Conservative treatment for breast cancer: long-term results (15 years)

Safety of pre- or postoperative accelerated radiotherapy in 5 fractions: A randomized pilot trial

OBJECTIVE

Neo-adjuvant radiotherapy (NART) for breast cancer has shown promising survival results in retrospective trials. However, there are some obstacles such as a chemotherapy delay, an increased overall treatment time (OTT) and the risk of increasing surgical morbidity. Accelerated radiotherapy (RT) in 5 fractions allows to deliver NART in a very short time span and minimizes the delay of surgery and chemotherapy. This trial investigates this NART schedule for safety, feasibility and OTT.

MATERIAL AND METHODS

Twenty patients eligible for neo-adjuvant chemotherapy (NACT) and breast conserving surgery, were randomized between NART before NACT or NACT and postoperative RT. In both arms, RT treatment was given in 5 fractions to the whole breast with a simultaneously integrated boost (SIB) on the tumor(bed). Lymph node irradiation was given concomitantly in case of lymph node involvement. OTT was defined as the time from diagnosis to last surgery in the intervention group, while in the control group the time between diagnosis and last RT-fraction was used. In the intervention group NACT-delay was defined as time between diagnosis and start of chemotherapy.

RESULTS

20 patients were included, and 19 patients completed treatment. OTT was significantly shorter in the intervention group (mean 218 days, range 196-253) compared to the control group (mean 237, range 211-268, p = 0.001). The difference in mean duration from diagnosis to the first treatment was a non-significant 4 days longer (31 vs 27 days, p = 0.28), but the start of NACT after diagnosis was delayed by 21 days (48 vs 27 days, p < 0.001). NART did not result in additional surgery complications.

CONCLUSION

This pilot trial is the first to report on accelerated NART in 5 fractions with SIB. NART before NACT resulted in a shorter OTT with good safety results.

Evolution, current challenges, and future possibilities in the objective assessment of aesthetic outcome of breast cancer locoregional treatment

The Breast Cancer overall survival rate has raised impressively in the last 20 years mainly due to improved screening and effectiveness of treatments. This increase in survival paralleled the awareness over the long-lasting impact of the side effects of treatments on patient quality of life, emphasizing the motto “a longer but better life for breast cancer patients”. In breast cancer more strikingly than in other cancers, besides the side effects of systemic treatments, there is the visible impact of surgery and radiotherapy on patients’ body image. This has sparked interest on the development of tools for the aesthetic evaluation of Breast Cancer locoregional treatments, which evolved from manual, subjective approaches to computerized, automated solutions. However, although studied for almost four decades, past solutions were not mature enough to become a standard.

Recent advancements in machine learning have inspired trends toward deep-learning-based medical image analysis, also bringing new promises to the field of aesthetic assessment of locoregional treatments. In this paper, a review and discussion of the previous state-of-the-art methods in the field is conducted and the extracted knowledge is used to understand the evolution and current challenges. The aim of this paper is to delve into the current opportunities as well as motivate and guide future research in the aesthetic assessment of Breast Cancer locoregional treatments.

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Past, present and future of objective assessment of aesthetic outcome of breast cancer treatments.

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Critical discussion of the role and impact of deep-learning-based methodologies in the field.

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Recommendation for future efforts in the objective assessment of aesthetic outcome of breast cancer treatments.

Dosimetric evaluation of the skin-sparing effects of 3-dimensional conformal radiotherapy and intensity-modulated radiotherapy for left breast cancer

The purpose of this study was to evaluate the skin-sparing effects of 3-dimensional conformal radiotherapy (3D-CRT) and intensity-modulated radiotherapy (IMRT) in patients with early left-sided breast cancer. Twenty left breast cancer patients treated with whole breast radiotherapy following breast-conserving surgery were enrolled in this study, and the 3D-CRT and IMRT plans were generated for each patient. To evaluate the dose delivered to the skin, 2 mm thickness skin (2-mm skin) and 3 mm thickness skin (3-mm skin) were contoured and a dosimetric comparison between the 2 plans was performed. The target volume coverage was better in IMRT than in 3D-CRT. The mean dose was 50.8 Gy for 3D-CRT and 51.1 Gy for IMRT. V40Gy was 99.4% for 3D-CRT and 99.9% for IMRT. In the case of skin, the mean dose was higher in 3D-CRT than in IMRT (mean dose of 2-mm skin: 32.8 Gy and 24.2 Gy; mean dose of 3-mm skin: 37.2 Gy and 27.8 Gy, for 3D-CRT and IMRT, respectively). These results indicated that the skin-sparing effect is more prominent in IMRT compared to 3D-CRT without compromising the target volume coverage.

[Role of locoregional radiation therapy in breast cancer patients with negative lymph nodes after preoperative chemotherapy and mastectomy. The Institut Curie-Hôpital René-Huguenin experience]

PURPOSE

Neoadjuvant chemotherapy generally induces significant changes in the pathological extent of disease and challenges the standard indications of adjuvant postmastectomy radiation therapy. We retrospectively evaluated the impact of postmastectomy radiation therapy in breast cancer patients with negative lymph nodes (pN0) after neoadjuvant chemotherapy.

PATIENTS AND MATERIALS

Among 1054 breast cancer patients treated with neoadjuvant chemotherapy in our institution between 1990 and 2004, 134 patients had pN0 status after neoadjuvant chemotherapy and mastectomy. Demographic data, tumor characteristics, metastatic sites, and treatments were prospectively recorded. The impact of postmastectomy radiation therapy on locoregional recurrence-free survival and overall survival was evaluated by multivariate analysis including known prognostic factors.

RESULTS

Among 134 eligible patients, 78 patients (58.2%) received postmastectomy radiation therapy, and 56 patients (41.8%) did not. With a median follow-up time of 91.4 months, the 10-year locoregional recurrence-free survival and overall survival rates were 96.2% and 77.2% with postmastectomy radiation therapy and 86.8% and 87.7% without radiation therapy, respectively (no significant difference). In multivariate analysis, there was a trend towards poorer overall survival among patients who did not have a pathologically complete primary tumour response after neoadjuvant chemotherapy (hazard ratio [HR], 6.65; 95% CI, 0.82-54.12; P=0.076). Postmastectomy radiation therapy had no effect on either locoregional recurrence-free survival (HR, 0.37; 95% CI, 0.09-1.61; P=0.18) or overall survival (HR, 2.06; 95% CI, 0.71-6; P=0.18). There was a trend towards poorer overall survival among patients who did not have pathologically complete in-breast tumour response after neoadjuvant chemotherapy (HR, 6.65; 95% CI, 0.82-54.12; P=0.076).

CONCLUSIONS

This retrospective study showed no increase in the risk of distant metastasis, locoregional recurrence or death when postmastectomy radiation therapy was omitted in breast cancer patients with pN0 status after neoadjuvant chemotherapy and mastectomy. Whether the omission of postmastectomy radiation therapy is acceptable for these patients should be addressed prospectively.

Radiotherapy for stage II and stage III breast cancer patients with negative lymph nodes after preoperative chemotherapy and mastectomy

PURPOSE

To evaluate the effect of postmastectomy radiotherapy (PMRT) in Stage II-III breast cancer patients with negative lymph nodes (pN0) after neoadjuvant chemotherapy (NAC).

PATIENTS AND MATERIALS

Of 1,054 breast cancer patients treated with NAC at our institution between 1990 and 2004, 134 had pN0 status after NAC and mastectomy. The demographic data, tumor characteristics, metastatic sites, and treatments were prospectively recorded. The effect of PMRT on locoregional recurrence-free survival and overall survival (OS) was evaluated by multivariate analysis, including known prognostic factors.

RESULTS

Of the 134 eligible patients, 78 (58.2%) received PMRT and 56 (41.8%) did not. At a median follow-up time of 91.4 months, the 5-year locoregional recurrence-free survival and OS rate was 96.2% and 88.3% with PMRT and 92.5% and 94.3% without PMRT, respectively (p = NS). The corresponding values at 10 years were 96.2% and 77.2% with PMRT and 86.8% and 87.7% without PMRT (p = NS). On multivariate analysis, PMRT had no effect on either locoregional recurrence-free survival (hazard ratio, 0.37; 95% confidence interval, 0.09-1.61; p = .18) or OS (hazard ratio, 2.06; 95% confidence interval, 0.71-6; p = .18). This remained true in the subgroups of patients with clinical Stage II or Stage III disease at diagnosis. A trend was seen toward poorer OS among patients who had not had a pathologic complete in-breast tumor response after NAC (hazard ratio, 6.65; 95% confidence interval, 0.82-54.12; p = .076).

CONCLUSIONS

The results from the present retrospective study showed no increase in the risk of distant metastasis, locoregional recurrence, or death when PMRT was omitted in breast cancer patients with pN0 status after NAC and mastectomy. Whether the omission of PMRT is acceptable for these patients should be addressed prospectively.

Exclusive and adjuvant radiotherapy in breast cancer patients with synchronous metastases

Background

Data from the Surveillance, Epidemiology, and End Results program and the European Concerted Action on survival and Care of Cancer Patients (EUROCARE) project indicate that about 6% of women newly diagnosed with breast cancer have stage IV disease, representing about 12 600 new cases per year in the United States in 2005. Historically, local therapy of the primary tumor in this setting has been aimed solely at symptom palliation. However, several studies suggest that surgical excision of the primary tumor can prolong these patients' survival.

Discussion

Exclusive locoregional radiotherapy is an alternative form of locoregional treatment in this setting and may represent an effective alternative to surgery in this setting. Here we discuss current issues regarding exclusive and adjuvant locoregional radiotherapy in breast cancer patients with synchronous metastases.

Summary

Several studies suggest that surgery or exclusive irradiation of the primary tumor is associated with better survival in breast cancer patients with synchronous metastases and that exclusive locoregional radiotherapy may represent an effective alternative to surgery in this setting. Results of well-designed prospective studies are needed to re-evaluate treatment of the primary breast tumor in patients with metastases at diagnosis, and to identify those patients who are most likely to benefit.

[Role of lymph node irradiation in breast cancer patients with negative pathologic node status after neoadjuvant chemotherapy: the René-Huguenin Cancer Center experience]

PURPOSE

Neoadjuvant chemotherapy generally induces significant changes in the pathological extent of disease. This potential down-staging challenges the standard indications of adjuvant radiation therapy. We assessed the utility of lymph node irradiation in breast cancer patients with pathological N0 status (pN0) after neoadjuvant chemotherapy and breast-conserving surgery.

PATIENTS AND MATERIALS

Among 1054 breast cancer patients treated with neoadjuvant chemotherapy in our institution between 1990 and 2004, 248 patients with clinical N0 or N1-N2 lymph node status at diagnosis had pN0 status after neoadjuvant chemotherapy and breast-conserving surgery. Cox regression analysis was used to identify factors influencing locoregional recurrence-free survival, disease-free survival and overall survival.

RESULTS

All 248 patients received breast irradiation, and 158 patients (63.7%) also received lymph node irradiation. With a median follow-up of 88 months, the 5-year locoregional recurrence-free survival and overall survival rates were respectively 89.4% and 88.7% with lymph node irradiation and 86.2% and 92% without lymph node irradiation (no significant difference). Survival was poorer among patients who did not have a pathological complete primary tumor response (pCR) (hazards ratio [HR]=3.05; 95% CI, 1.17 to 7.99) and in patients with N1-N2 clinical status at diagnosis ([HR]=2.24; 95% CI, 1.15 to 4.36). Lymph node irradiation did not significantly affect survival.

CONCLUSIONS

Relative to combined breast and local lymph node irradiation, isolated breast irradiation does not appear to be associated with a higher risk of locoregional relapse or death among breast cancer patients with pN0 status after neoadjuvant chemotherapy. These results need to be confirmed in a prospective study.

Breast cancer with synchronous metastases: survival impact of exclusive locoregional radiotherapy

PURPOSE

Several studies suggest that surgical excision of the primary tumor improves survival among patients with stage IV breast cancer at diagnosis. Exclusive locoregional radiotherapy (LRR) is an alternative form of locoregional treatment (LRT) in this setting. We retrospectively studied the impact of LRT on the survival of breast cancer patients with synchronous metastases.

PATIENTS AND METHODS

Among 18,753 breast cancer patients treated in our institution between 1980 and 2004, 598 patients (3.2%) had synchronous metastasis at diagnosis. Demographic data, tumor characteristics, metastatic sites, and treatments were prospectively recorded. The impact of LRT on overall survival (OS) was evaluated by multivariate analysis including known prognostic factors.

RESULTS

Among 581 eligible patients, 320 received LRT (group A), and 261 received no LRT (group B). LRT consisted of exclusive LRR in 249 patients (78%), surgery of the primary tumor with adjuvant LRR in 41 patients (13%), and surgery alone in 30 patients (9%). With a median follow-up time of 39 months, the 3-year OS rates were 43.4% and 26.7% in group A and group B (P =.00002), respectively. The association between LRT and improved survival was particularly marked in women with visceral metastases. LRT was an independent prognostic factor in multivariate analysis (hazard ratio [HR] = 0.70; 95% CI, 0.58 to 0.85; P = .0002). The adjusted HR for late death (>or= 1 year) was 0.76 (95% CI, 0.61 to 0.96; P = .02).

CONCLUSION

In our experience, LRT, consisting mainly of exclusive LRR, was associated with improved survival in breast cancer patients with synchronous metastases. Exclusive LRR may thus represent an active alternative to surgery.

Towards an intelligent medical system for the aesthetic evaluation of breast cancer conservative treatment

OBJECTIVE

This work presents a novel approach for the automated prediction of the aesthetic result of breast cancer conservative treatment (BCCT). Cosmetic assessment plays a major role in the study of BCCT. Objective assessment methods are being preferred to overcome the drawbacks of subjective evaluation.

METHODOLOGY

The problem is addressed as a pattern recognition task. A dataset of images of patients was classified in four classes (excellent, good, fair, poor) by a panel of international experts, providing a gold standard classification. As possible types of objective features we considered those already identified by domain experts as relevant to the aesthetic evaluation of the surgical procedure, namely those assessing breast asymmetry, skin colour difference and scar visibility. A classifier based on support vector machines was developed from objective features extracted from the reference dataset.

RESULTS

A correct classification rate of about 70% was obtained when categorizing a set of unseen images into the aforementioned four classes. This accuracy is comparable with the result of the best evaluator from the panel of experts.

CONCLUSION

The results obtained are rather encouraging and the developed tool could be very helpful in assuring objective assessment of the aesthetic outcome of BCCT.

Long-term cosmetic results and toxicity after accelerated partial-breast irradiation: a method of radiation delivery by interstitial brachytherapy for the treatment of early-stage breast carcinoma

BACKGROUND

The objective of this study was to assess the cosmesis and toxicities in patients with early-stage breast carcinoma who received treatment with accelerated partial breast irradiation (APBI) using interstitial brachytherapy.

METHODS

From April 1993 to December 2001, 199 patients with Stage I-II breast carcinoma received breast-conserving therapy with APBI to the tumor bed alone through a low-dose-rate (LDR) or high-dose-rate (HDR) implant. A template guide was used. The LDR dose was 50 Gray (Gy) over 96 hours; the outpatient HDR implant delivered 32 Gy in 8-Gy or 34 Gy in 10-Gy twice-daily fractions. Cosmesis (Harvard criteria) and toxicities (Radiation Therapy Oncology Group guidelines) were assessed at < or = 6 months, 2 years, and 5 years.

RESULTS

The median follow up was 6.4 years. Breast pain, edema, erythema, and hyperpigmentation all diminished over time. Breast fibrosis and hypopigmentation increased until the 2-year mark and then stabilized. Fat necrosis and telangiectasia increased over time, with a fat necrosis rate of 11% at 5 years. Nearly all telangiectasias (34% at 5 yrs) were Grade 1 (< 2 mm). The remaining toxicities were Grade 1 at all follow-up intervals. Infections (11%) occurred predominantly within the first month after treatment. Good-to-excellent cosmetic outcomes were noted in 95-99% of patients over time; cosmetic results stabilized at 2 years with excellent results increased out to 5 years.

CONCLUSIONS

APBI with interstitial brachytherapy resulted in mild chronic toxicities, the majority of which diminished or reached a plateau over time. Long-term cosmesis was good to excellent in 95-99% of patients and stabilized at 2 years.

A cosmetic evaluation of breast cancer treatment: A randomized study of radiotherapy boost technique

PURPOSE

To compare cosmetic results of two different radiotherapy (RT) boost techniques used in the treatment of breast cancer after whole breast radiotherapy and to identify factors affecting cosmetic outcomes.

METHODS AND MATERIALS

Between 1996 and 1998, 142 patients with Stage I and II breast cancer were treated with breast conservative surgery and adjuvant RT. Patients were then randomly assigned to receive a boost dose of 15 Gy delivered to the tumor bed either by iridium 192, or a combination of photons and electrons. Cosmetic evaluations were done on a 6-month basis, with a final evaluation at 36 months after RT. The evaluations were done using a panel of global and specific subjective scores, a digitized scoring system using the breast retraction assessment (BRA) measurement, and a patient's self-assessment evaluation. As cosmetic results were graded according to severity, the comparison of boost techniques was done using the ordinal logistic regression model. Adjusted odds ratios (OR) and their 95% confidence intervals (CI) are presented.

RESULTS

At 36 months of follow-up, there was no significant difference between the two groups with respect to the global subjective cosmetic outcome (OR = 1.40; 95%CI = 0.69-2.85, p = 0.35). Good to excellent scores were observed in 65% of implant patients and 62% of photon/electron patients. At 24 months and beyond, telangiectasia was more severe in the implant group with an OR of 9.64 (95%CI = 4.05-22.92, p < 0.0001) at 36 months. The only variable associated with a worse global cosmetic outcome was the presence of concomitant chemotherapy (OR = 3.87; 95%CI = 1.74-8.62). The BRA value once adjusted for age, concomitant chemotherapy, and boost volume showed a positive association with the boost technique. The BRA value was significantly greater in the implant group (p = 0.03). There was no difference in the patient's final self-assessment score between the two groups. Three variables were statistically associated with an adverse self-evaluation: an inferior quadrant tumor localization, postoperative hematoma, and concomitant chemotherapy.

CONCLUSIONS

Although this trial showed that at 36 months of follow-up, there were no significant differences in the overall global cosmetic scores between the implant boost group and the photon/electron boost group, telangiectasia was more severe and the BRA value was greater in the implant group.

Modelling ordinal relations with SVMs: An application to objective aesthetic evaluation of breast cancer conservative treatment

The cosmetic result is an important endpoint for breast cancer conservative treatment (BCCT), but the verification of this outcome remains without a standard. Objective assessment methods are preferred to overcome the drawbacks of subjective evaluation. In this paper a novel algorithm is proposed, based on support vector machines, for the classification of ordinal categorical data. This classifier is then applied as a new methodology for the objective assessment of the aesthetic result of BCCT. Based on the new classifier, a semi-objective score for quantification of the aesthetic results of BCCT was developed, allowing the discrimination of patients into four classes.

Sexual dysfunction in breast cancer survivors

AIM

The aim of this study was to determine differences in body image and sexuality of breast cancer survivors, depending on treatment: radical mastectomy or breast-conserving surgery.

PATIENTS AND METHODS

A total of 206 patients treated for breast cancer between January 2001 and January 2004 were asked to fill in the questionnaire 1-5 years after treatment. Patients were divided into 2 groups. The first group consisted of 108 patients with advanced stages of breast cancer and who were treated with modified mastectomy with adjuvant chemo- or radiation therapy. The second group consisted of 98 patients with early stages of breast cancer who were treated with breast conserving surgery, lumpectomy and radiotherapy.

RESULTS

A significant number of patients in both groups was satisfied with their sexual life before treatment, 70.37 and 73.47% respectively, which is grossly reduced after treatment of breast cancer (56.48 and 50.00%, respectively, p > 0.05). Most of patients found their partner's attitude towards them to be the same (31.48 and 45.92%), or even better (39.82 and 25.51%) after treatment, and they described them as very supportive and tender. In group 1, 58.33% of patients felt differences in their body image, in contrast to 44.90% in group 2. Similar proportions were observed in both groups for patients who felt mutilated (18.52 vs. 8.16%, p < 0.01).

CONCLUSION

These findings confirm and extend previous reports of impaired sexual functioning among breast cancer survivors.

Value of axillary lymphoscintigraphy in patients with operated breast carcinoma

PURPOSE

To evaluate axillary dissection with axillary lymphoscintigraphy (ALS) in postoperative patients with breast carcinoma and its role in adjuvant radiotherapy (RT). Additionally, to define axillary dissection as complete and incomplete with ALS and to correlate it with the number of removed lymph nodes.

MATERIAL AND METHODS

In the last two years, 121 women were studied four weeks after operation. Bilateral second interdigital subcutaneous injections were performed for ALS. Complete and incomplete axillary dissection were interpreted according to the number of surgically removed lymph nodes. ALS was interpreted as complete if no accumulation was shown.

RESULTS

There was a good correlation between the number of surgically removed lymph nodes and complete and incomplete interpretation on ALS (p < 0.004). The number of removed lymph nodes was equal to or greater than 15 in 72% patients with complete dissection according to ALS. Of 48 patients with surgically incomplete axillary dissection, 18 (38%) showed no accumulation in the axillary region, while 25 of 68 (37%) patients with surgically complete dissection showed accumulation in the axillary region and were interpreted as incomplete according to ALS. Indication of RT was changed after ALS in patients with 1 to 3 involved lymph nodes. While RT was not considered in 12 of these patients before ALS, they were included in RT planning. On the other hand, 17 patients, considered for RT previously, were excluded from RT planning after ALS.

CONCLUSION

Evaluation of axillary dissection with ALS especially in suspicious patients with 1 to 3 lymph node metastases might prevent unnecessary morbidity and can be useful in selecting patients who truly need axillary irradiation.

Limited-field radiation therapy in the management of early-stage breast cancer

BACKGROUND

Several phase III trials have demonstrated equivalent long-term survival between breast conserving surgery plus radiation therapy and mastectomy in patients with early-stage breast cancer but have not provided information on the optimal volume of breast tissue requiring post-lumpectomy radiation therapy. Therefore, we examined the 5-year results of a single institution's experience with radiation therapy limited to the region of the tumor bed (i.e., limited-field radiation therapy) in selected patients treated with breast-conserving therapy and compared them with results of matched breast-conserving therapy patients who underwent whole-breast radiation therapy.

METHODS

A total of 199 patients with early-stage breast cancer were treated prospectively with breast-conserving therapy and limited-field radiation therapy using interstitial brachytherapy. To compare potential differences in local recurrence rates based on the volume of breast tissue irradiated, patients in the limited-field radiation therapy group were matched with 199 patients treated with whole-breast radiation therapy. Match criteria included tumor size, lymph-node status, patient age, margins of excision, estrogen receptor status, and use of adjuvant tamoxifen therapy. Local-regional control and disease-free and overall survival were analyzed using the Kaplan-Meier method, and the statistical significance of differences between treatment groups was calculated using the log-rank test. All statistical tests were two-sided.

RESULTS

Median follow-up for surviving patients was 65 months (range = 12-115 months). Five ipsilateral breast failures (i.e., recurrences) were observed in patients treated with limited-field radiation therapy. The cumulative incidence of local recurrence was 1% (95% confidence interval [CI] = 0% to 2.8%). On matched-pair analysis, the rate of local recurrence was not statistically significantly different between the patient groups (1% [95% CI = 0% to 2.4%] for the whole-breast radiation therapy patients versus 1% [95% CI = 0% to 2.8%] for the limited-field radiation therapy patients; P =.65).

CONCLUSIONS

Limited-field radiation therapy administered to the region of the tumor bed has comparable 5-year local control rates to whole-breast radiation therapy in selected patients.

Risk factors for regional nodal failure after breast-conserving therapy: regional nodal irradiation reduces rate of axillary failure in patients with four or more positive lymph nodes

PURPOSE

To determine the incidence of, and risk factors for, regional nodal failure (RNF) and to evaluate the effectiveness of, and indications for, regional nodal irradiation (RNI) in patients with Stage I-II breast cancer treated with breast-conserving therapy.

METHOD AND MATERIALS

A total of 1500 cases of Stage I-II breast cancer were treated with breast-conserving therapy between February 1980 and December 2000. All patients underwent excisional biopsy, and 925 (62%) underwent re-excision. Level I-II axillary lymph node dissection was done in 94% of patients. The lymph nodes were pathologically involved in 335 patients (22%); 255 with 1-3 nodes and 80 with >/=4 nodes involved. All patients received whole breast irradiation to a median dose of 45 Gy, and 97% received a tumor bed boost to a median dose of 61 Gy. Treatment included the breast only in 1309 patients (87%), and the breast and regional lymphatics in 191 (13%).

RESULTS

With a median follow-up of 8.1 years, 35 patients had failure within the regional nodes: 12 patients (6%) who received RNI and 23 patients (2%) who did not. The 5- and 10-year rate for any RNF was 1.9% and 2.8%, respectively. The 5 and 10-year rates of axillary failure and supraclavicular failure were 0.6% and 1.0% and 0.9% and 1.6%, respectively. In patients with >/=4 positive lymph nodes, RNI reduced the 10-year rate of any RNF from 11% to 2% (p = 0.024), the rate of axillary failure from 5% to 0% (p = 0.019), and the rate of supraclavicular failure from 11% to 2% (p = 0.114). RNI did not affect the rate of axillary failure or supraclavicular failure in patients with 1-3 positive nodes. In node-negative patients, the rate of RNF was significantly greater if <6 nodes were removed at the time of axillary dissection. Multiple clinical, pathologic, and treatment-related factors were analyzed for association with RNF. On univariate analysis, RNF was associated with the number of nodes excised, number of positive nodes, percentage of positive nodes, size of nodal metastasis, presence of angiolymphatic invasion, estrogen receptor status, age, systemic chemotherapy, and RNI. Three subsets of patients had unusually high rates of RNF, those with >/=67% nodes positive (16%), nodal metastasis >/=2.0 cm (44%), or age </=35 years (14%). On multivariate analysis, the only significant predictor of RNF was the maximal size of the nodal metastasis. RNI did not improve the overall survival for any subset of patients. The number of lymph nodes excised had an impact on overall survival, with a 10-year survival rate of 33%, 65%, and 69% in patients with <6, 6-10, and >10 nodes excised, respectively (p = 0.05).

CONCLUSION

Failure within the regional lymph nodes as an isolated site of first relapse is uncommon in patients with Stage I-II breast cancer treated with breast-conserving therapy. RNI can significantly reduce the rate of RNF (axillary failure) in patients with >/=4 positive lymph nodes. The maximal size of the lymph node metastasis was found to be the only significant independent predictor of RNF, with nodal metastases >/=2.0 cm associated with extremely high regional failure rates. Despite this, young age and the extent of axillary dissection (particularly as related to the number of positive nodes) also appear to be important and should be considered when evaluating patients for RNI. Inadequate axillary dissection was not only associated with increased regional failure, but also reduced survival.

Breast conservation rates-barriers between tertiary care and community practice

PURPOSE

Low rates of breast conservation therapy (BCT) are reported in the southern United States. We evaluated the influence on BCT rates of opening a radiotherapy (RT) clinic at a community hospital in North Carolina. Before opening, RT was available 5 miles away at a tertiary care center.

METHODS AND MATERIALS

A review of the pathology database of the community hospital identified patients who underwent definitive surgery for invasive breast malignancy or ductal carcinoma in situ between 1994 and 1995, and 1997 and 1998, before and after the opening of the RT clinic in 1996. From these data, the mode of therapy, mastectomy or BCT, was determined. The results were compared using logistic regression analysis. Surgical and RT physician staffing were unchanged throughout the study period.

RESULTS

A total of 586 patients was evaluated. The BCT rate at the community hospital for 1994-1995 and 1997-1998 was 29% and 44%, respectively. On both univariate and multivariate logistic regression analysis, the era of treatment was statistically significant in its impact on the procedure performed (p <0.001).

CONCLUSION

The use of BCT increased at a community hospital after the opening of an on-site RT facility, even though RT was available 5 miles away previously.

Indications and technical aspects of brachytherapy in breast conserving treatment of breast cancer

Improved local control rates have been demonstrated in retrospective studies as well as in randomised trials on brachytherapy with increasing doses to the tumour bed. The higher local control obtained by interstitial breast implants, as compared to external photon or electron beam boosts, have been mainly attributed to the higher doses actually delivered to the tumour bed by these implants for the same nominal dose as compared to external beam radiotherapy (RT). On the other hand, poor cosmesis has also been correlated with radiation dose to the breast skin (radiation teleangiectases), and breast tissue (retraction due to fibrosis), the latter depending not only on RT dose but also on the treated boost volume. For this reason, a possible benefit of interstitial implants will only be realized when the gain in local control goes together with minimal cosmetic damage. Therefore, the ballistic advantages of interstitial implants have to be maximally exploited: i.e. the treated volume should be maximally adapted to the target volume, and additional irradiation of the breast skin by the boost technique should be avoided. This paper deals in detail with the technical aspects of breast brachytherapy that seem to be relevant for high quality outcome.

Long-term results (10 years) of intensive breast conserving therapy including a high-dose and large-volume interstitial brachytherapy boost (LDR/HDR) for T1/T2 breast cancer

BACKGROUND AND PURPOSE

During the past 15 years many retrospective studies and prospective randomized trials have been published supporting the use of breast conserving treatment (BCT) including surgery and radiotherapy. However, there are still many controversies on the necessary amount of resection, the width of the resection margins and the optimal radiation technique, dose and volume, in particular of the boost. In this retrospective study a large cohort of 410 women with early breast cancer treated with BCT including an interstitial brachytherapy (BT) boost is evaluated after a long follow-up period.

MATERIAL AND METHODS

In order to clarify the impact of the different treatment-related factors on local control, these were carefully discriminated, based on widely accepted classification and reporting systems for surgery as well as for radiotherapy. The surgical approach was classified according to EORTC criteria and a high rate of quadrantectomies (60%) was found. Dose and volume of interstitial BT is reported according to recommendations of ICRU 58, and reveals a significant radiation dose and volume: minimum target dose, mean central dose (MCD) and '85% of MCD' for low-dose rate (LDR) BT was mean 20, 28 and 24 Gy, for high-dose rate (HDR) BT it was mean '10, 15 and 13 Gy, respectively; the treated volume was 104 cc for LDR BT and 83 cc for HDR BT.

RESULTS

The actuarial rates for overall survival, disease-free survival and disease-specific survival were 97, 90 and 98% at 5 years and 85, 79 and 92% at 10 years. There have been only 16 breast recurrences in 410 treated patients resulting in a 5- and 10-year actuarial local recurrence rate of 2 and 3.9%, respectively; six recurrences (1.5%) were in the original quadrant. Except age and menopausal status, all tumour- and patient-related risk factors had no significant impact on local control.

CONCLUSIONS

Our data confirm that intensive BCT leads to excellent long-term results in terms of local control, masking classical risk factors. This high-dose and large-volume interstitial BT seems to be superior to classical BCT without BT.

The emerging role of brachytherapy in the management of patients with breast cancer

Brachytherapy remains an important treatment option in the overall management of patients with breast cancer. In patients treated with breast conserving therapy (BCT), prospective randomized trials have established the advantage of a boost in most patients. Interstitial brachytherapy has consistently been shown to provide an important option to boost patients, and in certain clinical settings it may provide a more appropriate means of dose delivery. The concept of delivering partial breast irradiation with accelerated treatment schedules has now provided brachytherapy a new and exciting role in the management of patients treated with BCT. There are now data available from several phase I/II studies suggesting that brachytherapy alone can be used safely and reproducibly in this setting in order to reduce the time, inconvenience, and toxicity associated with traditional radiation therapy. Although preliminary results with brachytherapy alone are encouraging, proper patient selection and optimal dosimetric guidelines must be employed in order to achieve success when used in this setting.

Long-term results of neoadjuvant radiation therapy for breast cancer

Our aim was to determine the long-term outcome and the possible role of neoadjuvant (preoperative) radiation therapy for breast cancers unsuitable for primary conservative surgery. From 1977 to 1992, 75 unifocal non-inflammatory and non-metastatic T2 and T3 breast cancers were treated in our department. All these patients underwent initial radiotherapy, followed by secondary limited surgery. A population of 74 patients, aged from 32 to 82 years (median 56 years), presenting 49 T2 and 26 T3 tumors, was studied. Seventy-two patients (96%) underwent secondary tumorectomy and three patients (4%) reduction mammaplasty. The secondary tumorectomy was followed by a postoperative boost. There were nine recurrences, treated by mastectomy in eight cases and by tumorectomy in one case. Twenty-five patients showed secondary dissemination. Forty-seven patients are still alive and free of disease. The cosmetic results were considered excellent or satisfactory in 71 cases. Under good conditions, preoperative radiotherapy (as well as preoperative chemotherapy) allows the possibility of conservative surgery for cancers of more than 3 cm. The choice between the two modalities depends on the patient's condition and on a precise analysis of all prognostic factors that would justify the need for systemic treatment.

Routine follow-up examinations in breast cancer patients have minimal impact on life expectancy: a simulation study

BACKGROUND

Little is known about the effects of routine follow-up examinations on life expectancy in cancer patients. Lately, the benefits of follow-up examinations have been debated, which has given rise to less extensive, though still frequent, follow-up strategies. In this study, a simulation model was applied to evaluate the impact of different follow-up strategies on life expectancy in breast cancer patients.

MATERIALS AND METHODS

A five-state Markov chain model was developed, with which various follow-up strategies with regard to frequency and elaborateness were simulated. Calculations were based on a hypothetical population of breast cancer patients treated with curative intent. Medical aspects were studied, such as life expectancy and the proportion of patients who died from breast cancer. Social and psychological aspects and quality of life were not taken into account. Data from the literature were used to estimate the parameters needed for the model.

RESULTS

The gain in life expectancy with standard follow-up compared to no follow-up examination, was about 2 months in breast cancer patients aged 50 years treated with curative intent. The percentage of patients who died from breast cancer was 45.4% with standard follow-up, versus 45.8% without follow-up. In older women, the gain was even less. Sensitivity analyses showed that the effects on life expectancy were robust.

CONCLUSIONS

Our model showed that standard follow-up had minimal impact on the prognosis of breast cancer patients. It may be unnecessary to continue standard follow-up by medical specialists after the end of the surveillance period of the primary therapy, provided that the patients continue to have easy access to health care facilities in the case of symptoms or concern. However, future research is needed to study quality of life aspects of follow-up.

[Breast-conserving surgery and irradiation for early breast cancer: value of surgical clips in the surgical cavity]

PURPOSE

To evaluate, qualitatively and quantitatively, the role of surgical clips in planning the tumor bed electron or brachytherapy boost in patients undergoing breast-conserving surgery and radiotherapy.

PATIENTS AND METHODS

In 60 patients with breast cancer stage I or II, the excision cavity boundaries were marked by clips at surgery. Patients received a boost with brachytherapy (n = 51) or electron beam (n = 9) after whole breast irradiation. The boost target volume was first planned using clinical, mammography and operative information and its accuracy evaluated by screening the surgical clips and, if necessary, adjusting the field to encompass all clips and to include the scar. Dosimetry was retrospectively performed for each brachytherapy patient and for each surgical clip.

RESULTS

It was necessary to modify the target volume field in 11 cases (18%). The average dose received by the surgical clips was 116.1% of the dose delivered to the reference isodose (median: 101.75%, range: 16-457%). However, dose heterogeneity was important in the same patient and between patients.

CONCLUSION

Delineation of the boost target volume with surgical clips is more accurate than with clinical landmarks alone but this technique does not allow measurements of the clip-chest wall and clip-skin distances. Virtual simulation with CT-scan cuts is recommended for optimising boost planning.

Breast carcinoma treated by conservative surgery: results of postoperative external radiotherapy with photons only and a nonsplit supraclavicular field

Eighty-nine breasts in 85 patients were treated by lumpectomy and then radiotherapy from a Co-60 source only. The supraclavicular field was nonsplit. Eighty percent were in their 40s, 60s, or 70s with almost equal distribution. The majority of cases (80%) was T1 followed by T2 (18%). Axillary dissection was not done in 26% of patients. The majority (84%) had infiltrating ductal carcinoma; 6% had carcinoma in situ only. The dose to the breast including the boost was in the range of 6,000 cGy to 7,000 cGy in 96%, whereas in 4% it was in the range of 5,000 cGy. Forty-four patients (49%) with N0 did not have nodal irradiation. The dose to the nodes in the remaining patients ranged from 5,040 to 6,840 cGy. The cosmetic result was good to excellent in 99% of evaluated patients. There was telangiectasia in 1, arm edema in 2, no fibrosis in supraclavicular-tangential fields junction and no other soft-tissue or bone complications. Fifteen percent died; 6% had no evidence of cancer, and 9% had metastatic disease. Two had local recurrence, but with salvage mastectomy and systemic therapy were alive and well. The use of external photons only for breast irradiation and a nonsplit supraclavicular field yielded good results compared with alternative methods.

Aichi Cancer Center 10-year experience with conservative breast treatment of early breast cancer: retrospective analysis regarding failure patterns and factors influencing local control

PURPOSE

We analyzed the clinical results of conservative breast therapy in our institute to determine the risk factors influencing local and distant disease recurrence.

METHODS AND MATERIALS

From 1989 to 1997, 301 breasts of 295 women with early breast cancer were treated with conservative surgery and adjuvant radiotherapy. There were 212 incidences of Stage I breast cancer, and 89 of Stage II. Patients were routinely treated with local resection, axillar dissection, and 46--50 Gy irradiation given in 23--25 fractions. Some also received a radiation boost to the tumor bed.

RESULTS

The 5-/8-year overall survival, disease-free survival, and local control rates were 93.2/91.5%, 86.0/80.6%, and 95.1/92.5%, respectively. Using both univariate and multivariate analyses, tumor volume, estrogen receptor status, and age < 40 years were significant prognostic factors for disease-free survival. Both age < 40 years and surgical method had a strong effect on local control by uni- and multivariate analysis. Surgical margin status was a significant prognostic factor for local control at the univariate level (p < 0.0001), though it had only borderline significance at the multivariate level (p = 0.08). No patient experienced severe morbidity due to radiotherapy.

CONCLUSION

The results obtained are comparable to previously reported data. Although the follow-up period was too short to draw definite conclusions about long-term outcomes, the outcome from conservative breast treatment was acceptable.

Locoregionally recurrent breast cancer: incidence, risk factors and survival

Locoregional recurrence (LRR) after therapy for early breast cancer is common. Patients with LRR can suffer both local consequences and symptoms of metastatic disease, as LRR is an independent predictor of subsequent distant metastases. Much of the available data on LRR is derived from small, single institution, retrospective studies, so marked differences in the incidence rates for LRR, it's risk factors and subsequent systemic recurrence are reported. The purpose of this review was to try and collate this data in a format that would be useful for both clinicians and their patients.

Low body mass index is an independent predictive factor of local recurrence after conservative treatment for breast cancer

BACKGROUND

Obesity or increased body mass index (BMI) has been shown to have two important adverse effects related to breast cancer. First, several studies have identified an association between increased BMI and advanced stage breast cancer. Second, increased BMI has been shown to be associated with poorer prognosis. In a previous report, we had identified low BMI as a risk factor for local reccurence at five years. The objectives of this study were to evaluate the relationship between BMI and local control and to confirm this prognostic factor in a larger population with an important follow-up.

MATERIALS AND METHODS

Between 1976 and 1988, 605 women with invasive breast carcinoma less than 4 cm in diameter underwent conservative surgery with axillary dissection and radiation therapy. The median follow-up time was 82 months. The risk of local recurrence and distant metastasis was evaluated by univariate retrospective analysis using Kaplan-Meier method for the main clinical and histologic factors. Those found to be significant were entered in a Cox model for multivariate analysis.

RESULTS

Since the beginning of the study, 80 patients had developed local recurrence. The 5 years and 10 years local control rates were 91% and 83%, respectively. Four parameters were independent predictive factors of local recurrence: Age lower than 40 years (HR = 2.42 95% CI = [1.35-4.34]), BMI: elevation of one unit reducing the local recurrence of 0.92 95%CI = [0.85-0.99], multifocality of the tumor on pathological examination (HR = 2.12 95% CI = [1.16-3.88]) and positive axillary nodes HR = 0.54 95% CI = [0.31-0.95]. Size of the breast was not a predictive factor for local cancer recurrence. Low BMI did not increase risk of distant.

CONCLUSION

Our study offers new data concerning the possibility that thinness may be related to local recurrence of breast cancer.

Ipsilateral breast tumor recurrence following breast-conserving surgery for early-stage invasive cancer

Ipsilateral breast tumor recurrence (IBTR) following conservative surgery and radiation for early stage invasive cancer occurs in approximately 15% of all patients at 10 years and is diminished with surgical excisions which achieve negative margins. Treatment strategies of breast-conserving surgery with or without radiation that result in IBTR rates of 30 40% will impact negatively on survival and the magnitude of this effect will be influenced by the predominant pattern of local failure as well as initial and subsequent distant metastases. Optimal local control in early-stage invasive breast cancer is important to minimize the risk of a salvage mastectomy and maximize the potential for long-term survival.

Cosmetic assessment of breast-conserving surgery for primary breast cancer

The goals of breast-conserving treatment are to achieve local control and survival rates equivalent to mastectomy and to preserve breast cosmetic appearance. This paper specifically addresses the different ways of cosmetic assessment by the observer (subjective and objective assessments) and by the patient (self-assessment), and the factors which influence the cosmetic outcome, based on a review of the current literature.

[Radiation-induced sarcoma after breast cancer. Apropos of 8 cases and review of the literature]

PURPOSE

Retrospective analysis of eight new cases of radiation-induced sarcomas following radiotherapy for breast carcinoma and literature review.

PATIENTS AND METHODS

Eleven patients presenting with radiation-induced sarcoma after radiotherapy for breast cancer have been treated between 1983 and 1997 at Henri Mondor University Hospital (France). Eight of these patients respected the criteria established by Cahan et al. The others had Stewart-Treves Syndrome and were thus excluded from the analysis. Only one of the eight patients had received chemotherapy. All of the patients at the time of diagnosis of radiation-induced sarcoma were free of breast cancer recurrence. Radiation-induced sarcoma appeared with a latency period of 5 to 18 years (mean: 10.3 years). Patients' ages ranged from 39 to 88 years (mean: 57.6 years) at the time of diagnosis of sarcoma. Three sarcomas occurred in the treated breast, two in the chest wall, one in the preclavicular area and two in the axillary region. There were two angiosarcomas, three fibrosarcomas, one osteosarcoma, one malignant fibrous histiocytoma (MFH), and one undifferentiated sarcoma. All patients have received treatment for their sarcoma: all of them underwent surgery, one patient combined radiotherapy and chemotherapy, and three patients chemotherapy.

RESULTS

Two patients were alive and free from disease. Six patients died (5-34 months); all six had local and/or metastatic recurrence.

CONCLUSIONS

Radiotherapy can induce malignancies after a latent period of several years. Radiation-induced sarcomas are associated with poor overall prognosis. The treatment in most of the cases is late and ineffective, therefore careful follow-up is needed. There are still many uncertainties and questions about radiation-induced sarcomas.

Treatment of early-stage breast cancer in the elderly: a health-outcome-based approach

PURPOSE

To evaluate the post-lumpectomy treatment of a nonpalpable, stage I, T1b tumor, mammographically detected, in a 74-year-old woman without comorbidities.

METHODS

A Markov process, through 120 monthly cycles, was used to model patient progression through a treatment program, employing literature data and a health-outcome utility. Treatments considered were: observation; radiation totaling 5,000 cGy over six weeks; tamoxifen, 20 mg/day, for five years; simple mastectomy; and radiation therapy plus tamoxifen. Health states included absence of disease (NED), loco-regional recurrence, distant metastasis, age-sex-race (ASR)-adjusted death, cancer mortality, treatment complications, and post-mastectomy death. Transition probabilities were established from the literature. Health-state utilities were determined from the responses of health care professionals to a basic reference gamble.

RESULTS

Quality-adjusted life years (QALYs) were determined to be 8.19 for radiation plus tamoxifen, decreasing to 8.04 for mastectomy, a difference of only a 0.15 years (1.8 months). Sensitivity analysis, however, showed relative stability in the ranking among treatment options.

CONCLUSION

Although the model showed little difference between QALYs with the treatments, the combination of radiation and tamoxifen provides the optimal therapy for this case.

The role of regional nodal irradiation in the management of patients with early-stage breast cancer treated with breast-conserving therapy

PURPOSE

To determine the incidence of regional nodal failure (RNF) and indications for regional nodal irradiation (RNI) in patients with Stage I and II breast cancer treated with breast-conserving therapy (BCT).

METHODS AND MATERIALS

Four hundred fifty-six patients with Stage I/II breast cancer were treated with BCT at William Beaumont Hospital. All patients underwent excisional biopsy and 288 (63%) were reexcised. A Level I/II ipsilateral axillary lymph node dissection was performed on 431 patients (95%). Pathologically involved nodes were found in 106 (23%) cases (69 with one to three nodes and 37 with > or = four nodes involved). All patients received whole breast irradiation (median dose 50 Gy) and 415 (91%) were boosted to the tumor bed (median total dose 60.4 Gy). Three hundred and sixty (79%) patients received breast alone irradiation and 96 (21%) also received RNI. The median axilla/supraclavicular fossa dose was 50 Gy.

RESULTS

With a median follow-up of 83 months, 15 patients developed a RNF for a 5- and 8-year actuarial rate of 3 and 4%, respectively. The 5- and 8-year actuarial rates of axillary failure (AF) were 0.7 and 1.0%, respectively. The incidence of RNF or AF was not affected by the use of RNI in N0 or N1 patients with one to three positive nodes. Only in patients with four or more positive nodes was there a trend towards improved regional control with RNI (p = 0.09). However, patient numbers were extremely small, and this improvement was limited to a reduction in the rate of failure in the supraclavicular fossa (SCF) (20 vs. 0%, p = 0.04). Multiple clinical, pathologic, and treatment related factors were analyzed for an association with AF. On univariate analysis, AF was associated with the number of lymph nodes excised (p < 0.0001) estrogen receptor status (p = 0.0016), and pathologic node status (p = 0.0021).

CONCLUSIONS

Regional nodal failure as the first site of failure is uncommon in patients with early-stage breast cancer treated with BCT with < or = three positive lymph nodes and appears unaffected by RNI. For patients with four or more positive lymph nodes, a trend towards improved RNF was noted with RNI, primarily in the SCF. However, patient numbers were extremely small in all subsets analyzed. Additional studies are needed to further define the need for RNI in these patients and help determine other factors associated with RNF.

Clinical indications for brachytherapy

Brachytherapy, or placing radioactive sources either temporarily or permanently into or near a malignant tumor, is a long-established cancer treatment method. During the past 25 years, brachytherapy has become safer and more versatile than earlier radium therapy, and its indications have increased dramatically during this period. One estimate is that at least 5-10% of all patients needing radiation therapy require brachytherapy. The site-specific clinical indications and methods for brachytherapy implementation are described.

Brachytherapy and breast cancer

Brachytherapy has been an important component of radiation therapy for breast cancer. It played a historical role in the development of breast-conserving techniques for early-stage breast cancer. The primary use for brachytherapy in this setting has been to deliver a localized boost dose of radiation to the lumpectomy bed after whole breast radiation therapy. In recent years, there has been less utilization of brachytherapy as a boost technique. This is predominantly related to wider availability of electrons for delivering a boost dose. Another significant factor for the decline is the controversy of whether routine boosting of the tumor bed is necessary for all early-stage breast cancer patients after conservative surgery and whole breast radiation therapy. Despite this, brachytherapy is still the preferred boost technique in certain subsets of patients. Newer applications of brachytherapy for the treatment of breast cancer have emerged and have shown promise. For early-stage breast cancer, these include brachytherapy as the sole radiation modality after lumpectomy and in combination with local excision as an alternative to mastectomy for treatment of local recurrences after conservative surgery and radiation therapy. In selected locally advanced cases of breast cancer, brachytherapy has been used as part of a technique that attempts breast conservation. At this time, these newer uses of brachytherapy for the treatment of breast cancer remain investigational.

Local Management of Primary Breast Cancer

BACKGROUND: Various options are available for the local control of cancer in the breast -- mastectomy, conservation therapy, and mastectomy with reconstruction. METHODS: To evaluate the benefits and drawbacks of the available management options, the authors combine their extensive experience with a review of the literature on outcomes from these approaches. RESULTS: Conservation therapy provides survival outcomes similar to those from mastectomy. Differences in local recurrence rates can be minimized by close adherence to guidelines for patient selection, operative approach, and radiation technique. CONCLUSIONS: The role of the physician in selecting a local therapy for breast cancer has changed from one of informing the patient of the treatment to assessing the presence of medical contraindications to any of the treatments, educating the patients on each treatment approach, providing access to multidisciplinary consultation, and allowing the patient to choose an appropriate treatment approach.

Long-term outcome with interstitial brachytherapy in the management of patients with early-stage breast cancer treated with breast-conserving therapy

PURPOSE

We reviewed our institution's experience with interstitial implant boosts to determine their long-term impact on local control and cosmetic results.

METHODS AND MATERIALS

Between January 1, 1980 and December 31, 1987, 390 women with 400 cases of Stage I and II breast cancer were managed with breast-conserving therapy (BCT) at William Beaumont Hospital. All patients were treated with an excisional biopsy and 253 (63%) underwent reexcision. Radiation consisted of 45-50 Gy external beam irradiation to the whole breast followed by a boost to the tumor bed to at least 60 Gy using either electrons [108], photons [15], or an interstitial implant [277] with either 192Ir [190] or 125I [87]. Long-term local control and cosmetic outcome were assessed and contrasted between patients boosted with either interstitial implants, electrons, or photons.

RESULTS

With a median follow-up of 81 months, 25 patients have recurred in the treated breast for a 5- and 8-year actuarial rate of local recurrence of 4 and 8%, respectively. There were no statistically significant differences in the 5- or 8-year actuarial rates of local recurrence using either electrons, photons, or an interstitial implant. Greater than 90% of patients obtained a good or excellent cosmetic result, and no statistically significant differences in cosmetic outcome were seen whether electrons, photons, or implants were used.

CONCLUSIONS

We conclude that patients with Stage I and II breast cancer undergoing BCT and judged to be candidates for boosts can be effectively managed with LDR interstitial brachytherapy. Long-term local control and cosmetic outcome are excellent and similar to patients boosted with either electrons or photons.

[Role of radiotherapy in the management of adenocarcinoma of the breast accessible to conservative surgery]

Standard treatment for limited stage adenocarcinoma of the breast includes lumpectomy (or a quadrantectomy), axillary node dissection, regional radiation therapy and, if the prognostic factors are unfavourable, chemotherapy and/or hormone therapy. This is supported by the results of American and European randomised trials. There have been many attempts at improving the modalities of conservative surgery and postoperative radiation therapy in order to maximize local control and minimize late sequellae. It is also likely that induction chemotherapy and external beam radiotherapy applied in selected cases increase the proportion of patients who can be offered conservative surgery.

Axillary lymph nodes and breast cancer: a review

BACKGROUND

The value of surgical staging and treatment of the axillary lymph nodes with either surgery or radiotherapy in the initial management of patients with Stage I or II invasive breast cancer is controversial.

METHODS

A review of retrospective and prospective clinical studies was performed to assess the risks of axillary lymph node involvement and the effectiveness and morbidity of various treatment options.

RESULTS

The risk of axillary lymph node involvement is substantial for most patients, even those with small tumors. The morbidity resulting from a careful Level I/II axillary dissection or moderate-dose axillary radiotherapy is limited. Such treatment is highly effective in preventing axillary recurrence. The symptoms resulting from axillary failure can be controlled in many, but not all, patients. The available data suggest, but do not prove, that the initial use of effective axillary treatment may result in a small improvement in long term outcome in some patient subgroups.

CONCLUSIONS

Most patients should be treated with either axillary surgery or irradiation. Highly selected subgroups of patients may have such low risks of involvement that specific axillary treatment is of little value. However, such subgroups have not yet been well defined. Treatment approaches that do not involve specific axillary treatment should be considered investigational at present, and the patients should be informed as to their potential risks. Prospective clinical studies of these issues should be pursued.

The influence of radiotherapy on cosmetic outcome after breast conservative surgery

PURPOSE

The influence of radiotherapy in the cosmetic outcome after conservative surgery for breast cancer was evaluated using an objective method of calculating the asymmetry between the two breasts.

METHODS AND MATERIALS

One hundred and one patients treated with the same conservative surgery were evaluated for cosmetic outcome. Sixty-one of them received external radiotherapy (50 + 10 Gy) to the residual breast; the remaining 40 underwent surgery only. The aspect of the patients' breasts was objectively assessed for symmetry by means of a computerized technique. A subjective assessment of the cosmetic outcome was performed both by physician and patient. These objective and subjective assessments were compared in the two groups treated with or without radiotherapy.

RESULTS

The results obtained did not show significant differences in terms of cosmetic outcome in the two groups. Skin telangectasia was noted in two radiotherapy patients, while hypertrophic breast scars were only noted in six nonirradiated patients.

CONCLUSIONS

We found that standard radiotherapy does not seem to influence the symmetry and the cosmetic results in breast conservative treatment when compared to a similar group of patients with the same quadrantectomy procedure and no radiotherapy.

Ten-year results in 1070 patients with stages I and II breast cancer treated by conservative surgery and radiation therapy

BACKGROUND

One thousand seventy patients treated conservatively for Stages I and II breast cancer between the years 1982 and 1994 were reviewed. The median follow-up was 40 months with a maximum follow-up of 152 months.

METHODS

All patients had a wide local excision and lower lymph axillary node dissection followed by radiation therapy. The entire breast received an external beam dose of 4500 cGy at 180 cGy/5 days/week. An additional boost dose of 2000 cGy to the tumor bed was given at the time of lumpectomy (perioperative) with an Ir-192 implant or with electron beam therapy after the external beam therapy.

RESULTS

The 5- and 10-year disease specific survival results were 97 and 90%, respectively for Stage I and 87 and 69% for patients with Stage II disease. The 5- and 10-year local control rates were 93 and 85% for Stage I and 92 and 87% for Stage II, respectively. The risk factors for local failure were premenopausal status and estrogen receptor-negative status at the univariate level but at the multivariate level the premenopausal and margins status were significant.

CONCLUSION

These 10-year results were at least equivalent to reported series of similarly staged patients treated by mastectomy. This should encourage more surgeons to offer conservative treatment as an alternative to mastectomy to patients with Stage I and II breast cancer.