/Herdecke University, Wuppertal, Germany
| | - Felix Sedlmayer
- Paracelsus Medical University Hospital Salzburg, Salzburg, Austria
| | | | - Rolf Sauer
- University Hospital Erlangen, Erlangen, Germany
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21
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Gabriel L, Schmidt M, Juhasz-Böss S, Melchior P, von Heesen A, Schmidt G, Kranzhöfer N, Solomayer EF, Juhasz-Böss I, Breitbach GP. Therapy of isolated locoregional recurrent carcinoma of the breast. Arch Gynecol Obstet 2019; 300:365-376. [PMID: 31222400 DOI: 10.1007/s00404-019-05220-x] [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: 01/16/2019] [Accepted: 06/15/2019] [Indexed: 11/25/2022]
Abstract
PURPOSE There is widespread consent that isolated locoregional recurrence (ILRR) in breast cancer should be treated surgically. On searching literature and guidelines most studies include ipsilateral recurrence in breast tissue or on thoracic wall post-mastectomy, recurrence in scar tissue as well as in ipsilateral axillary lymph nodes. Some studies discuss metachronous contralateral breast cancer as ILRR. About 10-35% of women with primary breast cancer suffer from ILRR. The existing data concerning the role of systemic therapy in the treatment of ILRR are insufficient. We investigated the influence of chemotherapy on disease-free- (DFS) and overall-survival (OS). METHODS Retrospective analysis of all patients with ILRR and without distant metastasis was done, which were treated at the Department of Gynecology, Obstetrics and Reproductive Medicine, Saarland University between 2005 and 2013. Data collection used patients' database system and was followed via patient questionnaires. RESULTS In total, we collected data of 93 patients with locally recurrent breast cancer and observed a 72.6% questionnaire response rate. Average timeline accounted for 99 months between primary diagnosis and local recurrence; average age of patients at diagnosis of local recurrence was 60.6 years. After a median follow-up of 63 months DFS reached 76% with and 73% without chemotherapy, and after 74 months overall survival amounted to 94% and 70%, respectively. CONCLUSION Almost all patients with ILRR were operated. Especially patients with hormone receptor-negative recurrent breast cancer seemed to show a benefit having been treated with chemotherapy. Most patients were without recurrence after their particular therapies.
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Affiliation(s)
- Lena Gabriel
- Department of Gynecology, Obstetrics and Reproductive Medicine, University Hospital Medical School, Kirrbergerstraße 100, 66421, Homburg/Saar, Germany
| | - Marina Schmidt
- Department of Gynecology, Obstetrics and Reproductive Medicine, University Hospital Medical School, Kirrbergerstraße 100, 66421, Homburg/Saar, Germany
| | - Stephanie Juhasz-Böss
- Department of Gynecology, Obstetrics and Reproductive Medicine, University Hospital Medical School, Kirrbergerstraße 100, 66421, Homburg/Saar, Germany
| | - Patrick Melchior
- Department of Radiation Oncology, University Hospital Medical School, Homburg, Germany
| | - Anika von Heesen
- Department of Gynecology, Obstetrics and Reproductive Medicine, University Hospital Medical School, Kirrbergerstraße 100, 66421, Homburg/Saar, Germany
| | - Gilda Schmidt
- Department of Gynecology, Obstetrics and Reproductive Medicine, University Hospital Medical School, Kirrbergerstraße 100, 66421, Homburg/Saar, Germany
| | - Nicole Kranzhöfer
- Department for Oncology and Hematology, University Hospital Medical School, Homburg, Germany
| | - Erich-Franz Solomayer
- Department of Gynecology, Obstetrics and Reproductive Medicine, University Hospital Medical School, Kirrbergerstraße 100, 66421, Homburg/Saar, Germany
| | - Ingolf Juhasz-Böss
- Department of Gynecology, Obstetrics and Reproductive Medicine, University Hospital Medical School, Kirrbergerstraße 100, 66421, Homburg/Saar, Germany
| | - Georg-Peter Breitbach
- Department of Gynecology, Obstetrics and Reproductive Medicine, University Hospital Medical School, Kirrbergerstraße 100, 66421, Homburg/Saar, Germany.
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22
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Oldenborg S, van Os R, Oei B, Poortmans P. Impact of Technique and Schedule of Reirradiation Plus Hyperthermia on Outcome after Surgery for Patients with Recurrent Breast Cancer. Cancers (Basel) 2019; 11:cancers11060782. [PMID: 31195763 PMCID: PMC6627207 DOI: 10.3390/cancers11060782] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2019] [Revised: 05/31/2019] [Accepted: 06/03/2019] [Indexed: 12/26/2022] Open
Abstract
Purpose: Combining reirradiation (reRT) with hyperthermia (HT) has shown to be of high therapeutic value for patients with loco-regionally recurrent breast cancer. The purpose of this study was to compare the long-term therapeutic effect and toxicity of reRT + HT following surgery of loco-regionally recurrent breast cancer using two different reRT regimens. Methods: The reRT regimen of the 78 patients treated in Institute A consisted of 8 × 4 Gy twice a week using mostly abutted photon-electron fields. The 78 patients treated in Institute B received a reRT regimen of 12 × 3 Gy, four times a week with single or multiple electron fields. Superficial hyperthermia was applied once a week in Institute A and twice a week in Institute B. Both institutes started HT treatment within 1 hour after reRT and used the same 434-MHz systems to heat the tumor area to 41–43 °C. Results: The 5-year-infield local control (LC) rates were similar; however, the 5-year-survival rates were 13% lower in Institute A. Most remarkable was the difference in risk with respect to 5-year ≥ grade 3 toxicity, which was more than twice as high in Institute A. Conclusion: The combination of reirradiation and hyperthermia after macroscopically complete excision of loco-regional breast cancer recurrences provides durable local control in patients at risk for locoregional recurrent breast cancer. Treatment is well tolerated with the 12 × 3 Gy schedule with limited-sized electron fields.
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Affiliation(s)
- Sabine Oldenborg
- Department of Radiation Oncology, Amsterdam UMC, University of Amsterdam (AMC), 1105 AZ Amsterdam, The Netherlands.
| | - Rob van Os
- Department of Radiation Oncology, Amsterdam UMC, University of Amsterdam (AMC), 1105 AZ Amsterdam, The Netherlands.
| | - Bing Oei
- Department of Radiation Oncology, Institute Verbeeten (BVI), 5042 SB Tilburg, The Netherlands.
| | - Philip Poortmans
- Department of Radiation Oncology, Institute Verbeeten (BVI), 5042 SB Tilburg, The Netherlands.
- Department of Radiation Oncology, Institut Curie, Paris Sciences & Lettres-PSL University, 75248 Paris, France.
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Hyperthermic chest wall re-irradiation in recurrent breast cancer: a prospective observational study. Strahlenther Onkol 2019; 195:318-326. [PMID: 30607453 DOI: 10.1007/s00066-018-1414-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Accepted: 12/11/2018] [Indexed: 01/08/2023]
Abstract
PURPOSE To prospectively investigate the role of re-irradiation (re-RT) combined with hyperthermia (HT) in a contemporary cohort of patients affected by recurrent breast cancer (RBC). METHODS Within the prospective registry HT03, patients with resected RBC and previous irradiation were included. Re-RT was applied to the recurrence region with doses of 50-50.4 Gy, with a boost up to 60-60.4 Gy to the microscopically or macroscopically positive resection margins (R1/R2) region. Concurrent HT was performed at 40-42 ℃. Primary endpoint was LC. Acute and late toxicity, overall survival, cancer-specific survival (CSS), and progression-free survival (PFS) were also evaluated. RESULTS 20 patients and 21 RBC were analyzed. Median re-RT dose was 50.4 Gy and a median of 11 HT fractions were applied. Re-RT+HT was well tolerated, with three patients who experienced a grade (G) 3 acute skin toxicity and no cases of ≥G3 late toxicity. With a median follow up of 24.7 months, two local relapses occurred. Ten patients experienced regional and/or distant disease progression. Five patients died, four of them from breast cancer. PFS was favorable in patients treated with re-RT+HT for the first recurrence with doses of 60 Gy. A trend towards better CSS was found in patients with negative or close margins and after doses of 60 Gy. CONCLUSION Full-dose re-RT+HT for RBC is well tolerated, provides good LC, and seems to be more effective when applied at the time of the first relapse and after doses of 60 Gy. The registry will be continued for validation in a larger cohort and with longer follow-up.
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