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Silverstein MJ, Kim B, Lin K, Lloyd S, Snyder L, Khan S, Kramme K, Chen P. Risk-Adapted Intraoperative Radiation Therapy (IORT) for Breast Cancer: A Novel Analysis. Ann Surg Oncol 2023; 30:6079-6088. [PMID: 37464138 PMCID: PMC10495476 DOI: 10.1245/s10434-023-13897-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 06/27/2023] [Indexed: 07/20/2023]
Abstract
BACKGROUND Randomized trials have shown that risk-adapted intraoperative radiation therapy (IORT) after breast-conserving surgery for low-risk breast cancer patients is a safe alternative to whole-breast radiation therapy (WBRT). The risk-adapted strategy allows additional WBRT for predefined high-risk pathologic characteristics discovered on final histopathology. The greater the percentage of patients receiving WBRT, the lower the recurrence rate. The risk-adapted strategy, although important and necessary, can make IORT appear better than it actually is. METHODS Risk-adapted IORT was used to treat 1600 breast cancers. They were analyzed by the intention-to-treat method and per protocol to better understand the contribution of IORT with and without additional whole-breast treatment. Any ipsilateral breast tumor event was considered a local recurrence. RESULTS During a median follow-up period of 63 months, local recurrence differed significantly between the patients who received local treatment and those who received whole-breast treatment. For 1393 patients the treatment was local treatment alone. These patients experienced 79 local recurrences and a 5-year local recurrence probability of 5.95 %. For 207 patients with high-risk final histopathology, additional whole-breast treatment was administered. They experienced two local recurrences and a 5-year local recurrence probability of 0.5 % (p = 0.0009). CONCLUSIONS Whole-breast treatment works well at reducing local recurrence, and it is a totally acceptable and necessary addition to IORT as part of a risk-adapted program. However, the more whole-breast treatment that is given, the more it dilutes the original plan of simplifying local treatment and the less we understand exactly what IORT contributes to local control as a stand-alone treatment.
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Affiliation(s)
- Melvin J Silverstein
- Department of Surgery, Hoag Memorial Hospital Presbyterian, Newport Beach, CA, USA.
- Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
| | - Brian Kim
- Department of Radiation Oncology, Hoag Memorial Hospital Presbyterian, Newport Beach, CA, USA
| | - Kevin Lin
- Department of Radiation Oncology, Hoag Memorial Hospital Presbyterian, Newport Beach, CA, USA
| | - Shane Lloyd
- Department of Radiation Oncology, Hoag Memorial Hospital Presbyterian, Newport Beach, CA, USA
| | - Lincoln Snyder
- Department of Surgery, Hoag Memorial Hospital Presbyterian, Newport Beach, CA, USA
| | - Sadia Khan
- Department of Surgery, Hoag Memorial Hospital Presbyterian, Newport Beach, CA, USA
- Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Katherine Kramme
- Department of Surgery, Hoag Memorial Hospital Presbyterian, Newport Beach, CA, USA
- Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Peter Chen
- Department of Radiation Oncology, Hoag Memorial Hospital Presbyterian, Newport Beach, CA, USA
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Vijayakumar S, Nittala MR, Buddala V, Mobit P, Duggar WN, Yang CC, Lirette ST, Mundra E, Ahmed HZ, Berry SM, Craft BS, Woods WC, Otts J, Rahimi A, Dobbs T. Real World and Public Health Perspectives of Intraoperative Radiotherapy in Early-Stage Breast Cancer: A Multidisciplinary Analysis Beyond the Statistical Facts. Cureus 2023; 15:e36432. [PMID: 37025715 PMCID: PMC10072193 DOI: 10.7759/cureus.36432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/20/2023] [Indexed: 04/08/2023] Open
Abstract
Breast conservation therapy (BCT) (usually a lumpectomy plus radiotherapy (RT)) has become a standard alternative to radical mastectomy in early-stage breast cancers with equal, if not higher, survival rates. The established standard of the RT component of the BCT had been about six weeks of Monday through Friday external beam RT to the whole breast (WBRT). Recent clinical trials have shown that partial breast radiation therapy (PBRT) to the region surrounding the lumpectomy cavity with shorter courses can result in equal local control, survival, and slightly improved cosmetic outcomes. Intraoperative RT (IORT) wherein RT is administered at the time of operation for BCT to the lumpectomy cavity as a single-fraction RT is also considered PBRT. The advantage of IORT is that weeks of RT are avoided. However, the role of IORT as part of BCT has been controversial. The extreme views go from "I will not recommend to anyone" to "I can recommend to all early-stage favorable patients." These divergent views are due to difficulty in interpreting the clinical trial results. There are two modalities of delivering IORT, namely, the use of low-energy 50 kV beams or electron beams. There are several retrospective, prospective, and two randomized clinical trials comparing IORT versus WBRT. Yet, the opinions are divided. In this paper, we try to bring clarity and consensus from a highly broad-based multidisciplinary team approach. The multidisciplinary team included breast surgeons, radiation oncologists, medical physicists, biostatisticians, public health experts, nurse practitioners, and medical oncologists. We show that there is a need to more carefully interpret and differentiate the data based on electron versus low-dose X-ray modalities; the randomized study results have to be extremely carefully dissected from biostatistical points of view; the importance of the involvement of patients and families in the decision making in a very transparent and informed manner needs to be emphasized; and the compromise some women may be willing to accept between 2-4% potential increase in local recurrence (as interpreted by some of the investigators in IORT randomized studies) versus mastectomy. We conclude that, ultimately, the choice should be that of women with detailed facts of the pros and cons of all options being presented to them from the angle of patient/family-focused care. Although the guidelines of various professional societies can be helpful, they are only guidelines. The participation of women in IORT clinical trials is still needed, and as genome-based and omics-based fine-tuning of prognostic fingerprints evolve, the current guidelines need to be revisited. Finally, the use of IORT can help rural, socioeconomically, and infrastructure-deprived populations and geographic regions as the convenience of single-fraction RT and the possibility of breast preservation are likely to encourage more women to choose BCT than mastectomy. This option can also likely lead to more women choosing to get screened for breast cancer, thus enabling the diagnosis of breast cancer at an earlier stage and improving the survival outcomes.
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Affiliation(s)
| | - Mary R Nittala
- Radiation Oncology, University of Mississippi Medical Center, Jackson, USA
| | - Vedanth Buddala
- Radiation Oncology, University of Mississippi Medical Center, Jackson, USA
| | - Paul Mobit
- Radiation Oncology, University of Mississippi Medical Center, Jackson, USA
| | - William N Duggar
- Radiation Oncology, University of Mississippi Medical Center, Jackson, USA
| | - Claus Chunli Yang
- Radiation Oncology, University of Mississippi Medical Center, Jackson, USA
| | | | - Eswar Mundra
- Radiation Oncology, University of Mississippi Medical Center, Jackson, USA
| | - Hiba Z Ahmed
- Radiation Oncology, University of Mississippi Medical Center, Jackson, USA
| | - Scott M Berry
- Surgery, University of Mississippi Medical Center, Jackson, USA
| | - Barbara S Craft
- Medicine, University of Mississippi Medical Center, Jackson, USA
| | - William C Woods
- Radiation Oncology, University of Mississippi Medical Center, Jackson, USA
| | - Jeremy Otts
- Radiation Oncology, University of Mississippi Medical Center, Jackson, USA
| | - Asal Rahimi
- Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, USA
| | - Thomas Dobbs
- Population Health, University of Mississippi Medical Center, Jackson, USA
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Mosiun JA, See MH, Teoh LY, Danaee M, Lai LL, Ng CH, Yip CH, Teh MS, Taib NAM, Bustam A, Malik RA, Saad M, Jamaris S, Ung NM. Comparison of Clinical Outcomes Between Low- and High-Risk Groups of Early Breast Cancer Patients Treated with Intraoperative Radiotherapy in Addition to External Beam Radiation: A Multi-Centre Prospective Study. World J Surg 2023; 47:201-208. [PMID: 36305952 DOI: 10.1007/s00268-022-06753-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/16/2022] [Indexed: 01/28/2023]
Abstract
BACKGROUND There is a paucity of data on the use of intraoperative radiotherapy (IORT) with low-energy X-rays in Malaysian women with early breast cancer. The aim of this study is to evaluate the clinical, cosmetic, and patient-reported outcomes in low- and high-risk early breast cancer patients treated with breast conserving surgery (BCS) and IORT. METHODOLOGY Patients suitable for BCS who were treated with IORT between January 2016 and June 2019 from three centres were analysed. They were divided into low-risk and high-risk groups based on the risk of recurrence according to the TARGeted Intraoperative radioTherapy (TARGIT) A and B study criteria. Outcomes of interest included local recurrence, wound complications, and radiation toxicity, with a subset analysed for cosmetic and patient-reported outcomes. RESULTS Within a median follow-up of 31 months, there were 104 and 211 patients in the low- and high-risk groups, respectively. No significant difference was observed in local recurrence rates (low-risk, 1.0% vs. high-risk, 1.4%; p = 1.000). Both cohorts exhibited low frequencies of severe wound complications ranging between 1.4 and 1.9%. No major radiation toxicities were reported in either group. In the subgroup analysis, low-risk patients had significantly better mean scores in the subscales of inframammary fold and scar. Based on the BREAST-Q patient-reported outcomes questionnaire, seven out of nine parameters were scored similarly between both groups with no significant difference. CONCLUSION This study showed that the use of IORT in both low- and high-risk early breast cancers is efficacious and safe with low recurrence rates and an acceptable toxicity profile.
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Affiliation(s)
- J A Mosiun
- Breast Surgery Unit, Department of Surgery, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
| | - Mee-Hoong See
- Breast Surgery Unit, Department of Surgery, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia.
| | - Li-Ying Teoh
- Breast Surgery Unit, Department of Surgery, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
| | - Mahmoud Danaee
- Department of Social and Preventive Medicine, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
| | - Lee-Lee Lai
- Department of Nursing Science, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
| | - Char-Hong Ng
- Sunway Medical Centre, 5, Jalan Lagoon Selatan, Bandar Sunway, 47500, Petaling Jaya, Selangor, Malaysia
| | - Cheng-Har Yip
- Ramsay Sime Darby Health Care, Jalan SS 12/1A, Subang Jaya, Malaysia
| | - Mei-Sze Teh
- Breast Surgery Unit, Department of Surgery, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
| | - Nur Aishah Md Taib
- Breast Surgery Unit, Department of Surgery, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
- Universiti Malaya Cancer Research Institute, Universiti Malaya, Kuala Lumpur, Malaysia
| | - Anita Bustam
- Clinical Oncology Unit, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
| | - Rozita Abdul Malik
- Clinical Oncology Unit, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
| | - Marniza Saad
- Clinical Oncology Unit, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
| | - Suniza Jamaris
- Breast Surgery Unit, Department of Surgery, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
| | - Ngie-Min Ung
- Clinical Oncology Unit, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
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Refaat T, Gros SE, Small W. The case for risk-stratified IORT for early breast cancer. Brachytherapy 2022; 21:719-722. [PMID: 36167653 DOI: 10.1016/j.brachy.2022.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 08/17/2022] [Indexed: 12/14/2022]
Affiliation(s)
- Tamer Refaat
- Department of Radiation Oncology, Stritch School of Medicine, Cardinal Bernardin Cancer Center, Loyola University Chicago, Maywood, IL
| | - Sebastien E Gros
- Department of Radiation Oncology, Stritch School of Medicine, Cardinal Bernardin Cancer Center, Loyola University Chicago, Maywood, IL
| | - William Small
- Department of Radiation Oncology, Stritch School of Medicine, Cardinal Bernardin Cancer Center, Loyola University Chicago, Maywood, IL.
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Intraoperative radiotherapy versus no radiotherapy for early stage low-risk breast cancer patients undergoing breast-conserving surgery: a propensity score matching study based on the SEER database. CLINICAL & TRANSLATIONAL ONCOLOGY : OFFICIAL PUBLICATION OF THE FEDERATION OF SPANISH ONCOLOGY SOCIETIES AND OF THE NATIONAL CANCER INSTITUTE OF MEXICO 2022; 24:2409-2419. [PMID: 35962917 DOI: 10.1007/s12094-022-02911-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 07/25/2022] [Indexed: 10/15/2022]
Abstract
PURPOSE To compare the effect of intraoperative radiotherapy (IORT) and no radiotherapy in early stage low-risk breast cancer patients undergoing breast-conserving surgery. METHODS According to the criteria recommended by ASTRO for patients eligible for IORT, we retrospectively selected women with early stage low-risk breast cancer who underwent breast-conserving surgery from 2010 to 2019 from the SEER database. Propensity score matching was used to balance the differences in baseline characteristics. The Kaplan-Meier method was used to calculate the overall survival (OS) and breast cancer-specific survival (BCSS) of patients, and the log-rank test was used to compare the differences. RESULTS A total of 20,245 patients were included in the analysis, including 1738 in the IORT group and 18,507 in the no radiotherapy group, with a median follow-up of 41 months. Before matching, the 5-year OS rates of the IORT group and the no radiotherapy group were 95.5% and 85.7% (p < 0.001), respectively, and the 5-year BCSS rates of the two groups were 99.6% and 98.3% (p < 0.001), respectively. After matching, the 5-year OS rates were 95.6% and 90.3% (p < 0.001) in the IORT group and the no radiotherapy group, respectively, and the 5-year BCSS rates were 99.5% and 99.1% (p = 0.028), respectively. Cox multivariate analysis of the original data showed that radiotherapy was an independent prognostic factor for both OS and BCSS (p < 0.05). CONCLUSIONS For patients aged 50 years or older with early stage low-risk breast cancer, IORT may be a better option, with improved BCSS compared to the elimination of radiotherapy. The study could not draw conclusions on OS, because underlying diseases may be unevenly distributed between the two groups.
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Vaidya JS, Vaidya UJ, Baum M, Bulsara MK, Joseph D, Tobias JS. Global adoption of single-shot targeted intraoperative radiotherapy (TARGIT-IORT) for breast cancer—better for patients, better for healthcare systems. Front Oncol 2022; 12:786515. [PMID: 36033486 PMCID: PMC9406153 DOI: 10.3389/fonc.2022.786515] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 06/28/2022] [Indexed: 12/30/2022] Open
Abstract
Micro abstractTargeted intraoperative radiotherapy (TARGIT-IORT) is delivered immediately after lumpectomy for breast cancer. We estimated its impact. At least 44,752 patients with breast cancer were treated with TARGIT-IORT in 260 centres in 35 countries, saving >20 million miles of travel and preventing ~2,000 non–breast cancer deaths. The TARGIT-IORT website (https://targit.org.uk/travel) provides maps and tools to find the nearest centre offering TARGIT-IORT and travel savings.BackgroundTargeted intraoperative radiotherapy (TARGIT-IORT) delivers radiotherapy targeted to the fresh tumour bed exposed immediately after lumpectomy for breast cancer. TARGIT-A trial found TARGIT-IORT to be as effective as whole-breast radiotherapy, with significantly fewer deaths from non–breast cancer causes. This paper documents its worldwide impact and provides interactive tools for clinicians and patients.MethodCentres using TARGIT-IORT provided the date of the first case and the total number of patients. We plotted these data on a customised Google Map. An interactive web-based tool provided directions to the closest centre. Using the data from the TARGIT-A trial, we estimated the total savings in travel miles, carbon footprint, and the number of non–breast cancer deaths that might be prevented.ResultsData from 242 (93%) of the 260 centres treating patients from 35 countries were available. From the first patient treated in 1998 to early 2020, at least 44,752 women with breast cancer have been treated with TARGIT-IORT. The TARGIT-IORT website (https://targit.org.uk/travel) displays the Google Map of centres with number of cases and an interactive tool for patients to find the nearest centre offering TARGIT-IORT and their travel savings. Scaling up to the already treated patients, >20 million miles of travel would have been saved and about 2,000 deaths prevented.ConclusionOne can ascertain the number of patients treated with a novel treatment. These data show how widely TARGIT-IORT has now been adopted and gives an indication of its beneficial worldwide impact on a large number of women with breast cancer.
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Affiliation(s)
- Jayant Sharad Vaidya
- Division of Surgery and Interventional Science, University College London, London, United Kingdom
- *Correspondence: Jayant Sharad Vaidya, ;
| | - Uma Jayant Vaidya
- Medical Sciences Division Brasenose College, University of Oxford, Oxford, United Kingdom
| | - Michael Baum
- Division of Surgery and Interventional Science, University College London, London, United Kingdom
| | - Max Kishor Bulsara
- Division of Surgery and Interventional Science, University College London, London, United Kingdom
- Department of Biostatistics, University of Notre Dame, Fremantle, WA, Australia
| | - David Joseph
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Perth, WA, Australia
| | - Jeffrey S. Tobias
- Department of Clinical Oncology, University College London Hospitals, London, United Kingdom
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Small W, Refaat T, Feldman SM, Holmes D. Risk-Stratified Intraoperative Radiation Therapy as a Definitive Adjuvant Radiation Therapy Modality for Women With Early Breast Cancer. Pract Radiat Oncol 2022; 12:320-323. [PMID: 35717048 DOI: 10.1016/j.prro.2022.03.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 03/30/2022] [Indexed: 11/26/2022]
Abstract
Radiation therapy is an integral component of adjuvant therapy in women who undergo breast conservative surgery, decreasing the likelihood of tumor recurrence and extending survival. The likelihood of tumor recurrence is highest within a proximity of the lumpectomy cavity, which prompted the idea of partial breast irradiation in place of the usual standard-of-care treatment with external beam whole breast radiation therapy. Targeted intraoperative radiation therapy (TARGIT-A) is a multicenter trial initially developed in 1999 and designed as a randomized clinical trial comparing whole breast radiation therapy to risk-adapted intraoperative radiation therapy (IORT). TARGIT-A recruited its first patient in March 2000, with the study concluding in 2012. At a median follow-up of 8.6 years, the prepathology TARGIT-A trial noted results to be noninferior to external beam radiation therapy, with no statistically significant difference in ipsilateral breast tumor recurrence, mastectomy-free survival, distant disease-free survival, or breast cancer-specific mortality. These results are consistent with the majority of retrospective and prospective trials. Risk-adapted IORT, as performed in the prospective randomized TARGIT-A trial, gives level 1 evidence that this approach is a standard option in the treatment of breast cancer.
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Affiliation(s)
- William Small
- Department of Radiation Oncology, Stritch School of Medicine, Loyola University Chicago, Cardinal Bernardin Cancer Center, Maywood, Illinois.
| | - Tamer Refaat
- Department of Radiation Oncology, Stritch School of Medicine, Loyola University Chicago, Cardinal Bernardin Cancer Center, Maywood, Illinois
| | - Sheldon M Feldman
- Department of Surgery, Montefiore Einstein Center for Cancer Care, Bronx, New York
| | - Dennis Holmes
- Department of Surgery, Adventist Health Glendale, Glendale, California
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Silverstein MJ, Epstein MS, Chen P, Lin K, Khan S, Snyder L, Coleman C, Guerra L, Dehkordi-Vakil F, Kim B. Recurrence and Survival Rates for 1400 Early Breast Tumors Treated with Intraoperative Radiation Therapy (IORT). Ann Surg Oncol 2022; 29:3726-3736. [PMID: 35066721 PMCID: PMC8783657 DOI: 10.1245/s10434-021-11295-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 12/14/2021] [Indexed: 01/01/2023]
Abstract
Introduction Intraoperative radiotherapy (IORT) permits accurate delivery of radiation therapy directly to the tumor bed. We report local, regional, and distant recurrence data along with overall and breast cancer-specific survival for 1400 tumors treated with x-ray IORT. Methods A total of 1367 patients with 1400 distinct tumors were enrolled in a registry trial. All received breast conservation surgery and low-energy 50 kV x-ray IORT. To be eligible for excision plus IORT as the only local treatment, histopathology had to confirm tumor size ≤30 mm, margins ≥2 mm, negative lymph nodes, and no extensive lymphovascular invasion. Patients who failed any parameters were referred for additional surgery and/or whole breast radiation therapy (WBRT). Results There were 64 ipsilateral local recurrences, 60 were in the IORT only group, 7 axillary recurrences, and 7 distant recurrences. Forty-one local recurrences were within the same quadrant as the index cancer. Twenty-three were in different quadrants. With 62 months of median follow-up, the 5-year Kaplan–Meier probability of any event for all 1400 tumors was 5.27%. For 1175 patients who received IORT only, it was 5.98%. For favorable subtypes, it ranged from 2.41 to 4.31%. Multivariate analysis revealed that biologic subtype luminal A and the addition of WBRT significantly reduced the risk of local recurrence. Conclusions The local, regional, and distant recurrence rates observed were comparable to those reported in the literature for IORT but higher than those reported for standard forms of WBRT, hypofractionated treatment, or APBI. IORT benefits include convenience, decreased exposure to medical environments, and low complication rates.
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Affiliation(s)
- Melvin J Silverstein
- Department of Surgery, Hoag Memorial Hospital Presbyterian, Newport Beach, CA, 92663, USA.
- Keck School of Medicine, University of Southern California, Los Angeles, CA, 90033, USA.
| | - Melinda S Epstein
- Hoag Department of Clinical Research, Hoag Memorial Hospital Presbyterian, Newport Beach, CA, 92663, USA
| | - Peter Chen
- Department of Radiation Oncology, Hoag Memorial Hospital Presbyterian, Newport Beach, CA, 92663, USA
| | - Kevin Lin
- Department of Radiation Oncology, Hoag Memorial Hospital Presbyterian, Newport Beach, CA, 92663, USA
| | - Sadia Khan
- Department of Surgery, Hoag Memorial Hospital Presbyterian, Newport Beach, CA, 92663, USA
- Keck School of Medicine, University of Southern California, Los Angeles, CA, 90033, USA
| | - Lincoln Snyder
- Department of Surgery, Hoag Memorial Hospital Presbyterian, Newport Beach, CA, 92663, USA
| | - Colleen Coleman
- Department of Surgery, Hoag Memorial Hospital Presbyterian, Newport Beach, CA, 92663, USA
| | - Lisa Guerra
- Department of Surgery, Hoag Memorial Hospital Presbyterian, Newport Beach, CA, 92663, USA
| | - Farideh Dehkordi-Vakil
- Center for Statistical Consulting, University of California, Irvine, Irvine, CA, 92697, USA
| | - Brian Kim
- Department of Radiation Oncology, Hoag Memorial Hospital Presbyterian, Newport Beach, CA, 92663, USA
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Friedman-Eldar O, Layton C, De Castro Silva I, Moller MG, Allen A, Franceschi D, Isrow D, Samuels S, Takita C, Avisar E. Surgical and Oncologic Outcomes With Intraoperative Radiation Therapy for Early Breast Cancer. Am Surg 2021:31348211047499. [PMID: 34732085 DOI: 10.1177/00031348211047499] [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] [Indexed: 12/21/2022]
Abstract
BACKGROUND For selected patients with early-stage breast cancer (BC), intraoperative radiation therapy (IORT) has emerged as a convenient alternative to standard whole breast irradiation (WBI). We report a single institution experience with IORT in terms of oncologic outcomes, toxicities, and cosmesis. METHODS Clinicopathological and perioperative outcomes of patients who underwent IORT for early-stage BC at a public hospital from 2017 to 2020 were retrospectively retrieved. Toxicity was categorized to acute or chronic based on 6 months post-IORT cutoff. RESULTS 85 patients underwent IORT and had complete data, aged 49-85 years (mean 62). Intraoperative radiation therapy added 23 minutes on average to the total operative time. Final stage was 0, I, and II in 40%, 58.9%, and 1.1% of patients, respectively. Mean tumor size was 0.8 cm (range .1-2.1), with ductal histology comprising 94% of cases. Surgical margins were positive in 2 patients, and adjuvant WBI was required in 5 patients. After a median follow-up of 17 months (range 3-41), none of the patients had local recurrence and no mortality was recorded. Early wound complications included wound dehiscence (n = 1), seroma/hematoma (n = 15), and re-operation with loss of nipple-areola complex (n = 1). Chronic skin toxicities were reported in 10 (12%) patients and good or excellent cosmetic outcome was reported in 93% of patients. CONCLUSIONS Utilizing IORT among low-risk early BC patients may be a safe and more convenient alternative to traditional WBI, with low toxicity rate, acceptable cosmetic results, and good oncologic outcomes at 17 months. Longer follow-up and further prospective controlled studies are needed to confirm these findings.
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Affiliation(s)
- Orli Friedman-Eldar
- Department of Surgical Oncology, 23215Jackson Memorial Hospital, Miami, FL, USA.,Division of Surgical Oncology, DeWitt Daughtry Family Department of Surgery, 12235University of Miami Miller School of Medicine, Miami, FL, USA
| | - Christina Layton
- Division of Surgical Oncology, DeWitt Daughtry Family Department of Surgery, 12235University of Miami Miller School of Medicine, Miami, FL, USA
| | - Iago De Castro Silva
- Division of Surgical Oncology, DeWitt Daughtry Family Department of Surgery, 12235University of Miami Miller School of Medicine, Miami, FL, USA
| | - Mecker G Moller
- Division of Surgical Oncology, DeWitt Daughtry Family Department of Surgery, 12235University of Miami Miller School of Medicine, Miami, FL, USA
| | - Ahkeel Allen
- Division of Surgical Oncology, DeWitt Daughtry Family Department of Surgery, 12235University of Miami Miller School of Medicine, Miami, FL, USA
| | - Dido Franceschi
- Division of Surgical Oncology, DeWitt Daughtry Family Department of Surgery, 12235University of Miami Miller School of Medicine, Miami, FL, USA
| | - Derek Isrow
- Department of Radiation Oncology, 12235University of Miami Sylvester Comprehensive Cancer Center and Jackson Memorial Hospital, Miami, FL, USA
| | - Stuart Samuels
- Department of Radiation Oncology, 12235University of Miami Sylvester Comprehensive Cancer Center and Jackson Memorial Hospital, Miami, FL, USA
| | - Cristiane Takita
- Department of Radiation Oncology, 12235University of Miami Sylvester Comprehensive Cancer Center and Jackson Memorial Hospital, Miami, FL, USA
| | - Eli Avisar
- Division of Surgical Oncology, DeWitt Daughtry Family Department of Surgery, 12235University of Miami Miller School of Medicine, Miami, FL, USA
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Guillerm SO, Bourstyn E, Itti R, Cahen-Doidy L, Quéro L, Labidi M, Marchand E, Lorphelin H, Giacchetti S, Cuvier C, Espié M, Teixeira L, Hennequin C. Intraoperative Radiotherapy for Breast Cancer in Elderly Women. Clin Breast Cancer 2021; 22:e109-e113. [PMID: 34154928 DOI: 10.1016/j.clbc.2021.05.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 04/18/2021] [Accepted: 05/06/2021] [Indexed: 11/17/2022]
Abstract
PURPOSE To evaluate outcomes and postoperative toxicities after intraoperative radiotherapy (IORT) in elderly women. POPULATION Women older than 65 years, with infiltrating ductal breast cancer ≤3 cm, expressing estrogen receptor (ER+) without Her2 overexpression, and with negative axillary nodes. TREATMENT Treatment consisted of partial mastectomy with a sentinel lymph node biopsy (SLNB) procedure; in case of positive SLNB, IORT was cancelled. IORT consisted in a total dose of 20 Gy in 1 fraction delivered at the surface of the applicator with the Intrabeam® technique. RESULTS IORT was planned to be administered to a total of 225 patients but was cancelled for 34 patients during surgery. Thus 191 patients were analyzed; mean age was 76 years, with 57 patients (30%) >80 years. Despite inclusion criteria, 15 had lobular carcinoma and 7 were triple negative. With a median follow-up of 40 months, we observed only 1 local recurrence, located in the skin over the initial tumor. The 5-year local relapse rate was 1.7%. A wound healing delay (>15 days) was observed in 21 patients (11%). Sixty-six patients (35%) had postoperative complications, mainly grade 2, resolving within a few days. Two patients needed surgical drainage for local abscesses. Long-term (>1 year) cosmetic outcome was evaluated in 120 patients and was judged excellent or good in 102 (91%). CONCLUSION IORT can be safely given to elderly women, with a good local control rate and without major toxicities.
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Affiliation(s)
- S Ophie Guillerm
- Radiation Oncology Department, Saint-Louis Hospital, Paris, France; Breast Cancer Unit, Saint-Louis Hospital, Paris, France
| | - Edwige Bourstyn
- Radiation Oncology Department, Saint-Louis Hospital, Paris, France; Breast Cancer Unit, Saint-Louis Hospital, Paris, France
| | - Ramona Itti
- Radiation Oncology Department, Saint-Louis Hospital, Paris, France; Breast Cancer Unit, Saint-Louis Hospital, Paris, France
| | - Laurence Cahen-Doidy
- Radiation Oncology Department, Saint-Louis Hospital, Paris, France; Breast Cancer Unit, Saint-Louis Hospital, Paris, France
| | - Laurent Quéro
- Radiation Oncology Department, Saint-Louis Hospital, Paris, France; Breast Cancer Unit, Saint-Louis Hospital, Paris, France
| | - Mouna Labidi
- Radiation Oncology Department, Saint-Louis Hospital, Paris, France; Breast Cancer Unit, Saint-Louis Hospital, Paris, France
| | - Eva Marchand
- Radiation Oncology Department, Saint-Louis Hospital, Paris, France; Breast Cancer Unit, Saint-Louis Hospital, Paris, France
| | - Henri Lorphelin
- Radiation Oncology Department, Saint-Louis Hospital, Paris, France; Breast Cancer Unit, Saint-Louis Hospital, Paris, France
| | - Sylvie Giacchetti
- Radiation Oncology Department, Saint-Louis Hospital, Paris, France; Breast Cancer Unit, Saint-Louis Hospital, Paris, France
| | - Caroline Cuvier
- Radiation Oncology Department, Saint-Louis Hospital, Paris, France; Breast Cancer Unit, Saint-Louis Hospital, Paris, France
| | - Marc Espié
- Radiation Oncology Department, Saint-Louis Hospital, Paris, France; Breast Cancer Unit, Saint-Louis Hospital, Paris, France
| | - Luis Teixeira
- Radiation Oncology Department, Saint-Louis Hospital, Paris, France; Breast Cancer Unit, Saint-Louis Hospital, Paris, France
| | - Christophe Hennequin
- Radiation Oncology Department, Saint-Louis Hospital, Paris, France; Breast Cancer Unit, Saint-Louis Hospital, Paris, France.
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11
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Intraoperative Radiation Therapy for Breast Cancer. CURRENT BREAST CANCER REPORTS 2021. [DOI: 10.1007/s12609-021-00411-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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12
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Casey DL, Gupta GP, Ollila DW. The Role of Intraoperative Radiation in Early-stage Breast Cancer. Clin Breast Cancer 2021; 21:103-111. [PMID: 34030857 DOI: 10.1016/j.clbc.2020.12.007] [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: 10/05/2020] [Revised: 12/01/2020] [Accepted: 12/21/2020] [Indexed: 11/17/2022]
Abstract
Intraoperative radiation therapy (IORT) is a specialized form of accelerated partial breast irradiation in which a single dose of radiation is delivered to the tumor bed at the time of breast conserving surgery. With completion of radiation to the tumor bed at the time of surgery, IORT promises improved patient convenience, compliance, and quality of life. In addition, with its potentially skin-sparing properties and ability to deliver a high biologically effective dose to the tumor bed while reducing dose to nontarget tissues, IORT results in different but overall less toxicities compared with other modalities of radiation for breast cancer. However, skepticism over the role of IORT in breast cancer exists, and the 2 randomized trials that have analyzed IORT as the definitive radiation component of breast conservation therapy have shown an increase in local recurrence rates with IORT compared with whole breast irradiation, but similar rates of overall survival. In this review, we discuss the practicalities of IORT, the prospective data supporting and negating the role of IORT in lieu of whole breast irradiation, and the toxicity after IORT in early-stage breast cancer. We also review the role of IORT as a radiation boost and specific strategies for successful implementation of IORT in breast cancer.
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Affiliation(s)
- Dana L Casey
- Department of Radiation Oncology, University of North Carolina School of Medicine, Chapel Hill, NC.
| | - Gaorav P Gupta
- Department of Radiation Oncology, University of North Carolina School of Medicine, Chapel Hill, NC
| | - David W Ollila
- Division of Surgical Oncology, Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, NC
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Smith BD, Kuerer HM. Same-Day Breast Cancer Surgery and TARGIT-IORT: Better than Selective Omission of Radiotherapy? Ann Surg Oncol 2021; 28:2419-2420. [PMID: 33452605 DOI: 10.1245/s10434-021-09588-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 12/31/2020] [Indexed: 11/18/2022]
Affiliation(s)
- Benjamin D Smith
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Henry M Kuerer
- Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Valente SA, Tendulkar RD, Cherian S, Shah C, Ross DL, Lottich SC, Laronga C, Broman KK, Donnelly ED, Bethke KP, Shaw C, Lockney NA, Pederson A, Rudolph R, Hasselle M, Kelemen P, Hermanto U, Ashikari A, Kang S, Hoefer RA, McCready D, Fyles A, Escallon J, Rohatgi N, Graves J, Graves G, Willey SC, Tousimis E, Riley L, Deb N, Tu C, Small W, Grobmyer SR. TARGIT-R (Retrospective): 5-Year Follow-Up Evaluation of Intraoperative Radiation Therapy (IORT) for Breast Cancer Performed in North America. Ann Surg Oncol 2021; 28:2512-2521. [PMID: 33433786 DOI: 10.1245/s10434-020-09432-3] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 11/11/2020] [Indexed: 12/30/2022]
Abstract
BACKGROUND Intraoperative radiation therapy (IORT) has been investigated for patients with low-risk, early-stage breast cancer. The The North American experience was evaluated by TARGIT-R (retrospective) to provide outcomes for patients treated in "real-world" clinical practice with breast IORT. This analysis presents a 5-year follow-up assessment. METHODS TARGIT-R is a multi-institutional retrospective registry of patients who underwent lumpectomy and IORT between the years 2007 and 2013. The primary outcome of the evaluation was ipsilateral breast tumor recurrence (IBTR). RESULTS The evaluation included 667 patients with a median follow-up period of 5.1 years. Primary IORT (IORT at the time of lumpectomy) was performed for 72%, delayed IORT (after lumpectomy) for 3%, intended boost for 8%, and unintended boost (primary IORT followed by whole-breast radiation) for 17% of the patients. At 5 years, IBTR was 6.6% for all the patients, with 8% for the primary IORT cohort and 1.7% for the unintended-boost cohort. No recurrences were identified in the delayed IORT or intended-boost cohorts. Noncompliance with endocrine therapy (ET) was associated with higher IBTR risk (hazard ratio [HR], 3.67). Patients treated with primary IORT who were complaint with ET had a 5-year IBTR rate of 3.9%. CONCLUSION The local recurrence rates in this series differ slightly from recent results of randomized IORT trials and are notably higher than in previous published studies using whole-breast radiotherapy for similar patients with early-stage breast cancer. Understanding differences in this retrospective series and the prospective trials will be critical to optimizing patient selection and outcomes going forward.
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Affiliation(s)
| | | | | | | | - Darrel L Ross
- Community Physician Network Breast Care, Community Health Network, Indianapolis, IN, USA
| | - S Chace Lottich
- Community Physician Network Breast Care, Community Health Network, Indianapolis, IN, USA
| | | | | | - Eric D Donnelly
- Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, Chicago, IL, USA
| | - Kevin P Bethke
- Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, Chicago, IL, USA
| | | | | | | | - Ray Rudolph
- Memorial University Medical Center, Savannah, GA, USA
| | | | - Pond Kelemen
- St. Johns Riverside Hospital, Dobbs Ferry, NY, USA
| | | | | | - Song Kang
- The Sentara Dorothy G. Hoefer Comprehensive Breast Center, Newport News, VA, USA
| | - Richard A Hoefer
- The Sentara Dorothy G. Hoefer Comprehensive Breast Center, Newport News, VA, USA
| | | | | | | | | | | | | | | | - Eleni Tousimis
- Medstar Georgetown University Hospital, Washington, DC, USA
| | - Lee Riley
- St. Luke's University Health Network, Bethlehem, PA, USA
| | - Nimisha Deb
- St. Luke's University Health Network, Bethlehem, PA, USA
| | - Chao Tu
- Cleveland Clinic, Cleveland, OH, USA
| | - William Small
- Loyola University Chicago, Stritch School of Medicine, Maywood, IL, USA
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Mi Y, Lv P, Wang F, Li L, Zhu M, Wang Y, Zhang Y, Liu L, Cao Q, Dong M, Shi Y, Fan R, Li J, Gu Y, Zuo X. Targeted Intraoperative Radiotherapy Is Non-inferior to Conventional External Beam Radiotherapy in Chinese Patients With Breast Cancer: A Propensity Score Matching Study. Front Oncol 2020; 10:550327. [PMID: 33134162 PMCID: PMC7578338 DOI: 10.3389/fonc.2020.550327] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 09/07/2020] [Indexed: 11/13/2022] Open
Abstract
Purpose: To investigate the efficacy of targeted intraoperative radiotherapy (TARGIT) vs. conventional external beam radiotherapy (EBRT) in Chinese patients with breast cancer. Methods: We retrospectively analyzed breast cancer patients who underwent breast-conserving surgery (BCS) at our hospital between April 2009 and October 2017. Patients were divided into TARGIT group and EBRT group according to different radiotherapy methods. TARGIT was performed with low-energy X-rays emitted by the Intrabeam system to deliver a single dose of 20 Gy to the applicator surface. Propensity score matching was performed at 1:1. The Kaplan-Meier method was used to calculate the locoregional recurrence (LR), distant metastasis-free survival (DMFS), disease-free survival (DFS), and overall survival (OS) of the two groups, and the log-rank test was run to analyse between-group difference before and after matching. Results: A total of 281 patients were included, with a median follow-up of 43 months. Of them, 82 were included in the TARGIT group and 199 in the EBRT group. Using the risk-adapted approach, 6.1% of patients received supplemental EBRT in the TARGIT group. The 5-year LR rate was 3.2% in the TARGIT group and 3.1% in the EBRT group (P = 0.694), the 5-year DMFS rates were 100 and 96.7%, respectively (P = 0.157); the 5-year DFS rates were 96.8 and 94.2% (P = 0.604); and the 5-year OS rates were 97.6 and 97.8% (P = 0.862). After matching which eliminated interference from imbalanced baseline factors, 128 matched patients were analyzed by the Kaplan-Meier method. The 5-year LR rate was 2.3% in the TARGIT group and 1.6% in the EBRT group; the 5-year DMFS rates were 100 and 98.4%, respectively; the 5-year DFS rates were 97.7 and 98.4%; and the 5-year OS rates were 98.4 and 98.4% (P = 0.659, 0.313, 0.659, 0.987). There was no significant difference in efficacy between TARGIT group and EBRT group. Conclusion: TARGIT and EBRT have similar 5-year outcomes in selected Chinese breast cancer patients undergoing BCS, and it can be used as an effective alternative to standard therapy, with substantial benefits to patients. The results need to be further confirmed by extending the follow-up time.
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Affiliation(s)
- Yin Mi
- Department of Radiation Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Pengwei Lv
- Department of Breast Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Fang Wang
- Department of Breast Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Lin Li
- Department of Breast Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Mingzhi Zhu
- Department of Breast Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yanyan Wang
- Department of Breast Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yingying Zhang
- Department of Breast Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Lele Liu
- Department of Radiation Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Qinchen Cao
- Department of Radiation Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Meilian Dong
- Department of Radiation Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yonggang Shi
- Department of Radiation Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Ruitai Fan
- Department of Radiation Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Jingruo Li
- Department of Breast Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yuanting Gu
- Department of Breast Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Xiaoxiao Zuo
- Department of Radiation Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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16
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Wang L, Zhu M, Cui Y, Zhang X, Li G. Efficacy analysis of intraoperative radiotherapy in patients with early-stage breast cancer. Cancer Cell Int 2020; 20:446. [PMID: 32943994 PMCID: PMC7488558 DOI: 10.1186/s12935-020-01533-z] [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: 09/22/2019] [Accepted: 09/01/2020] [Indexed: 11/10/2022] Open
Abstract
Background To analyze the clinical efficacy of intraoperative radiotherapy (IORT) after breast-conserving surgery (BCS) in patients with early-stage breast cancer (BC), and to investigate the relationship between its influencing factors and clinical efficacy and prognosis. Methods A total of 73 patients with early-stage BC who underwent IORT after BCS in our hospital were selected in this research. Results Kaplan-Meier survival analysis was used to analyze the related factors of BCS and IORT of disease-free survival (DFS) and overall survival (OS). It was found that only age (χ2 = 14.035, P = 0.003) was statistically positively correlated with the patient’s DFS, and local recurrence and metastasis rate and mortality were higher in patients over 70 years old. Log rank test was used to analyze multiple factors. Only the diameter of the applicator (χ2 = 70.378, P < 0.05) was statistically significant with wound complications, and the larger the diameter, the higher incidence of wound complications. The remaining risk factors did not increase the incidence of wound complications. COX multivariate analysis showed that age was an independent risk factor for DFS rate and the risk factor had no significant effect on the OS rate of patients undergoing IORT after BCS. Conclusions IORT may be a safe form of treatment for the selected patients with early-stage BC, and can achieve satisfactory esthetic effect. Larger applicator diameters may increase the incidence of wound complications. Age is an independent risk factor for DFS in early-stage BC patients undergoing IORT after BCS.
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Affiliation(s)
- Lin Wang
- Radiotherapy Inpatient Ward II, The First Affiliated Hospital of Zhengzhou University, No. 1 Eastern Jianshe Road, Zhengzhou, 450000 Henan China
| | - Minmin Zhu
- Radiotherapy Inpatient Ward II, The First Affiliated Hospital of Zhengzhou University, No. 1 Eastern Jianshe Road, Zhengzhou, 450000 Henan China.,Nanshi Hospital of Nanyang, Nanyang, Henan China
| | - Yuelong Cui
- Anyang District Hospital of Puyang, Anyang, Henan China
| | - Xudong Zhang
- Radiotherapy Inpatient Ward II, The First Affiliated Hospital of Zhengzhou University, No. 1 Eastern Jianshe Road, Zhengzhou, 450000 Henan China
| | - Guowen Li
- Radiotherapy Inpatient Ward II, The First Affiliated Hospital of Zhengzhou University, No. 1 Eastern Jianshe Road, Zhengzhou, 450000 Henan China
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Outcomes of Radical and Boost Dose of Intraoperative Radiotherapy with Electron and Low KV X-Ray Based on Islamic Republic Intraoperative Radiotherapy (IRIORT) Consensus and the External Beam Radiotherapy in Pure Ductal Carcinoma in Situ (DCIS) in Breast Cancer Patients. INTERNATIONAL JOURNAL OF CANCER MANAGEMENT 2020. [DOI: 10.5812/ijcm.105639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Radiotherapy plays an essential role in breast cancer treatment following breast conserving surgery even in good-risk patients with ductal carcinoma in situ (DCIS) histology. It can be delivered by many techniques, among which is intraoperative radiotherapy (IORT). In recent years, intraoperative radiation therapy has had the same outcome compared with EBRT. Objectives: We studied whether whole breast radiotherapy (WBRT) could safely be replaced by IORT and its ability to control local recurrence like EBRT in pure DCIS. Methods: We assigned 138 patients into the external beam radiotherapy (EBRT), radical, and boost groups. The patients were treated during the last 6 years in the Cancer Research Center of Shahid Beheshti University of Medical Sciences. A total of 57 patients received EBRT, 45 patients received the radical dose of radiotherapy by IORT (36 patients received intraoperative electron radiotherapy [IOeRT] and 9 patients received intraoperative X-ray radiotherapy [IOxRT]) according to the IRIORT consensus protocol, and 36 patients received the boost dose of radiotherapy by IORT (15 patients received IOeRT and 21 patients received IOxRT). The IORT and EBRT groups were compared. The primary endpoint was local recurrence and death and the secondary endpoint was the role of variables in local recurrence. Results: With the mean follow-up of 37 months for the IORT group and 40.1 months for the EBRT group, local recurrence occurred in 8.8% (5 patients), 13.9% (5 patients), and 2.2% (1 patient) of the patients in the EBRT, boost, and radical groups, respectively. Concerning the local recurrence, no significant difference was observed between the radical and EBRT groups (P = 0.058) and between the boost and EBRT groups (P = 0.12). Hazard ratios (HRs) of grade, hormone receptor (HR), tumor size, and age in disease-free survival were evaluated and none of these variables had a significant role in local recurrence. Conclusions: IORT is a good alternative for WBRT in DCIS patients because of its non-inferiority results in comparison with EBRT. Being careful about age, tumor size, biological markers, and margin status is of high importance when using IORT for DCIS.
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Utility of Taking Additional Margins When Performing Breast-Conserving Surgery with Intraoperative Radiation Therapy for Early Breast Cancer. World J Surg 2020; 44:3410-3416. [PMID: 32696098 DOI: 10.1007/s00268-020-05490-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Intraoperative radiation therapy (IORT) is an alternative to external beam radiation therapy (EBRT) after lumpectomy, in which radiation is delivered before the final margin analysis. Practices vary regarding excision of close or positive margins pre- and post-IORT. MATERIALS AND METHODS In a retrospective cohort of women with hormone receptor-positive, clinically node-negative breast cancer undergoing lumpectomy with IORT and selective EBRT at our institution from 2011 to 2015, we compared the impact of pre- and post-IORT margin excisions on in-breast tumor recurrence. Additional pre-IORT margins were taken at surgical team discretion. Re-excisions post-IORT were performed for positive/close margins. We describe rate of invasive or in situ malignancy in additional pre-IORT and post-IORT re-excised specimens and compare IBTR using Chi-squared tests. RESULTS There were 195 cases in 193 women (2 bilateral breast cancer). Pre-IORT, ≥1 additional margin was obtained in 139 (71%). The final margin on the initial lumpectomy was positive in 13 (9%) and ≤2 mm in 72 (52%). Additional pre-IORT margins contained in situ/invasive cancer in 16 (12%). Thirty-one patients (16%) underwent post-IORT re-excision and nine (29%) contained invasive/in situ malignancy. Twenty-three (12%) received EBRT. In 45.6-month mean follow-up, 13 had IBTR (7%) with no difference by additional pre-IORT margin excision (5 vs. 11%, p = 0.150), post-IORT margin re-excision (10 vs. 6%, p = 0.464), or EBRT (0 vs. 8%, p = 0.172). Adjuvant endocrine therapy was associated with lower IBTR (4 vs. 17%, p = 0.003). CONCLUSIONS Taking additional pre-IORT margins and re-excising close/positive margins post-IORT improved margin clearance rates but had an unclear effect on IBTR. Adjuvant endocrine therapy significantly reduced IBTR.
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Oliver Guillén JR, Hernando Almudi E, Molina Osorio G, Ibañez Carreras R, Font Gómez JA, Vicente Gómez I, García Mur C, Casamayor Franco MC. Intraoperative radiotherapy in early breast cancer: observational comparison with whole breast radiotherapy. Cir Esp 2020; 99:132-139. [PMID: 32493607 DOI: 10.1016/j.ciresp.2020.04.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 04/10/2020] [Accepted: 04/13/2020] [Indexed: 11/16/2022]
Abstract
INTRODUCTION In early breast cancer (EBC), a single dose of intraoperative radiotherapy (IORT) might be an option to standard whole breast radiotherapy (WBRT). However, there is no consensus about its use and clinical results. AIM to analyse the morbidity and oncological outcomes of IORT as monotherapy in EBC. METHODS A single centre observational analytic study was performed. A prospective IORT cohort (2015-17) and a retrospective WBRT cohort (2012-17) were selected following the same criteria: ≥ 45 y.o., invasive ductal carcinoma or variants, radiological tumour size ≤ 3 cm, positive oestrogenic receptors, negative HER2, cN0; exclusion criteria: lymphovascular invasion, multicentricity/multifocality, BRCA mutation and neoadjuvant therapy. Clinical, histological, surgical, oncological characteristics and complications were collected. RESULTS A total of 425 cases were selected: 217 in IORT cohort and 208 in WBRT cohort. Average age in IORT and WBRT groups was 67±9.5 and 64.8 ± 9.9 y.o. respectively (p = 0.01). ASA 3 risk score patients were 17.7% in IORT and 24 cases in WBRT (p = 0.027). There were no differences in histological results or tumoral stage. Average follow up was 24.4 ± 8 months in IORT and 50.5 ± 18 months in WBRT (p < 0.001). No differences were detected in local recurrence, metastases or mortality. Complications that required reintervention or hospitalization were similar in both groups. A total of 3 and 14 cases developed early severe dermatitis in IORT and WBRT groups respectively (p = 0.01). CONCLUSION IORT as monotherapy in selected patients with EBC stands for an alternative option versus WBRT. It seems especially useful in advanced-age patients with severe comorbidities. IORT associates lesser early severe dermatitis.
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Affiliation(s)
- José Ramón Oliver Guillén
- IIS Aragón. S. de Cirugía General y del Ap. Digestivo, Hospital Universitario Miguel Servet, Zaragoza, España.
| | - Ernesto Hernando Almudi
- S. de Cirugía General y del Ap. Digestivo, Hospital Universitario Miguel Servet, Zaragoza, España
| | | | - Reyes Ibañez Carreras
- S. de Oncología Radioterápica, Hospital Universitario Miguel Servet, Zaragoza, España
| | | | | | - Carmen García Mur
- S. de Radiología, Hospital Universitario Miguel Servet, Zaragoza, España
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Obi E, Tom MC, Manyam BV, Grobmyer SR, Al‐Hilli Z, Valente S, Fanning A, Radford DM, Cherian S, Tendulkar RD, Shah C. Outcomes with intraoperative radiation therapy for early‐stage breast cancer. Breast J 2020; 26:454-457. [DOI: 10.1111/tbj.13574] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Revised: 08/05/2019] [Accepted: 08/16/2019] [Indexed: 02/05/2023]
Affiliation(s)
- Elizabeth Obi
- Department of Radiation Oncology Taussig Cancer Institute Cleveland Clinic Cleveland Ohio
| | - Martin C. Tom
- Department of Radiation Oncology Taussig Cancer Institute Cleveland Clinic Cleveland Ohio
| | - Bindu V. Manyam
- Department of Radiation Oncology Taussig Cancer Institute Cleveland Clinic Cleveland Ohio
| | - Stephen R. Grobmyer
- Section of Breast Surgery Department of Surgery Cleveland Clinic Cleveland Ohio
| | - Zahraa Al‐Hilli
- Section of Breast Surgery Department of Surgery Cleveland Clinic Cleveland Ohio
| | - Stephanie Valente
- Section of Breast Surgery Department of Surgery Cleveland Clinic Cleveland Ohio
| | - Alicia Fanning
- Section of Breast Surgery Department of Surgery Cleveland Clinic Cleveland Ohio
| | - Diane M. Radford
- Section of Breast Surgery Department of Surgery Cleveland Clinic Cleveland Ohio
| | - Sheen Cherian
- Department of Radiation Oncology Taussig Cancer Institute Cleveland Clinic Cleveland Ohio
| | - Rahul D. Tendulkar
- Department of Radiation Oncology Taussig Cancer Institute Cleveland Clinic Cleveland Ohio
| | - Chirag Shah
- Department of Radiation Oncology Taussig Cancer Institute Cleveland Clinic Cleveland Ohio
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Alouani E, Parent L, Massabeau C, Selmes G, Jouve E, Izar F. [Rib fracture following intra-operative radiotherapy for breast cancer. Case Report and local experience]. Cancer Radiother 2020; 24:64-66. [PMID: 32044159 DOI: 10.1016/j.canrad.2019.10.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 10/14/2019] [Accepted: 10/15/2019] [Indexed: 11/30/2022]
Abstract
Intra-operative radiotherapy for breast cancer has been developed throughout the last two decades. It is already well-established regarding local control and toxicity for intra-operative radiotherapy using electrons as we now have the necessary background knowledge. However, very few data on later toxicity are available for intra-operative radiotherapy using low-energy photons. We report here the case of a 36-year-old woman who experienced rib fracture following intra-operative and external radiotherapy. This patient has been included in the Targit-boost trial. The intra-operative irradiation has been operated with an INTRABEAM device delivering low-energy photons of 50-kV.
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Affiliation(s)
- E Alouani
- Département d'oncoradiothérapie, institut Claudius-Regaud, institut universitaire du cancer de Toulouse - Oncopole, 1, avenue Irène-Joliot-Curie, 31059 Toulouse cedex 9, France.
| | - L Parent
- Département d'oncoradiothérapie, institut Claudius-Regaud, institut universitaire du cancer de Toulouse - Oncopole, 1, avenue Irène-Joliot-Curie, 31059 Toulouse cedex 9, France
| | - C Massabeau
- Département d'oncoradiothérapie, institut Claudius-Regaud, institut universitaire du cancer de Toulouse - Oncopole, 1, avenue Irène-Joliot-Curie, 31059 Toulouse cedex 9, France
| | - G Selmes
- Département de chirurgie, institut Claudius-Regaud, institut universitaire du cancer de Toulouse - Oncopole, 1, avenue Irène-Joliot-Curie, 31059 Toulouse cedex 9, France
| | - E Jouve
- Département de chirurgie, institut Claudius-Regaud, institut universitaire du cancer de Toulouse - Oncopole, 1, avenue Irène-Joliot-Curie, 31059 Toulouse cedex 9, France
| | - F Izar
- Département d'oncoradiothérapie, institut Claudius-Regaud, institut universitaire du cancer de Toulouse - Oncopole, 1, avenue Irène-Joliot-Curie, 31059 Toulouse cedex 9, France
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Shaikh MY, Burmeister J, Scott R, Kumaraswamy LK, Nalichowski A, Joiner MC. Dosimetric evaluation of incorporating the revised V4.0 calibration protocol for breast intraoperative radiotherapy with the INTRABEAM system. J Appl Clin Med Phys 2020; 21:50-59. [PMID: 32039545 PMCID: PMC7020998 DOI: 10.1002/acm2.12807] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 11/20/2019] [Accepted: 12/10/2019] [Indexed: 12/18/2022] Open
Abstract
In breast‐targeted intraoperative radiotherapy (TARGIT) clinical trials (TARGIT‐B, TARGIT‐E, TARGIT‐US), a single fraction of radiation is delivered to the tumor bed during surgery with 1.5‐ to 5.0‐cm diameter spherical applicators and an INTRABEAM x‐ray source (XRS). This factory‐calibrated XRS is characterized by two depth‐dose curves (DDCs) named "TARGIT" and "V4.0.” Presently, the TARGIT DDC is used to treat patients enrolled in clinical trials; however, the V4.0 DDC is shown to better represent the delivered dose. Therefore, we reevaluate the delivered prescriptions under the TARGIT protocols using the V4.0 DDC. A 20‐Gy dose was prescribed to the surface of the spherical applicator, and the TARGIT DDC was used to calculate the treatment time. For a constant treatment time, the V4.0 DDC was used to recalculate the dosimetry to evaluate differences in dose rate, dose, and equivalent dose in 2‐Gy fractions (EQD2) for an α/β = 3.5 Gy (endpoint of locoregional relapse). At the surface of the tumor bed (i.e., spherical applicator surface), the calculations using the V4.0 DDC predicted increased values for dose rate (43–16%), dose (28.6–23.2 Gy), and EQD2 (95–31%) for the 1.5‐ to 5.0‐cm diameter spherical applicator sizes, respectively. In general, dosimetric differences are greatest for the 1.5‐cm diameter spherical applicator. The results from this study can be interpreted as a reevaluation of dosimetry or the dangers of underdosage, which can occur if the V4.0 DDC is inadvertently used for TARGIT clinical trial patients. Because the INTRABEAM system is used in TARGIT clinical trials, accurate knowledge about absorbed dose is essential for making meaningful comparisons between radiation treatment modalities, and reproducible treatment delivery is imperative. The results of this study shed light on these concerns.
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Affiliation(s)
- Mubin Y Shaikh
- Department of Radiation Oncology, Rochester Regional, Rochester, NY, USA
| | - Jay Burmeister
- Wayne State University School of Medicine, Gershenson Radiation Oncology Center, Barbara Ann Karmanos Cancer Institute, Detroit, MI, USA
| | | | - Lalith K Kumaraswamy
- Department of Radiation Medicine, Roswell Park Cancer Institute, Buffalo, NY, USA
| | - Adrian Nalichowski
- Wayne State University School of Medicine, Gershenson Radiation Oncology Center, Barbara Ann Karmanos Cancer Institute, Detroit, MI, USA
| | - Michael C Joiner
- Department of Oncology, Gershenson Radiation Oncology Center, Wayne State University, Detroit, USA
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Tom MC, Joshi N, Vicini F, Chang AJ, Hong TS, Showalter TN, Chao ST, Wolden S, Wu AJ, Martin D, Husain Z, Badiyan SN, Kolar M, Sherertz T, Mourtada F, Cohen GN, Shah C. The American Brachytherapy Society consensus statement on intraoperative radiation therapy. Brachytherapy 2019; 18:242-257. [PMID: 31084904 DOI: 10.1016/j.brachy.2019.01.015] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2018] [Accepted: 01/30/2019] [Indexed: 12/12/2022]
Abstract
PURPOSE Although radiation therapy has traditionally been delivered with external beam or brachytherapy, intraoperative radiation therapy (IORT) represents an alternative that may shorten the course of therapy, reduce toxicities, and improve patient satisfaction while potentially lowering the cost of care. At this time, there are limited evidence-based guidelines to assist clinicians with patient selection for IORT. As such, the American Brachytherapy Society presents a consensus statement on the use of IORT. METHODS Physicians and physicists with expertise in intraoperative radiation created a site-directed guideline for appropriate patient selection and utilization of IORT. RESULTS Several IORT techniques exist including radionuclide-based high-dose-rate, low-dose-rate, electron, and low-energy electronic. In breast cancer, IORT as monotherapy should only be used on prospective studies. IORT can be considered in the treatment of sarcomas with close/positive margins or recurrent sarcomas. IORT can be considered in conjunction with external beam radiotherapy for retroperitoneal sarcomas. IORT can be considered for colorectal malignancies with concern for positive margins and in the setting of recurrent gynecologic cancers. For thoracic, head and neck, and central nervous system malignancies, utilization of IORT should be evaluated on a case-by-case basis. CONCLUSIONS The present guidelines provide clinicians with a summary of current data regarding IORT by treatment site and guidelines for the appropriate patient selection and safe utilization of the technique. High-dose-rate, low-dose-rate brachytherapy methods are appropriate when IORT is to be delivered as are electron and low-energy based on the clinical scenario.
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Affiliation(s)
- Martin C Tom
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland, OH
| | - Nikhil Joshi
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland, OH
| | - Frank Vicini
- 21st Century Oncology, Michigan Healthcare Professionals, Farmington Hills, MI
| | | | - Theodore S Hong
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA
| | - Timothy N Showalter
- Department of Radiation Oncology, University of Virginia, Charlottesville, VA
| | - Samuel T Chao
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland, OH
| | - Suzanne Wolden
- Departments of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Abraham J Wu
- Departments of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Douglas Martin
- Department of Radiation Oncology, Ohio State University, Columbus, OH
| | - Zain Husain
- Department of Therapeutic Radiology, Yale University, New Haven, CT
| | - Shahed N Badiyan
- Department of Radiation Oncology, Washington University, St. Louis, MO
| | - Matthew Kolar
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland, OH
| | - Tracy Sherertz
- Department of Radiation Oncology, Kaiser Capitol Hill, Seattle, WA
| | - Firas Mourtada
- Helen F. Graham Cancer Center & Research Institute, Christiana Care Health System, Newark, DE
| | - Gilad N Cohen
- Department Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Chirag Shah
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland, OH.
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24
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Mi Y, Lv P, Wang F, Li L, Zhu M, Cao Q, Liu J, Dong M, Shi Y, Fan R. Efficacy, late complications, and cosmetic outcomes of targeted intraoperative radiotherapy in breast-conserving surgery for early-stage breast cancer: a single-centre study in China. Jpn J Clin Oncol 2019; 49:1120-1125. [PMID: 31665413 DOI: 10.1093/jjco/hyz128] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Accepted: 07/30/2019] [Indexed: 11/14/2022] Open
Abstract
Abstract
Objective
The purpose of this study was to evaluate the efficacy, late complications, and cosmetic outcomes of targeted intraoperative radiotherapy for the treatment of Chinese patients with early-stage breast cancer.
Methods
Between September 2014 and May 2017, breast cancer patients undergoing targeted intraoperative radiotherapy at our facility were retrospectively recruited for this study. Intraoperative radiotherapy was performed with a 50-kV X-ray source in an Intrabeam system (Carl Zeiss Meditec, Oberkochen, Germany). The one-time prescribed irradiation dose to the tumour bed was 20 Gy. Recurrence, death, late complications, and cosmetic outcomes were recorded. Late radiotoxicity was assessed based on the grading criteria of the Radiation Therapy Oncology Group.
Results
A total of 77 patients who were treated with targeted intraoperative radiotherapy only were recruited. The cohort had a mean age of 58 years; patients with T1, N0, and invasive ductal carcinoma accounted for 75.3, 89.6, and 84.4%, respectively; the median follow-up duration was 40 months; there were 2 patients of recurrence and 2 patients of death. There were no patients of cardiac toxicity or skin or lung radiotoxicity of grade 2 or above. The main complications were breast oedema (18.2%), seroma (15.6%), chromatosis (9.1%), induration (7.8%), pain (5.2%), skin depression (2.6%), mild dry cough (2.6%), delayed wound healing (1.3%), and wound infection (1.3%). Seventy-three patients participated in the cosmetic outcome evaluation, which yielded an excellent or good rate of 95.9%.
Conclusions
Due to its low recurrence rates, lack of high-grade late radiotoxicity, and excellent cosmetic outcomes, targeted intraoperative radiotherapy may be a suitable treatment for select early-stage breast cancer patients in China.
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Affiliation(s)
- Yin Mi
- Department of Radiation Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Pengwei Lv
- Department of Breast Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Fang Wang
- Department of Breast Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Lin Li
- Department of Breast Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Mingzhi Zhu
- Department of Breast Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Qinchen Cao
- Department of Radiation Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Junqi Liu
- Department of Radiation Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Meilian Dong
- Department of Radiation Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yonggang Shi
- Department of Radiation Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Ruitai Fan
- Department of Radiation Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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25
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Single-center long-term results from the randomized phase-3 TARGIT-A trial comparing intraoperative and whole-breast radiation therapy for early breast cancer. Strahlenther Onkol 2019; 195:640-647. [DOI: 10.1007/s00066-019-01438-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Accepted: 02/04/2019] [Indexed: 11/26/2022]
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26
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Larson KE, Valente SA, Shah C, Tendulkar RD, Cherian S, Abraham J, Yanda C, Tu C, Echle J, Grobmyer SR. Oncotype testing in patients undergoing intraoperative radiation for breast cancer. Mol Clin Oncol 2018; 9:535-538. [PMID: 30345048 DOI: 10.3892/mco.2018.1704] [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: 02/02/2018] [Accepted: 06/27/2018] [Indexed: 11/06/2022] Open
Abstract
Oncotype DX recurrence score (RS) predicts risk of distant disease recurrence, and can guide chemotherapy recommendations in hormone positive, human epidermal growth factor 2-negative, early stage breast cancer. The present study aimed to evaluate the pattern of oncotype testing, RS and adjuvant treatment in patients undergoing intraoperative radiotherapy (IORT). Single center prospective data registry was queried for patients receiving IORT between October 2011 and February 2017. Patient demographics, tumor characteristics, RS, systemic therapy and recurrence information were analyzed. A total of 150 women with mean age of 70.8 years were included. The majority had invasive ductal cancer (60.6%) with 1.0 cm average tumor size and no lymph node involvement (99%). Oncotype testing was performed in 36 patients (24.3%). Low risk score (<18) was confirmed in 19 women (53%); intermediate risk score (18-30) in 16 women (44%); and high risk score (>30) in one woman (3%). Patients with RS testing had significantly increased tumor sizes (1.2 vs. 1.0 cm; P<0.001) and were younger (68.5 vs. 71.3 years; P=0.02) compared with those not tested. A total of 4/150 patients (2.6%) received chemotherapy; two received chemotherapy based on RS testing. Based on the current selection criteria for IORT, oncotype testing rarely results in a high-risk score or utilization of chemotherapy for IORT patients. The present study supports selective use of RS testing in IORT patients and confirms that biologically low-risk patients are being selected for IORT based on current guidelines.
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Affiliation(s)
- Kelsey E Larson
- Department of Surgery, Division of Breast Services, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Stephanie A Valente
- Department of Surgery, Division of Breast Services, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Chirag Shah
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Rahul D Tendulkar
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Sheen Cherian
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Jame Abraham
- Department of Medical Oncology, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Courtney Yanda
- Department of Surgery, Division of Breast Services, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Chao Tu
- Department of Quantitative Health Science, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Jessica Echle
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Stephen R Grobmyer
- Department of Surgery, Division of Breast Services, Cleveland Clinic, Cleveland, OH 44195, USA
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27
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Application of 21-gene recurrence score results and ASTRO suitability criteria in breast cancer patients treated with intraoperative radiation therapy (IORT). Am J Surg 2018; 216:689-693. [DOI: 10.1016/j.amjsurg.2018.07.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Revised: 03/29/2018] [Accepted: 07/14/2018] [Indexed: 11/20/2022]
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Esposito E, Douek M. Update on intraoperative radiotherapy: new challenges and issues. Ecancermedicalscience 2018; 12:793. [PMID: 29434659 PMCID: PMC5804714 DOI: 10.3332/ecancer.2018.793] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Indexed: 01/11/2023] Open
Abstract
Intraoperative radiotherapy (IORT) for breast cancer has challenged the standard external beam radiotherapy (EBRT) and has been shown to be non-inferior for treating early breast cancer in the past decade. Several technologies have been tested for IORT and various randomised controlled trials are still ongoing. Different methods of application of IORT have also been evaluated, from early breast cancer to tumour bed boost radiotherapy amongst high risk women. TARGIT-A and ELIOT trials have reported a low incidence of local recurrence and good survival in both arms. Moreover, mortality has been found to be lower amongst women who underwent partial breast radiotherapy compared to those treated with EBRT in a recent meta-analysis. Despite this, IORT has not been introduced in the current clinical practice as yet, and many clinicians do not mention this treatment option to patients awaiting breast cancer surgery. The scientific community does not unanimously support the effectiveness of IORT and still raises concerns about introducing IORT as a standard treatment option for breast cancer. Current evidence demonstrates that IORT is ready for roll-out; it is time to let well-selected and informed patients be offered this treatment option in the current clinical practice.
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Affiliation(s)
- Emanuela Esposito
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Italy.,Division of Cancer Studies, King's College London, 3rd Floor Bermondsey Wing, Guy's Hospital, Great Maze Pond, London SE1 9RT, United Kingdom
| | - Michael Douek
- Division of Cancer Studies, King's College London, 3rd Floor Bermondsey Wing, Guy's Hospital, Great Maze Pond, London SE1 9RT, United Kingdom
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29
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The American Brachytherapy Society consensus statement for accelerated partial-breast irradiation. Brachytherapy 2018; 17:154-170. [DOI: 10.1016/j.brachy.2017.09.004] [Citation(s) in RCA: 98] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Revised: 09/11/2017] [Accepted: 09/18/2017] [Indexed: 12/29/2022]
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30
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Harris EER, Small W. Intraoperative Radiotherapy for Breast Cancer. Front Oncol 2017; 7:317. [PMID: 29312887 PMCID: PMC5743678 DOI: 10.3389/fonc.2017.00317] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Accepted: 12/06/2017] [Indexed: 01/15/2023] Open
Abstract
Intraoperative radiotherapy (IORT) for early stage breast cancer is a technique for partial breast irradiation. There are several technologies in clinical use to perform breast IORT. Regardless of technique, IORT generally refers to the delivery of a single dose of radiation to the periphery of the tumor bed in the immediate intraoperative time frame, although some protocols have performed IORT as a second procedure. There are two large prospective randomized trials establishing the safety and efficacy of breast IORT in early stage breast cancer patients with sufficient follow-up time on thousands of women. The advantages of IORT for partial breast irradiation include: direct visualization of the target tissue ensuring treatment of the high-risk tissue and eliminating the risk of marginal miss; the use of a single dose coordinated with the necessary surgical excision thereby reducing omission of radiation and the selection of mastectomy for women without access to a radiotherapy facility or unable to undergo several weeks of daily radiation; favorable toxicity profiles; patient convenience and cost savings; radiobiological and tumor microenvironment conditions which lead to enhanced tumor control. The main disadvantage of IORT is the lack of final pathologic information on the tumor size, histology, margins, and nodal status. When unexpected findings on final pathology such as positive margins or positive sentinel nodes predict a higher risk of local or regional recurrence, additional whole breast radiation may be indicated, thereby reducing some of the convenience and low-toxicity advantages of sole IORT. However, IORT as a tumor bed boost has also been studied and appears to be safe with acceptable toxicity. IORT has potential efficacy advantages related to overall survival related to reduced cardiopulmonary radiation doses. It may also be very useful in specific situations, such as prior to oncoplastic reconstruction to improve accuracy of adjuvant radiation delivery, or when used as a boost in higher risk patients to improve tumor control. Ongoing international clinical trials are studying these uses and follow-up data are accumulating on completed studies.
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Affiliation(s)
- Eleanor E R Harris
- Department of Radiation Oncology, Brody School of Medicine, East Carolina University, Greenville, NC, United States
| | - William Small
- Department of Radiation Oncology, Stritch School of Medicine, Loyola University, Chicago, IL, United States
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31
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Valente SA, Fanning A, Stewart RA, Grundfest S, Tendulkar RD, Cherian S, Shah C, Tu C, Yanda C, Radford D, Al-Hilli Z, Grobmyer SR. Intraoperative Radiation for Breast Cancer with Intrabeam™: Factors Associated with Decreased Operative Times in Patients Having IORT for Breast Cancer. Front Oncol 2017; 7:237. [PMID: 29124038 PMCID: PMC5662891 DOI: 10.3389/fonc.2017.00237] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Accepted: 09/14/2017] [Indexed: 11/14/2022] Open
Abstract
Introduction Intraoperative radiation with Intrabeam™ (IORT) for breast cancer is a newer technology recently implemented into the operating room (OR). This procedure requires time and coordination between the surgeon and radiation oncologist, who both perform their treatments in a single operative setting. We evaluated the surgeons at our center, who perform IORT and their OR times to examine changes in OR times following implementation of this new surgical procedure. We hypothesized that IORT is a technique for which timing could be improved with the increasing number of cases performed. Methods A prospectively maintained IRB approved database was queried for OR times (incision and close) in patients who underwent breast conserving surgery (BCS), sentinel lymph node biopsy with and without IORT using the Intrabeam™ system at our institution from 2011 to 2015. The total OR times were compared for each surgeon individually and over time. Next, the OR times of each surgeon were compared to each other. Continuous variables were summarized and then a prediction model was created using IORT time, OR time, surgeon, and number of cases performed. Results There were five surgeons performing IORT at our institution during this time period with a total of 96 cases performed. There was a significant difference observed in baseline surgeon-specific OR time for BSC (p = 0.03) as well as for BCS with IORT (p < 0.05), attributable to surgeon experience. The average BCS times were faster than the BCS plus IORT procedure times for all surgeons. The overall mean OR time for the entire combined surgical and radiation procedure was 135.5 min. The most common applicator sizes used were the 3.5 and 4 cm, yielding an average 21 min IORT time. Applicator choice did not differ over time (p = 0.189). After adjusting for IORT time and surgeon, the prediction model estimated that surgeons decreased the total BCS plus IORT OR time at a rate of −4.5 min per each additional 10 cases performed. Conclusion Surgeon experience and applicator size are related to OR times for performing IORT for breast cancer. OR time for IORT in breast cancer treatment can be improved over time, even among experienced surgeons.
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Affiliation(s)
- Stephanie A Valente
- Division of Breast Services, Department of General Surgery, Cleveland Clinic, Cleveland, OH, United States
| | - Alicia Fanning
- Division of Breast Services, Department of General Surgery, Cleveland Clinic, Cleveland, OH, United States
| | - Robyn A Stewart
- Division of Breast Services, Department of General Surgery, Cleveland Clinic, Cleveland, OH, United States
| | - Sharon Grundfest
- Division of Breast Services, Department of General Surgery, Cleveland Clinic, Cleveland, OH, United States
| | - Rahul D Tendulkar
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, OH, United States
| | - Sheen Cherian
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, OH, United States
| | - Chirag Shah
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, OH, United States
| | - Chao Tu
- Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, United States
| | - Courtney Yanda
- Division of Breast Services, Department of General Surgery, Cleveland Clinic, Cleveland, OH, United States
| | - Diane Radford
- Division of Breast Services, Department of General Surgery, Cleveland Clinic, Cleveland, OH, United States
| | - Zahraa Al-Hilli
- Division of Breast Services, Department of General Surgery, Cleveland Clinic, Cleveland, OH, United States
| | - Stephen R Grobmyer
- Division of Breast Services, Department of General Surgery, Cleveland Clinic, Cleveland, OH, United States
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32
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Are Patients Traveling for Intraoperative Radiation Therapy? Int J Breast Cancer 2017; 2017:6395712. [PMID: 29130001 PMCID: PMC5654333 DOI: 10.1155/2017/6395712] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Revised: 08/30/2017] [Accepted: 09/05/2017] [Indexed: 11/18/2022] Open
Abstract
Purpose One benefit of intraoperative radiation therapy (IORT) is that it usually requires a single treatment, thus potentially eliminating distance as a barrier to receipt of whole breast irradiation. The aim of this study was to evaluate the distance traveled by IORT patients at our institution. Methods Our institutional prospective registry was used to identify IORT patients from 10/2011 to 2/2017. Patient's home zip code was compared to institution zip code to determine travel distance. Characteristics of local (<50 miles), regional (50-100 miles), and faraway (>100 miles) patients were compared. Results 150 were patients included with a median travel distance of 27 miles and mean travel distance of 121 miles. Most were local (68.7%), with the second largest group living faraway (20.0%). Subset analysis of local patients demonstrated 20.4% traveled <10 miles, 34.0% traveled 10-20 miles, and 45.6% traveled 20-50 miles. Six patients traveled >1000 miles. The local, regional, and faraway patients did not differ with respect to age, race, tumor characteristics, or whole breast irradiation. Conclusions Breast cancer patients are traveling for IORT, with 63% traveling >20 miles for care. IORT is an excellent strategy to promote breast conservation in selected patients, particularly those who live remote from a radiation facility.
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Bhandari T, Babaran W, Forouzannia A, Williams V, Harness J, Carpenter M, Gobran M, Khanijou R, Wagman B, Ash R, Wagman LD. A prospective phase I comparison of toxicity and cosmesis outcomes of single-fraction IORT and hypofractionated radiotherapy with IORT boost in early-stage breast cancer. Brachytherapy 2017; 16:1232-1238.e2. [PMID: 29032999 DOI: 10.1016/j.brachy.2017.09.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Revised: 08/31/2017] [Accepted: 09/02/2017] [Indexed: 11/18/2022]
Abstract
PURPOSE Radiation therapy is proven to reduce local recurrence in patients with early-stage breast cancer. To reduce toxicity, treatment time, and improve accuracy, intraoperative radiation therapy was used as definitive treatment or as a boost. The study's objective was to compare the short-term toxicity and cosmesis of single-fraction (SF) IORT and hypofractionated radiotherapy with IORT boost (HfB) given as definitive treatment. METHODS AND MATERIALS Between March 2011 and December 2013, 57 patients aged 45-91 years and 24 patients aged 43-83 years (total n = 81) with Stage 0-II were treated with SF or HfB (Mobetron, IntraOp Medical, Sunnyvale, CA). For SF treatment, 21 Gy was delivered using 4.5-6 cm applicators with electron energies from 6 to 12 MeV. For HfB, an intraoperative boost of 10 Gy was delivered using 4-7 cm applicators with energies from 4 to 12 MeV followed by whole-breast radiation with 40.5 Gy over 15 fractions. Toxicity was assessed at 2 weeks, 6 months, and 12 months per Radiation Therapy Oncology Group acute skin toxicity criteria and cosmesis. RESULTS At 12 months, SF and HfB were well tolerated by all patients with no Grade 3+ toxicity. At 1 year, Grade-2 toxicity was resolved. Ninety-eight percent of SF patients and ninety percent of HfB patients had 0-1 grade toxicity. In the SF and HfB groups, 100% of patients had excellent or good cosmesis at 12-month followup interval. The SF exhibited a more favorable cosmesis with a higher percentage of excellent scores compared with HfB (80.4% vs. 45%; p = 0.0033). CONCLUSIONS After breast conservation surgery, SF or HfB may be an option for patients with early-stage breast cancer compared to conventional external beam radiotherapy.
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Affiliation(s)
- Tanuja Bhandari
- The Center for Cancer Prevention and Treatment at St. Joseph Hospital, Orange, CA
| | - Wesley Babaran
- The Center for Cancer Prevention and Treatment at St. Joseph Hospital, Orange, CA
| | - Afshin Forouzannia
- The Center for Cancer Prevention and Treatment at St. Joseph Hospital, Orange, CA
| | - Venita Williams
- The Center for Cancer Prevention and Treatment at St. Joseph Hospital, Orange, CA
| | - Jay Harness
- The Center for Cancer Prevention and Treatment at St. Joseph Hospital, Orange, CA
| | - Michele Carpenter
- The Center for Cancer Prevention and Treatment at St. Joseph Hospital, Orange, CA
| | - Maher Gobran
- The Center for Cancer Prevention and Treatment at St. Joseph Hospital, Orange, CA
| | - Rajesh Khanijou
- The Center for Cancer Prevention and Treatment at St. Joseph Hospital, Orange, CA
| | - Brittany Wagman
- The Center for Cancer Prevention and Treatment at St. Joseph Hospital, Orange, CA
| | - Robert Ash
- The Center for Cancer Prevention and Treatment at St. Joseph Hospital, Orange, CA
| | - Lawrence D Wagman
- The Center for Cancer Prevention and Treatment at St. Joseph Hospital, Orange, CA.
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Abbott AM, Valente SA, Loftus L, Tendulkar RD, Greif JM, Bethke KP, Donnelly ED, Lottich C, Ross DL, Friedman NB, Bedi CG, Joh JE, Kelemen P, Hoefer RA, Kang SK, Ruffer J, Police A, Fyles A, Graves GM, Willey SC, Tousimis EA, Small W, Lyons J, Grobmyer S, Laronga C. A multi-institutional analysis of intraoperative radiotherapy for early breast cancer: Does age matter? Am J Surg 2017; 214:629-633. [PMID: 28918848 DOI: 10.1016/j.amjsurg.2017.06.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Revised: 06/19/2017] [Accepted: 06/20/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Single-session intraoperative radiation therapy (IORT) minimizes treatment demands associated with traditional whole breast radiation therapy (WBRT) but outcomes on local disease control and morbidity among the elderly is limited. METHODS A multi-institutional retrospective registry was established from 19 centers utilizing IORT from 2007 to 2013. Patient, tumor, and treatment variables were analyzed for ages <70 and ≥70. RESULTS We evaluated 686 patients (<70 = 424; ≥70 = 262) who were margin and lymph node negative. Patients <70 were more likely to have longer operative time, oncoplastic closure, higher rates of IORT used as planned boost, and receive chemotherapy and post-operative WBRT. Wound complication rates were low and not significantly different between age groups. Median follow-up was 1.06 (range 0.51-1.9) years for < 70 and 1.01 (range 0.5-1.68) years for ≥ 70. There were 5 (0.73%) breast recurrences (4 in <70 and 1 ≥ 70, p = 0.65) and no axillary recurrences during follow-up. CONCLUSIONS IORT was associated with a low rate of wound complication and local recurrence on short-term follow-up in this cohort.
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Affiliation(s)
| | | | - L Loftus
- Moffitt Cancer Center, Tampa, USA
| | | | - J M Greif
- Alta Bates Summit Medical Center, Oakland, CA, USA
| | | | | | - C Lottich
- Community Physician Network Breast Care, Community Health Network, Indianapolis, IN, USA
| | - D L Ross
- Community Physician Network Breast Care, Community Health Network, Indianapolis, IN, USA
| | | | - C G Bedi
- Mercy Medical Center, Baltimore, MD, USA
| | - J E Joh
- Mercy Medical Center, Baltimore, MD, USA
| | - P Kelemen
- Ashikari Breast Center, Dobbs Ferry, NY, USA
| | - R A Hoefer
- The Sentara Dorothy G. Hoefer Comprehensive Breast Center, Newport News, VA, USA
| | - S K Kang
- The Sentara Dorothy G. Hoefer Comprehensive Breast Center, Newport News, VA, USA
| | - J Ruffer
- Advocate Good Shepherd Hospital, Barrington, IL, USA
| | - A Police
- University of California Irvine Medical Center, Irvine, CA, USA
| | - A Fyles
- Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - G M Graves
- Sutter Cancer Center, Sacramento, CA, USA
| | - S C Willey
- MedStar Georgetown University Hospital, Washington, DC, USA
| | - E A Tousimis
- MedStar Georgetown University Hospital, Washington, DC, USA
| | - W Small
- Loyola University, Maywood, IL, USA
| | - J Lyons
- The Cleveland Clinic, Cleveland, OH, USA
| | - S Grobmyer
- The Cleveland Clinic, Cleveland, OH, USA
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Silverstein MJ, Epstein MS, Lin K, Chen P, Khan S, Snyder L, Guerra LE, De Leon C, Mackintosh R, Coleman C, Lopez J, Kim B. Intraoperative Radiation Using Low-Kilovoltage X-Rays for Early Breast Cancer: A Single Site Trial. Ann Surg Oncol 2017; 24:3082-3087. [DOI: 10.1245/s10434-017-5934-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Indexed: 12/25/2022]
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Holmes DR. Early complications after intraoperative radiotherapy revisited. J Surg Oncol 2017; 115:779-781. [DOI: 10.1002/jso.24590] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Accepted: 02/01/2017] [Indexed: 11/11/2022]
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Rakhra S, Bethke K, Strauss J, Hayes JP, Hansen N, Khan SA, Helenowski I, Donnelly ED. Risk Factors Leading to Complications in Early-Stage Breast Cancer Following Breast-Conserving Surgery and Intraoperative Radiotherapy. Ann Surg Oncol 2016; 24:1258-1261. [PMID: 27853900 DOI: 10.1245/s10434-016-5679-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2016] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate outcomes after breast-conserving surgery (BCS) and intraoperative radiotherapy (IORT), and to identify risk factors associated with complications. MATERIALS/METHODS We evaluated patients with early-stage breast cancer treated from January 1, 2011 to January 31, 2014 with BCS and IORT at a single institution. The presence of breast cancer recurrences, complications, or fat necrosis were assessed at subsequent follow-up visits using physical examination and breast imaging. RESULTS Overall, 113 patients, of whom three were undergoing bilateral treatments, were identified. The median length of time for IORT was 29 min and 36 s (range 15:50-59:00). Fifteen patients received additional external beam radiotherapy (EBRT), and the median follow-up was 40.3 months (range 1.6-58.3) for all patients. To date, one biopsy-proven ipsilateral recurrence has been noted (0.9%), for which the patient elected to undergo a mastectomy. Nine patients were found to have wound complications (7.7%) and two had fat necrosis (1.7%) on follow-up. Of all the evaluated risk factors, only applicator size (p < 0.01) had a statistically significant association with an increase in complications. CONCLUSIONS With a short follow-up, IORT appears to be a safe treatment modality for a select group of patients, leading to a reasonable increase in operating room time and complication rates following BCS. The utilization of larger applicators at the time of IORT was associated with an increase in wound complications and fat necrosis.
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Affiliation(s)
- Sunpreet Rakhra
- Department of Radiation Oncology, The Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, IL, USA
| | - Kevin Bethke
- Department of Surgery, The Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, IL, USA
| | - Jonathan Strauss
- Department of Radiation Oncology, The Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, IL, USA
| | - John P Hayes
- Department of Radiation Oncology, The Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, IL, USA
| | - Nora Hansen
- Department of Surgery, The Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, IL, USA
| | - Seema A Khan
- Department of Surgery, The Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, IL, USA
| | - Irene Helenowski
- Northwestern University Cancer Biostatistics Core, Chicago, IL, USA
| | - Eric D Donnelly
- Department of Radiation Oncology, The Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, IL, USA.
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Shah C, Tendulkar R, Smile T, Nanavati A, Manyam B, Balagamwala E, Pham Y, Takiar R, Wobb J, Khan A, Arthur D, Wazer D, Vicini F. Adjuvant Radiotherapy in Early-Stage Breast Cancer: Evidence-Based Options. Ann Surg Oncol 2016; 23:3880-3890. [DOI: 10.1245/s10434-016-5503-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2016] [Indexed: 01/22/2023]
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Epstein MS, Silverstein MJ, Lin K, Kim B, De Leon C, Khan S, Guerra LE, Snyder L, Coleman C, Lopez J, Mackintosh R, Chen P. Acute and Chronic Complications in Patients with Ductal Carcinoma in Situ Treated with Intraoperative Radiation Therapy. Breast J 2016; 22:630-636. [DOI: 10.1111/tbj.12650] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Melinda S. Epstein
- Hoag Institute for Research and Education; Hoag Memorial Hospital Presbyterian; Newport Beach California
| | - Melvin J. Silverstein
- Department of Surgery; Hoag Memorial Hospital Presbyterian; Newport Beach California
- Keck School of Medicine; University of Southern California; Los Angeles California
| | - Kevin Lin
- Department of Radiology; Hoag Memorial Hospital Presbyterian; Newport Beach California
| | - Brian Kim
- Department of Radiology; Hoag Memorial Hospital Presbyterian; Newport Beach California
| | - Cristina De Leon
- Hoag Institute for Research and Education; Hoag Memorial Hospital Presbyterian; Newport Beach California
| | - Sadia Khan
- Department of Surgery; Hoag Memorial Hospital Presbyterian; Newport Beach California
- Keck School of Medicine; University of Southern California; Los Angeles California
| | | | - Lincoln Snyder
- Department of Surgery; Hoag Memorial Hospital Presbyterian; Newport Beach California
| | - Colleen Coleman
- Department of Surgery; Hoag Memorial Hospital Presbyterian; Newport Beach California
| | - January Lopez
- Department of Radiology; Hoag Memorial Hospital Presbyterian; Newport Beach California
| | - Ralph Mackintosh
- Department of Radiology; Hoag Memorial Hospital Presbyterian; Newport Beach California
| | - Peter Chen
- Department of Radiology; Hoag Memorial Hospital Presbyterian; Newport Beach California
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