Comparison of survival and regional failure between accelerated partial breast irradiation and whole breast irradiation

The Challenges of Lobular Carcinomas from a Surgeon's Point of View

Invasive lobular breast cancer (ILC) presents unique challenges and considerations in the realm of surgical management. Characterized by its distinct histological features, including the loss of E-cadherin expression and dys-cohesive growth pattern, ILC often poses diagnostic and therapeutic dilemmas for clinicians. This abstract explores the surgical landscape of ILC, focusing on its epidemiology, clinical presentation, diagnostic modalities, and surgical interventions. Emphasizing the importance of individualized treatment strategies, this narrative delves into the nuances of surgical decision-making, including the role of breast-conserving surgery versus mastectomy, axillary staging, and the significance of margin status. Additionally, advancements in surgical techniques, such as oncoplastic approaches and sentinel lymph node biopsy, are examined in the context of optimizing oncologic outcomes and preserving cosmesis. Through a comprehensive review of current literature and clinical guidelines, this overview aims to provide a nuanced understanding of the surgical considerations inherent to the management of invasive lobular breast cancer.

Modern Approaches for Breast Brachytherapy

Breast brachytherapy represents a radiation technique that can be utilized as both monotherapy and as a tumor bed boost following breast conserving surgery. As monotherapy, the rationale for brachytherapy is that the majority of residual disease and therefore recurrences occur in close proximity to the lumpectomy cavity; for boost treatment, brachytherapy represents a technique that provided a more conformal approach prior to 3D treatment planning, and more recently can be used in conjunction with oncoplastic surgery. Multiple guidelines are available to assist clinicians with patient selection for accelerated partial breast irradiation (APBI), and recent guidelines support brachytherapy as an appropriate technique to deliver APBI. Modern breast brachytherapy can be performed with interstitial or applicator-based brachytherapy with multilumen and strut devices offering the ability to provide greater skin, chest wall, and normal breast sparing than previous devices. Novel strategies are being evaluated, including high dose rate perioperative/intraoperative radiotherapy, permanent breast seed implants, and noninvasive breast brachytherapy. Additionally, studies are evaluating shorter courses of brachytherapy. Multiple Level I studies are now available supporting interstitial brachytherapy to deliver APBI while prospective data and the National Surgical Adjuvant Breast and Bowel Project B-39/Radiation Therapy Oncology Group 0413 trial are available with applicator brachytherapy and provide standardized prescriptions, target volume definitions, and dosimetric goals.

A prospective feasibility study of MammoSite accelerated partial breast irradiation for early breast Cancer

BACKGROUND

Accelerated partial breast irradiation is a potential alternative to standard whole breast irradiation, following breast-conserving surgery, in the management of breast cancer. The MammoSite applicator-based technique allows for the delivery of a higher dose of radiation to the tumour bed and adjacent area, over a shorter treatment period.

AIMS

To investigate the long-term feasibility of the MammoSite technique in early stage breast cancer in an Irish cohort.

METHODS

Sixty-two patients with early stage breast cancer were enrolled in this prospective study between November 2005 and October 2012 at the University Hospital Galway. A single-entry MammoSite applicator was inserted post-operatively. A CT scan was performed to assess the balloon to skin distance, the conformance of target tissue to balloon surface and balloon symmetry. A total dose of 34 Gy was delivered over 10 fractions twice daily.

RESULTS

Median follow-up was 10 years. 91.9% (57/62) completed the full course of MammoSite treatment. Technical issues with the MammoSite balloon precluded three patients from completing the full course of treatment. On last follow-up, 6.4% (4/62) of patients had developed an ipsilateral breast recurrence. Half of these recurrences occurred more than 10 years after the initial breast cancer treatment. The most common toxicities observed were fibrosis (67.7%), pain (61.3%) and skin erythema (35.5%).

CONCLUSION

The use of the MammoSite technique, as an alternative to standard whole breast irradiation, is feasible in a typical Irish clinical setting with integrated multidisciplinary team input.

Partial versus whole breast irradiation: Side effects, patient satisfaction and costs

PURPOSE

Since accelerated partial breast irradiation has demonstrated non-inferiority to whole breast irradiation regarding recurrence rate in patients with early stage breast cancer, our objective was to compare its impact on short-term adverse events, patient satisfaction and costs.

MATERIALS AND METHODS

Patients with early stage breast cancer treated by breast-conserving surgery between 2007 and 2012 were included: 48 women who received three-dimensional conformal accelerated partial breast irradiation in a multicentre phase-II trial were paired with 48 patients prospectively treated with whole breast irradiation. Adverse events, and patients' opinions concerning cosmesis, satisfaction and pain, were gathered 1 month after treatment. Direct and indirect costs were collected from the French National Health Insurance System perspective until the end of radiotherapy.

RESULTS

When comparing its impact, skin reactions occurred in 37% of patients receiving three-dimensional conformal accelerated partial breast radiotherapy and 60% of patients receiving whole breast irradiation (P=0.07); 98% were very satisfied in the group three-dimensional conformal accelerated partial breast radiotherapy versus 46% in the group treated with whole breast irradiation (P<0.001); direct costs were significantly lower in the group treated with partial breast irradiation (mean cost: 2510€ versus 5479€/patient), due to less radiation sessions.

CONCLUSION

In patients with early-stage breast cancer, partial irradiation offered a good alternative to whole breast irradiation, as it was less expensive and satisfactory. These, and the clinical safety and tolerance results, need to be confirmed by long-term accelerated partial breast irradiation results in on-going phase III trials.

Accelerated partial breast radiotherapy: a review of the literature and future directions

Breast conservation therapy exemplifies the tailoring of medicine in the care of patients with cancer. Akin to improvements in surgical approaches, accelerated partial breast irradiation (APBI) tailors the treatment volume and duration to the needs of well selected patients. Here, we examine the evidence supporting APBI as well as the lessons in patient selection, dose and delivery techniques. Examination of historical techniques and their associated outcomes will support more correct patient selection and treatment delivery in an era where we await the reports of several large prospective trials.

Mono-institutional Italian Experience with a Double-lumen Balloon-brachytherapy Device for Early Breast Cancer: Results at a 5-year Minimum follow-up

Aims and Background

To report the 5-year minimum follow-up in low-risk breast cancer patients treated with a double-lumen balloon-brachytherapy device in one mono-institutional Italian experience. Local control data and cosmetic outcomes were collected and analyzed.

Methods

Between October 2004 and December 2007, we treated 30 early stage breast cancer patients who underwent conservative surgery followed by adjuvant accelerated partial breast irradiation with a double-lumen balloon-brachytherapy system. Eligibility criteria for the protocol were based on the indications of the American Brachytherapy Society and the American Society of Breast Surgeons. The device was placed inside the lumpectomy cavity during surgery by open technique in all the patients. Computed tomography images and standard X-ray were used for treatment planning. The total irradiation dose was 34 Gy in 10 fractions of 3.4 Gy (twice daily) over 5 days to the lumpectomy cavity.

Results

Median follow-up was 80.5 months (range, 60–98). No patient developed local recurrence or distant metastasis. At the end of treatment, there was evidence of a symptomatic seroma in 83% of the total patients, with a yearly decreasing trend. However, the incidence of mild and moderate fibrosis progressively increased. Seventy seven percent of the patients were satisfied with their cosmetic results.

Conclusions

Our findings reinforce the hypothesis that an accelerated double-lumen balloon-breast brachytherapy catheter in selected low-risk patients is safe, and a favorable cosmetic outcome can be achieved.

Brachytherapy in the treatment of breast cancer

Brachytherapy is an important radio-therapeutic modality for a variety of malignancies, including prostate cancer, cervix cancer, breast cancer, vagina cancer, endometrium cancer, head and neck cancer, and many more. This technique has been shown to be an effective and safe non-pharmaceutical treatment with fewer serious complications and better outcome than other treatments for breast cancer. Every year, hundreds of thousands of patients around the world benefit from brachytherapy, which reliably delivers a relatively higher radiation dose to the intended target. However, the follow-up time, patient eligibility criteria, treatment strategy, and radiation doses used in published studies are somewhat inconsistent, making it difficult to strictly compare and evaluate the performance of the treatment. More rigorous studies are required to confirm the safety of this technique and to make outcome data more comparable. In this review, we focus on recent advances in breast brachytherapy techniques and provide an overview of outcomes, cosmetic outcome, toxicity, complications, and limitations of brachytherapy for the treatment of breast cancer. We also summarize the clinical outcomes and toxicity results in patients receiving or not receiving brachytherapy.

Accelerated partial breast irradiation compared with whole breast radiation therapy: a breast cancer cohort study measuring change in radiation side-effects severity and quality of life

PURPOSE

Radiotherapy (RT) after breast-conserving surgery for early-stage breast cancer patients has similar survival benefits with whole breast RT (WBRT) or accelerated partial breast irradiation (APBI). However, the impact of RT type and side-effects severity on change in quality of life (QOL) is unknown. We examined changes in RT side-effects severity and QOL by RT type.

METHODS

We analyzed data from a cohort of 285 newly diagnosed early-stage breast cancer patients with tumor size ≤3.0 cm and lymph node-negative disease. Patients (93 [32.6%] stage 0; 49 [17.2%] non-white; mean age = 59.3 years) completed four interviews (6 weeks, 6, 12, and 24 months) after definitive surgical treatment. We measured severity of RT side effects, fatigue and skin irritation, using a 5-point scale (1 "not at all" to 5 "all the time") and measured QOL using the Functional Assessment of Cancer Therapy-Breast (FACT-B) and RAND 36-item Health Survey Vitality subscale. Repeated-measures analysis of covariance of each outcome controlled for demographic, clinical/treatment, and psychosocial factors.

RESULTS

Patients initiated RT by 6 months (113 received APBI; 172 received WBRT) and completed RT by 12 months. Patients receiving WBRT (vs. APBI) reported greater increase in fatigue and skin irritation severity from 6-week to 6-month interviews (each P < 0.001). Improvement in neither total FACT-B nor Vitality differed significantly by RT type over 2-year follow-up.

CONCLUSIONS

Findings suggest that early-stage breast cancer patients can benefit from less-severe, short-term side effects of APBI with no differential impact on QOL change within 2-year follow-up.

Locoregional recurrence by molecular subtype after multicatheter interstitial accelerated partial breast irradiation: Results from the Pooled Registry Of Multicatheter Interstitial Sites research group

PURPOSE

To determine in breast tumor recurrence (IBTR) and regional nodal recurrence (RNR) rates for women treated with multicatheter interstitial accelerated partial breast irradiation.

METHODS AND MATERIALS

Data from five institutions were collected for patients treated from 1992 to 2013. We report outcomes of 582 breast cancers with ≥1 year of followup. Molecular subtype approximation was performed using estrogen receptor, progesterone receptor, Her2, and grade. The Kaplan-Meier method was used to calculate overall survival, IBTR, RNR, and distant recurrence rates. Univariate and multivariate Cox proportional hazard models were performed to estimate risks of IBTR and RNR.

RESULTS

With a median followup time of 5.4 years, the 5-year IBTR rate was 4.7% overall, 3.5% for Luminal A, 4.1% for Luminal B, 5.2% for Luminal Her2, 13.3% for Her2, and 11.3% for triple-negative breast cancer. Positive surgical margins and high grade were associated with increased risk for IBTR, as was Her2 subtype in comparison with Luminal A subtype. Other individual subtypes comparisons did not show a significant difference. Analysis of Luminal A vs. all other subtypes demonstrated lower IBTR risk for Luminal A (5-year IBTR 3.5% vs. 7.3%, p = 0.02). The 5-year RNR rate was 2.1% overall, 0.3% for Luminal A, 4.6% for Luminal B, 2.6% for Luminal Her2, 34.5% for Her2, and 2.3% for triple-negative breast cancer. RNR risk was higher for women with Her2 compared to the other four subtypes and for Luminal B compared to Luminal A subtype.

CONCLUSIONS

Molecular subtype influences IBTR and RNR rates in women treated with multicatheter interstitial accelerated partial breast irradiation.

Comparison of chronic toxicities between brachytherapy-based accelerated partial breast irradiation and whole breast irradiation using intensity modulated radiotherapy

PURPOSE

Brachytherapy-based APBI (bAPBI) shortens treatment duration and limits dose to normal tissue. While studies have demonstrated similar local control when comparing bAPBI and whole breast irradiation using intensity modulated radiotherapy (WBI-IMRT), comparison of late side effects is limited. Here, we report chronic toxicity profiles associated with these two treatment modalities.

METHODS

1034 patients with early stage breast cancer were treated at a single institution; 489 received standard-fractionation WBI-IMRT between 2000 and 2013 and 545 received bAPBI (interstitial 40%, applicator-based 60%) between 1993 and 2013. Chronic toxicity was evaluated ≥6 months utilizing CTCAE version 3.0; cosmesis was evaluated using the Harvard scale.

RESULTS

Median follow-up was 4.6 years (range 0.1-13.4) for WBI-IMRT versus 6.7 years (range 0.1-20.1) for bAPBI (p < 0.001). Compared to WBI-IMRT, bAPBI was associated with higher rates of ≥grade 2 seroma formation (14.4% vs 2.9%, p < 0.001), telangiectasia (12.3% vs 2.1%, p = 0.002) and symptomatic fat necrosis (10.2% vs 3.6%, p < 0.001). Lower rates of hyperpigmentation were observed (5.8% vs 14.5%; p = 0.001). Infection rates were similar (3.3% vs 1.3%, p = 0.07). There was no difference between rates of fair (6.1% vs. 4.1%, p = 0.30) or poor (0.2% vs. 0.5%, p = NS) cosmesis. Mastectomy rates for local recurrence (3.1% for WBI-IMRT and 1.2% for bAPBI, p = 0.06), or for other reasons (0.8% and 0.6%, p = 0.60) were similar between groups.

CONCLUSION

With 5-year follow-up, WBI-IMRT and bAPBI are associated with similar, acceptable rates of toxicity. These data further support the utilization of bAPBI as a modality to deliver adjuvant radiation in a safe and efficacious manner.

Intraoperative full-dose of partial breast irradiation with electrons delivered by standard linear accelerators for early breast cancer

Purpose. To assess feasibility, efficacy, toxicity, and cosmetic results of intraoperative radiotherapy (IORT) with electrons delivered by standard linear accelerators (Linacs) during breast conserving surgeries for early infiltrating breast cancer (BC) treatment. Materials and Methods. A total of 152 patients with invasive ductal carcinoma (T ≤ 3.0 cm) at low risk for local relapses were treated. All had unicentric lesions by imaging methods and negative sentinel node. After a wide local excision, 21 Gy were delivered on the parenchyma target volume with electron beams. Local recurrences (LR), survival, toxicity, and cosmetic outcomes were analyzed. Results. The median age was 58.3 years (range 40–85); median follow-up was 50.7 months (range 12–101.5). There were 5 cases with LR, 2 cases with distant metastases, and 2 cases with deaths related to BC. The cumulative incidence rates of LR, distant metastases, and BC death were 3.2%, 1.5%, and 1.5%, respectively. Complications were rare, and the cosmetic results were excellent or good in most of the patients. Conclusions. IORT with electrons delivered by standard Linacs is feasible, efficient, and well tolerated and seems to be beneficial for selected patients with early infiltrating BC.

Evaluating radiotherapy options in breast cancer: does intraoperative radiotherapy represent the most cost-efficacious option?

INTRODUCTION

This study analyzed the cost-efficacy of intraoperative radiation therapy (IORT) compared with whole-breast irradiation (WBI) and accelerated partial-breast irradiation (APBI) for early-stage breast cancer.

MATERIALS AND METHODS

Data for this analysis came from 2 phase III trials: the TARGIT (Targeted Intraoperative Radiotherapy) trial and the ELIOT (Electron Intraoperative Radiotherapy) trial. Cost analyses included a cost-minimization analysis and an incremental cost-effectiveness ratio analysis including a quality-adjusted life-year (QALY) analysis. Cost analyses were performed comparing IORT with WBI delivered using 3-dimensional conformal radiotherapy (3D-CRT), APBI 3D-CRT, APBI delivered with intensity-modulated radiotherapy (IMRT), APBI single-lumen (SL), APBI multilumen (ML), and APBI interstitial (I).

RESULTS

Per 1000 patients treated, the cost savings with IORT were $3.6-$4.3 million, $1.6-$2.4 million, $3.6-$4.4 million, $7.5-$8.2 million, and $2.8-$3.6 million compared with WBI 3D-CRT, APBI IMRT, APBI SL, APBI ML, and APBI I, respectively, with a cost decrement of $1.6-$2.4 million compared with APBI 3D-CRT based on data from the TARGIT trial. The costs per QALY for WBI 3D-CRT, APBI IMRT, APBI SL, APBI ML, and APBI I compared with IORT were $47,990-$60,002; $17,335-$29,347; $49,019-$61,031; $108,162-$120,173; and $36,129-$48,141, respectively, based on data from the ELIOT trial. These results are consistent with APBI and WBI being cost-effective compared with IORT.

CONCLUSION

Based on cost-minimization analyses, IORT represents a potential cost savings in the management of early-stage breast cancer. However, absolute reimbursement is misleading, because when additional medical and nonmedical costs associated with IORT are factored in, WBI and APBI represent cost-effective modalities based on cost-per-QALY analyses. They remain the standard of care.

[Accelerated partial breast irradiation with multicatheters during breast conserving surgery for cancer]

INTRODUCTION

Accelerated partial breast irradiation (APBI) with multicatheters after lumpectomy for breast cancer (BC) may be an alternative to whole breast irradiation in selected patients. The aim is to show our 5 year experience.

METHOD

Between June 2007 and June 2012, 87 BC patients have been evaluated for APBI. Inclusion criteria were: age over 40 years, unifocal tumour, infiltrating ductal or intraductal carcinoma, tumour size smaller than 3 cm and no lymph node involvement. Complications, cosmetic results and local and distant recurrences were evaluated.

RESULTS

Treatment was completed in 48 patients and contraindicated in 39. The average age of treated patients was 59 years. Operating time was 123 min with 9 implanted catheters in each patient. No complications were observed during surgery or radiotherapy. Patients were discharged from hospital after 4 days. Tumour size was 11 mm. Of these, 35 were infiltrating ductal and 13 intraductal carcinomas. A total of 44 patients received adjuvant treatment. Mean follow-up was 22 months with no evidence of local or distant recurrence. The cosmetic outcome was good or excellent in 66% of cases.

CONCLUSIONS

APBI with multicatheter placed after lumpectomy for BC is feasible and safe but requires a strict selection of patients.

The American Brachytherapy Society consensus statement for accelerated partial breast irradiation

PURPOSE

To develop clinical guidelines for the quality practice of accelerated partial breast irradiation (APBI) as part of breast-conserving therapy for women with early-stage breast cancer.

METHODS AND MATERIALS

Members of the American Brachytherapy Society with expertise in breast cancer and breast brachytherapy in particular devised updated guidelines for appropriate patient evaluation and selection based on an extensive literature search and clinical experience.

RESULTS

Increasing numbers of randomized and single and multi-institution series have been published documenting the efficacy of various APBI modalities. With more than 10-year followup, multiple series have documented excellent clinical outcomes with interstitial APBI. Patient selection for APBI should be based on a review of clinical and pathologic factors by the clinician with particular attention paid to age (≥50 years old), tumor size (≤3cm), histology (all invasive subtypes and ductal carcinoma in situ), surgical margins (negative), lymphovascular space invasion (not present), and nodal status (negative). Consistent dosimetric guidelines should be used to improve target coverage and limit potential for toxicity following treatment.

CONCLUSIONS

These guidelines have been created to provide clinicians with appropriate patient selection criteria to allow clinicians to use APBI in a manner that will optimize clinical outcomes and patient satisfaction. These guidelines will continue to be evaluated and revised as future publications further stratify optimal patient selection.