Phase II Trial of Definitive Therapy for Osseous Oligometastases in Breast Cancer

PURPOSE/OBJECTIVE(S)

Phase II data for consolidative local therapy for oligometastatic disease demonstrated improved outcomes for various malignancies. However, a randomized phase II study of oligometastatic breast cancer patients testing predominantly ablative dose radiotherapy (RT) did not demonstrate progression-free survival (PFS) benefit. We conducted a single-arm phase II trial evaluating local therapy as part of the multidisciplinary management of breast cancer patients with limited bone metastases.

MATERIALS/METHODS

Patients with synchronous (n = 15) and metachronous (n = 15) oligometastatic breast cancer involving ≤3 osseous sites were enrolled from July 2009 to April 2016 and treated to a total of 44 bone metastases. The trial closed early due to slow accrual. Following ≤9 months of systemic therapy, local therapy entailed surgery (n = 3) or RT delivered via conventional fractionation (≥60 Gy, n = 36) or stereotactic technique (27 Gy/3 fractions for spine mets, n = 6). When indicated, RT to the primary was delivered concurrently (n = 15). The primary endpoint was to determine PFS. Secondary endpoints were overall survival (OS), local control (LC) and toxicity. Outcomes were evaluated with Kaplan-Meier and univariate Cox proportional hazards analyses.

RESULTS

Of the 30 patients included in the trial, 23 (77%) had ER+ or PR+/HER2- disease, 4 (13%) had Her2+ disease, and 3 (10%) were triple negative. Median age was 53, and 20 patients (67%) presented with 1 distant metastasis. A total of 21 patients (70%) experienced disease progression at a median 20.5 months (IQR: 8.2-41.2), including 5 local failures among 44 treated bone metastases (11%). At a median follow-up of 76.7 mon (IQR: 45.4-108.8), the median PFS was 37.8 mon, with 2- and 5-year rates (95% CI) of 60% (45-80%) and 32% (19-55%), respectively. The 2- and 5-year OS rates were 93% (85-100%) and 64% (48-85%), respectively, and the 2- and 5-year LC rates were 91% (80-100%) and 71% (51-98%). For patients who achieved LC, median PFS was 47.7 months (IQR 12.2-73.0). Twenty-one patients (70%) received cytotoxic chemotherapy with or without endocrine therapy for newly diagnosed oligometastatic disease. Nine patients (30%) were still alive with no evidence of disease (NED) at a median 96.9 mon (range: 47.7-158.6). PFS was worse among triple negative patients (p = 0.03), with no difference based on synchronous vs non-synchronous presentation (p = 0.10), receipt of cytotoxic chemotherapy prior to definitive therapy (p = 0.08) or Her2+ status (p = 0.21). There were no Grade ≥3 adverse events.

CONCLUSION

Definitive, predominantly conventionally fractionated local therapy was associated with long-term NED status for 30% of patients with oligometastatic breast cancer involving osseous sites, with minimal treatment-associated toxicity. Developing randomized trials for breast cancer subsets may warrant consideration of standard fractionation regimen data and the need for strategies to identify patients who may benefit from definitive local therapy.

Abstract P2-11-12: Prospective comparison of late toxicity and cosmetic outcome after accelerated partial breast irradiation with conformal external beam radiotherapy or single-entry multi-lumen intracavitary brachytherapy

Purpose/Objective(s):

To prospectively compare late toxicity after accelerated partial breast irradiation (APBI) with 3D-conformal external beam radiotherapy (3D-CRT) or single-entry multi-lumen intracavitary brachytherapy.

Patients/Methods:

Two hundred eighty-one patients with pTis or pT2N0 (≤3.0 cm) breast cancer treated with segmental mastectomy were prospectively enrolled on a multi-institution observational protocol from 12/2008 – 8/2014. Patients were enrolled and treated at primary, satellite, and affiliated academic institutions. APBI was delivered using 3D-CRT or with a Contura®, MammoSite®, or SAVI® brachytherapy catheter. 3D-CRT patients were treated to 34.0 Gy (7%) or 38.5 Gy (93%) at 3.4-3.85 Gy/fx BID and brachytherapy patients were treated to 34.0 Gy at 3.4 Gy/fx BID. Per protocol, patients were clinically evaluated at 2, 6, 12, 18, and 24 months and then annually. At each clinical evaluation the radiation oncologist scored cosmetic outcome (excellent/good/fair/poor according to the Harvard Cosmesis Scale), toxicity (seroma/infection/fat necrosis/pain/telangiectasia/radiation dermatitis/hyperpigmentation/hypopigmentation/fibrosis/induration/edema/other according to CTCAE v3.0) and recurrence status.

Results:

The median age was 61 years. Of 281 patients, 211 (75%) had invasive breast cancer and 70 (25%) had in situ disease. Among patients with invasive disease, 90% were HR+/HER2-, and among patients with in situ disease, 83% were HR+. APBI was delivered with 3D-CRT in 29 (10%) patients and with single-entry multi-lumen intracavitary brachytherapy in 252 (90%) patients. Among the brachytherapy patients, APBI was delivered with the SAVI®, Contura®, and MammoSite® devices in 176 (70%), 56 (22%), and 20 (8%) patients, respectively. With a median follow-up of 49 months, rates of Grade 1 (G1) and Grade 2-3 (G2-3) toxicity are:

 3D-CRTBrachytherapy   G1G2-3G1G2-3G1G2-3 N (%)N (%)N (%)N (%)  Fibrosis13 (46%)1 (4%)176 (72%)6 (2%)p=0.008p=0.54Fat Necrosis0 (0%)0 (0%)0 (0%)4 (2%)p=1.00p=1.00Telangiectasia6 (21%)1 (4%)44 (18%)5 (2%)p=0.61p=0.48Seroma2 (7%)1 (4%)135 (55%)12 (5%)p<0.0001p=1.00

Mean skin dose of the maximally-irradiated 0.1 cc (D0.1cc) of skin was significantly higher in patients who developed telangiectasia (103.4% ± 16.1% compared to 96.5% ± 18.6% of prescription dose, p=0.007) and fibrosis (100.1% ± 15.5% compared to 92.8% ± 23.0% of prescription dose, p=0.02). Crude rates of fair or poor cosmetic outcome at 2-4 and 4-6 years were 6.9% and 14.8%, respectively, for 3D-CRT and 14.8% and 21.3%, respectively, for brachytherapy (p>0.05 at both timepoints). Five-year recurrence-free survival was 96.3% with 3D-CRT and 96.1% for brachytherapy (p>0.05).

Conclusion:

APBI with single-entry multi-lumen intracavitary brachytherapy is associated with increased rates of grade 1 fibrosis and seroma than APBI with 3D-CRT. Higher mean skin D0.1cc is associated with increased risk of telangiectasia and fibrosis. Despite increased low-grade fibrosis, there is no significant difference in radiation oncologist-reported fair or poor cosmetic outcome out to six years, or rate of five-year ipsilateral breast recurrence.

Citation Format: Stecklein SR, Babiera GV, Bedrosian I, Shaitelman SF, Ballo MT, Tereffe W, Arzu IY, Perkins GH, Strom EA, Reed VK, Dvorak T, Smith BD, Woodward WA, Hoffman KE, Schlembach PJ, Chronowski GM, Shah SJ, Kirsner SM, Nelson CL, Guerra W, Dibaj SS, Bloom ES. Prospective comparison of late toxicity and cosmetic outcome after accelerated partial breast irradiation with conformal external beam radiotherapy or single-entry multi-lumen intracavitary brachytherapy [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P2-11-12.

Abstract P5-14-08: Prospective phase II study of concurrent capecitabine and radiation demonstrates futility in triple negative chemo-resistant breast cancer

Background: Capecitabine is an established radiosensitizer in rectal and other cancers. We conducted a prospective single arm phase II study to examine the response rate of gross chemo-refractory breast cancer treated with concurrent capecitabine and radiotherapy.

Methods: Patients who had inoperable or marginally operable gross disease in the breast and/or lymph node(s) after chemotherapy or gross disease on the chest wall or in the regional lymphatics after mastectomy were eligible. Patients 1-9 received capecitabine 825 mg/m2 BID daily beginning on the first day of radiotherapy. Excess grade 3 toxicity (%) was observed; the protocol was amended and subsequent patients received drug only on radiation treatment days. Radiation dose was at the discretion of the treating physician (50Gy-72 Gy, with no more than 2.5 Gy/fraction). Response was assessed by a single physician using paired radiation planning CTs (pretreatment and on-treatment after 45 Gy). Clinical correlation to all other available imaging was also made. Kaplan-Meier curves were used to estimate overall survival (OS) and local recurrence-free survival (LRFS). Circulating tumor cells (CTCs) in blood were examined in consenting patients.

Results: The trial was stopped early after an unplanned interim analysis prompted by slow accrual suggested futility independent of response. From 2009-2012, 32 patients were accrued; 26 completed protocol specific treatment (17 post-mastectomy radiation with gross nodes, 4 pre-op, 5 aggressive palliation) and are included in this analysis. Median follow up was 7.3 months (interquartile range 6.7 – 17.4). Nineteen patients (73%) had a partial or complete response. Fourteen patients (53.9%) experienced at least one grade 3 non-dermatitis toxicity including 7/9 treated with continuous dosing. Four inoperable patients were treated with pre-op radiation therapy and 3 converted to operable. None achieved a pCR or near pCR. One-year actuarial OS was 52%. There was no difference in OS comparing among PMRT vs. preoperative or palliative RT (P = 0.90). One-year actuarial local recurrence free survival among PMRT patients was 38%. Ten patients had triple negative (TN) receptor status. There was no difference in radiation response by receptor status (P = 0.56); however, treatment was deemed subjectively futile (i.e., converted to operable but death secondary to new widespread M1 disease immediately post-op) in 9 of the 10 patients with TN disease versus 6 of the 16 patients with non-TN disease (P = 0.014). Median OS and 1-yr actuarial OS, among non-TN vs. TN patients were not reached vs. 6.1 months and 77% vs. 10% (P < 0.001), respectively. Eight/fifteen patients tested were positive for CTCs. CTCs did not correlate to receptor status, futility of RT or OS.

Conclusions: Capecitabine can be safely administered as a daily concurrent chemoradiation regimen with weekend holidays. However, in this small, prospective and selected cohort, concurrent chemoradiation with capecitabine was futile among patients with TN breast cancer. Alternative strategies are urgently needed in TN patients.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P5-14-08.

Accelerated partial-breast irradiation using intensity-modulated proton radiotherapy: do uncertainties outweigh potential benefits?

OBJECTIVE

Passive scattering proton beam (PSPB) radiotherapy for accelerated partial-breast irradiation (APBI) provides superior dosimetry for APBI three-dimensional conformal photon radiotherapy (3DCRT). Here we examine the potential incremental benefit of intensity-modulated proton radiotherapy (IMPT) for APBI and compare its dosimetry with PSPB and 3DCRT.

METHODS

Two theoretical IMPT plans, TANGENT_PAIR and TANGENT_ENFACE, were created for 11 patients previously treated with 3DCRT APBI and were compared with PSPB and 3DCRT plans for the same CT data sets. The impact of range, motion and set-up uncertainties as well as scanned spot mismatching between fields of IMPT plans was evaluated.

RESULTS

IMPT plans for APBI were significantly better regarding breast skin sparing (p<0.005) and other normal tissue sparing than 3DCRT plans (p<0.01) with comparable target coverage (p=ns). IMPT plans were statistically better than PSPB plans regarding breast skin (p<0.002) and non-target breast (p<0.007) in higher dose regions but worse or comparable in lower dose regions. IMPT plans using TANGENT_ENFACE were superior to that using TANGENT_PAIR in terms of target coverage (p<0.003) and normal tissue sparing (p<0.05) in low-dose regions. IMPT uncertainties were demonstrated for multiple causes. Qualitative comparison of dose-volume histogram confidence intervals for IMPT suggests that numeric gains may be offset by IMPT uncertainties.

CONCLUSION

Using current clinical dosimetry, PSPB provides excellent dosimetry compared with 3DCRT with fewer uncertainties compared with IMPT.

ADVANCES IN KNOWLEDGE

As currently delivered in the clinic, PSPB planning for APBI provides as good or better dosimetry than IMPT with less uncertainty.

Abstract P4-11-15: Outcomes for Breast Cancer Patients with Isolated Metastasis or Recurrence to the Contralateral Nodal Basins

Background: Aggressive treatment of isolated breast cancer metastasis to either bone or lung has been reported to achieve long term survival. For the first time, we analyzed outcomes for patients (pts) with isolated metastasis to the contralateral (contra) supraclavicular (SCV) and/or axillary nodal basins.

Material and Methods: Pts treated with definitive or palliative radiation to the contra nodal basin(s) at M.D. Anderson were analyzed from the period of 2005-2010. They were divided into two groups: pts initially diagnosed with contra SCV and/or axilla as the only site of metastasis (designated Primary), and pts with recurrence in the contra SCV and/or axilla, without other distant metastasis (designated Recurrent).

Results: Of 34 potential pts with contra lymph node metastasis, 13 had isolated disease and were analyzed. In the Primary group (N=8, T4d N1- 3c M1), median survival was 25 mos, and 2-yr actuarial overall survivalwas 62.5%. All received neoadjuvant anthracycline and/or taxane-based chemotherapy followed by ipsilateral (ipsi) modified radical mastectomy and ipsi axillary lymph node dissection (ALND). The contra lymphatics were treated with ALND followed by radiation (N=5, 56-60 Gy) or with radiation alone (N=3, 45-66 Gy). Radiation fields included ipsi chest wall as well as ipsi and involved contra lymphatics. The contra chest wall or breast was radiated in 3 of the 8 pts. Two pts had estrogen receptor (ER) positive disease, and all had Her2-neu negative disease. Both ER+ pts are alive with no evidence of disease (NED; 1 had contra ALND; survival 25 and 51 mos). All 6 ER-pts died with disease (WD; 4 had contra ALND; survival 10 to 32 mos). One pt had an in-field recurrence in the contra nodal basin (51 Gy post ALND). No contra chest wall/breast recurrences were seen. All ER-pts developed additional distant metastasis, most within 4 mos of starting adjuvant radiation.

Regarding the Recurrent group (N=5), median survival was 25 mos after recurrence. Two ER+ pts received initial anti-estrogen therapy; all ER-pts initially received a taxane-based chemotherapy. The contra chest wall or breast was radiated in addition to the involved contra lymphatics in 3 of the 5 pts. Two pts had adjuvant radiation treatment with definitive intent to the contra lymphatics after ALND (50-50.4 Gy), with 1 alive/NED (66 mos from recurrence, no radiation to the contra breast) and 1 dead/WD (25 mos from recurrence). Radiation intent was palliation in 3 pts (none received ALND) with 1 alive/WD (60 Gy, 64 mos from recurrence) and 2 dead/WD (53.8 and 45 Gy, 6 and 18 mos from recurrence, respectively). In-field recurrence in the contra nodal basin occurred in 1 pt (50.4 Gy). Pts who died had progressive disease or additional distant metastasis within 3 mos of starting radiation.

Discussion: In this uncommon clinical scenario, locoregional control of the contra lymphatics was achieved with radiation alone or with surgery followed by radiation for a select group of pts; control was achieved without radiating the contra chest wall/breast. Only ER+ pts were rendered NED. Most ER-pts quickly developed other distant metastasis, highlighting the need for more effective systemic therapy.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P4-11-15.

Local-regional recurrence with and without radiation after neoadjuvant chemotherapy and mastectomy for T3N0 breast cancer patients

Abstract #74

Purpose: The goal of this study was to compare the local-regional recurrence (LRR) risk in patients with clinical T3N0 breast cancer who were treated with neoadjuvant chemotherapy (NeoChemo) and mastectomy (Mastx) according to the use of adjuvant radiation (RT).&#x2028; Methods: Clinicopathologic data from 164 patients with clinical T3N0 breast cancer who received NeoChemo and Mastx from 1985 to 2004 were retrospectively reviewed. In this cohort, 121 (74%) patients received adjuvant radiation (RT) while 43 (26%) patients did not. The median number of axillary lymph nodes (LN) dissected was 15. After NeoChemo, 54% of patients (n=89) had no pathologically involved lymph nodes at the time of surgery (ypLN-) while 46% (n=75) had at least 1 lymph node pathologically positive (ypLN+). Actuarial rates were calculated using Kaplan-Meier analysis and compared using log-rank test. Cox proportional hazards models were fit to determine the association of RT with the risk of LRR after adjustment for other patient and disease characteristics.&#x2028; Results: At a median follow-up of 77 months, 17 of the 164 patients had a LRR. For all patients, the 5-year local-regional control rates (5-yr LRC) were 90%. The 5-yr LRC for those who received RT (n=121) was 95% and for those who did not received RT (n=43) was 76% (p = 0.002), with a higher proportion of the patients who received RT having pathologically involved LN (+RT 53% vs –RT 23%, p=0.002).&#x2028; Among the entire cohort, the 5-yr LRC was 85% for patients with ypLN+ disease and 94% for patients with ypLN- disease (p=0.093). In patients with ypLN+, the 5-yr LRC with no RT (n=11) was 47% and with RT (n=64) was 92% (p&lt;0.001). In patients with ypLN-, the 5-yr LRC with no RT (n=32) was 86% and with RT (n=57) was 98% (p=0.063). Patients who had tumors with high nuclear grade had worse 5-yr LRC (Grade low 100%, intermediate 97%, high 81%, p=0.023). The presence of lymphovascular invasion, close/positive margin, or estrogen receptor status did not statistically correlate with LRC. In a Cox regression model, patients with tumor exhibiting high nuclear grade (Hazard Ratio (HR) 5.0, 95% Confidence Interval (CI) 1.6-15.4), ypLN+ (HR 6.6, 95% CI 2.0-22.1) and no adjuvant RT (HR 7.6, 95% CI 2.4-24.0) had increased risk of LRR.&#x2028; Conclusions: Post mastectomy adjuvant RT appears to improve LRC in clinical T3N0 breast cancer patients treated with neoadjuvant chemotherapy and mastectomy.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 74.

A custom three-dimensional electron bolus technique for optimization of postmastectomy irradiation

PURPOSE

Postmastectomy irradiation (PMI) is a technically complex treatment requiring consideration of the primary tumor location, possible risk of internal mammary node involvement, varying chest wall thicknesses secondary to surgical defects or body habitus, and risk of damaging normal underlying structures. In this report, we describe the application of a customized three-dimensional (3D) electron bolus technique for delivering PMI.

METHODS AND MATERIALS

A customized electron bolus was designed using a 3D planning system. Computed tomography (CT) images of each patient were obtained in treatment position and the volume to be treated was identified. The distal surface of the wax bolus matched the skin surface, and the proximal surface was designed to conform to the 90% isodose surface to the distal surface of the planning target volume (PTV). Dose was calculated with a pencil-beam algorithm correcting for patient heterogeneity. The bolus was then fabricated from modeling wax using a computer-controlled milling device. To aid in quality assurance, CT images with the bolus in place were generated and the dose distribution was computed using these images.

RESULTS

This technique optimized the dose distribution while minimizing irradiation of normal tissues. The use of a single anterior field eliminated field junction sites. Two patients who benefited from this option are described: one with altered chest wall geometry (congenital pectus excavatum), and one with recurrent disease in the medial chest wall and internal mammary chain (IMC) area.

CONCLUSION

The use of custom 3D electron bolus for PMI is an effective method for optimizing dose delivery. The radiation dose distribution is highly conformal, dose heterogeneity is reduced compared to standard techniques in certain suboptimal settings, and excellent immediate outcome is obtained.

Relationship of sentinel and axillary level I-II lymph nodes to tangential fields used in breast irradiation

PURPOSE

To evaluate the volume of nodal irradiation associated with breast-conserving therapy, we defined the anatomic relationship of sentinel lymph nodes and axillary level I and II lymph nodes in patients receiving tangential breast irradiation.

METHODS AND MATERIALS

A retrospective analysis of 65 simulation fields in women with breast cancer treated with sentinel lymph node surgery and 39 women in whom radiopaque clips demarcated the extent of axillary lymph node dissection was performed. We measured the relationship of the surgical clips to the anatomic landmarks and calculated the percentage of prescribed dose delivered to the sentinel lymph node region.

RESULTS

A cranial field edge 2.0 cm below the humeral head the sentinel lymph node region was included or at the field edge in 95% of the cases and the entire extent of axillary I and II dissection in 43% of the axillary dissection cases. In the remaining 57%, this field border encompassed an average of 80% of cranial/caudal extent of axillary level I and II dissection. In 98.5% of the cases, all sentinel lymph nodes were anterior to the deep field edge and 71% were anterior to the chest wall-interface, whereas 61% of the axillary dissection cohort had extension deep to the chest wall-lung interface. If the deep field edge had been set 2 cm below the chest wall-lung interface, the entire axillary dissection would have been included in 82% of the cases, and the entire sentinel lymph node would have been covered with a 0.5-cm margin. The median dose to the sentinel lymph node region was 98% of the prescribed dose.

CONCLUSIONS

By extending the cranial border to 2 cm below the humeral head and 2 cm deep to the chest wall-lung interface, the radiotherapy fields used to treat the breast can include the sentinel lymph node region and most of axillary levels I and II.

Coronary artery dosimetry in intact left breast irradiation

PURPOSE

The purpose of this article is to report dose-volume histograms of coronary vessels from irradiation of the intact left breast.

PATIENTS AND METHODS

Fifteen women with cancer of the left breast underwent computed tomographic treatment planning for radiation treatments of an intact left breast. Images through the heart were reconstructed at 1-mm increments to permit contouring of the coronary vessels. Five treatment plans were created for each patient; one plan from the simulated treatment fields and four additional plans that were generated from virtual treatment fields created by shifting the isocenter 5 mm and 10 mm both superficially and deep. The radiation dose was calculated using a three-dimensional treatment planning system that incorporated heterogeneity correction factors.

RESULTS

With no adjustment to the perpendicular lung distance, a mean volume of 12% of the left anterior descending coronary artery received 20 Gy, 6% received 30 Gy, and 3% received 40 Gy. The dose to the left anterior descending coronary artery varied significantly with changes in the perpendicular lung distance. From the mean perpendicular lung distance of 1.87 for the simulated fields, a 5-mm increase in the perpendicular lung distance resulted in an increase of 20%, 15%, and 12% in the percentage of the left anterior descending coronary artery treated to 20 Gy, 30 Gy, and 40 Gy, respectively. With a 10-mm increase, the respective volumes were increased to 49%, 41%, and 34%, respectively. A 5-mm reduction of lung distance in the original plan resulted in a decrease of 10%, 5%, and 3% in the percentage treated to 20 Gy, 30 Gy, and 40 Gy, respectively. The dose to the left main coronary artery, the right main coronary artery, and the left circumflex coronary artery was limited to scatter and was less than 7 Gy. Changes in the perpendicular lung distance did not significantly affect the dose administered to these vessels.

DISCUSSION

The left anterior descending coronary artery is anatomically located at the edge of the cardiac silhouette on traditional treatment films. Small changes in the perpendicular lung distance can significantly change the dose delivered to this vessel. A fundamental change in the shape of the dose-volume histogram occurs at a perpendicular lung distance of 2.3 cm, whereas the dose is very low when the perpendicular lung distance is less than 1.3 cm. These points may serve as clinically important values in the treatment planning for cancer of an intact breast.

The influence of pathologic tumor characteristics on locoregional recurrence rates following mastectomy

PURPOSE

The objective of this study was to evaluate the influence of pathologic factors other than tumor size and number of involved axillary nodes on the risk of locoregional recurrence (LRR) following mastectomy.

PATIENTS AND METHODS

We reviewed the medical records of 1031 patients treated with mastectomy and doxorubicin-based chemotherapy without radiation on 5 prospective clinical trials. Median follow-up was 116 months (range, 6-262 months).

RESULTS

Patients with gross multicentric disease were at increased risk of LRR (37% at 10 years). However, patients with multifocal disease and those with microscopic multicentric disease did not experience higher rates of LRR than those with single lesions (17% at 10 years). Patients with lymph-vascular space invasion (LVSI) or involvement of the skin or nipple also experienced high rates of LRR (25%, 32%, and 50%, respectively). The presence of close (<5 mm) or positive margins was associated with an increased risk of LRR (45%). The increased risk of LRR observed for patients with pectoral fascial invasion (33%) was not reduced when negative deep margins were obtained. On multivariate analysis, the presence of 4 or more involved axillary nodes, tumor size of greater than 5 cm, close or positive surgical margins, and gross multicentric disease were found to be independent predictors of LRR (all, p < 0.01). In a separate analysis including only patients with 1-3 involved axillary nodes, microscopic invasion of the skin or nipple, pectoral fascial invasion, and the presence of close or positive margins were significant predictors of LRR.

CONCLUSION

In addition to the extent of primary and nodal disease, other factors that predict for high rates of LRR include the presence of LVSI, involvement of the skin, nipple or pectoral fascia, close or positive margins, or gross multicentric disease. These factors predict for high LRR rates regardless of the number of involved axillary nodes.

Recursive partitioning analysis of locoregional recurrence patterns following mastectomy: implications for adjuvant irradiation

PURPOSE

Postmastectomy irradiation improves overall survival for breast cancer patients at high risk for locoregional recurrence (LRR). The objective of this study was to use recursive partitioning analysis (RPA) to define patient subgroups at high risk for LRR following mastectomy.

PATIENTS AND METHODS

A cohort of 1031 patients treated on prospective trials with mastectomy and doxorubicin-based chemotherapy without irradiation was analyzed. The variables considered in the RPA were tumor size, number of involved nodes, number of nodes examined, and percentage of nodes involved (nodes involved/nodes examined). The endpoint was LRR +/- distant metastasis. Only patients with complete data were analyzed (n = 913). Median follow-up was 8 years (range, 0.7-22 years).

RESULTS

Involvement of 20% or more of the lymph nodes examined was the most significant variable predicting LRR. Three risk categories were defined. Patients with 20% or more involved nodes and tumors of 3.5 cm or more were at greatest risk for LRR (41% at 8 years). An intermediate-risk group included patients with 20% or more involved nodes and tumors of less than 3.5 cm as well as those with less than 20% involved nodes and tumor size of 5 cm or greater (18% at 8 years). Patients with less than 20% involved nodes and tumor size of less than 5 cm were at lowest risk for LRR (10% at 8 years).

CONCLUSION

Tumor size and extent of nodal involvement play interrelated roles in predicting LRR following mastectomy and systemic therapy. Patients with 20% or greater involved nodes and those with less than 20% nodes and tumors of 5.0 cm or greater are at significant risk of LRR and should be considered for postoperative irradiation.

Impact of systemic treatment on local control for patients with lymph node-negative breast cancer treated with breast-conservation therapy

PURPOSE

To determine the impact of tamoxifen and chemotherapy on local control for breast cancer patients treated with breast-conservation therapy.

PATIENTS AND METHODS

The data from 484 breast cancer patients who were treated with breast-conserving surgery and radiation were analyzed. Only patients with lymph node-negative disease were studied to provide comparative groups with a similar stage of disease and a similar competing risk for distant metastases. Actuarial local control rates of the 277 patients treated with systemic therapy (128, chemotherapy with or without tamoxifen; 149, tamoxifen alone) were compared with the rates for the 207 patients who received no systemic treatment. Only 10% of the patients had positive (2%), close (3%), or unknown margin status (5%).

RESULTS

Patients treated with systemic therapy had improved 5-year (97.5% v 89.8%) and 8-year (95.6% v 85.2%) local control rates compared with those that did not receive systemic treatment (P =.004, log-rank test). There was no statistical difference in local control between patients treated with chemotherapy and patients treated with tamoxifen alone (P =.219). Systemic treatment, margin status, young patient age, estrogen and progesterone receptor status, and primary tumor size were analyzed in a Cox regression analysis. The use of systemic treatment was the most powerful predictor of local control: patients who did not receive systemic treatment had a relative risk of local recurrence of 3.3 (95% confidence interval, 1.5 to 7.5; P =.004).

CONCLUSION

In this retrospective analysis, systemic therapy appears to contribute to long-term local control in patients with lymph node-negative breast cancer treated with breast-conservation therapy.

Local-regional control in breast cancer patients with a possible genetic predisposition

PURPOSE

Local control rates for breast cancer in genetically predisposed women are poorly defined. Because such a small percentage of breast cancer patients have proven germline mutations, surrogates, such as a family history for breast cancer, have been used to examine this issue. The purpose of this study was to evaluate local-regional control following breast conservation therapy (BCT) in patients with bilateral breast cancer and a breast cancer family history.

METHODS AND MATERIALS

We retrospectively reviewed records of all 58 patients with bilateral breast cancer and a breast cancer family history treated in our institution between 1959 and 1998. The primary surgical treatment was a breast-conserving procedure in 55 of the 116 breast cancer cases and a mastectomy in 61. The median follow-up was 68 months for the BCT patients and 57 months for the mastectomy-treated patients.

RESULTS

Eight local-regional recurrences occurred in the 55 cases treated with BCT, resulting in 5- and 10-year actuarial local-regional control rates of 86% and 76%, respectively. In the nine cases that did not receive radiation as a component of their BCT, four developed local-regional recurrences (5- and 10-year local-regional control rates of BCT without radiation: 49% and 49%). The 5- and 10-year actuarial local-regional control rates for the 46 cases treated with BCT and radiation were 94% and 83%, respectively. In these cases, there were two late local recurrences, developing at 8 years and 9 years, respectively. A log rank comparison of radiation versus no radiation actuarial data was significant at p = 0.009. In the cases treated with BCT, a multivariate analysis of radiation use, patient age, degree of family history, margin status, and stage revealed that only the use of radiation was associated with improved local control (Cox regression analysis p = 0.021). The 10-year actuarial rates of local-regional control following mastectomy with and without radiation were 91% and 89%, respectively.

CONCLUSIONS

Patients with a possible genetic predisposition to breast cancer had low 5-year rates of local recurrence when treated with breast conserving surgery and radiation, but the local failure rate exceeded 50% when radiation was omitted. Our data are consistent with the hypothesis that patients with an underlying genetic predisposition develop cancers with radiosensitive phenotypes.

Ductal carcinoma-in-situ: long-term results of breast-conserving therapy

BACKGROUND

The role of breast-conserving therapy (BCT) in the management of ductal carcinoma-in-situ (DCIS) is controversial because of reported high recurrence rates. We reviewed our experience to determine whether the rate and pattern of locoregional recurrence after BCT were similar in patients with DCIS and patients with early-stage (T1) invasive breast tumors and whether local recurrence affected survival.

METHODS

Between 1973 and 1994, 87 patients with DCIS alone, 22 patients with DCIS with microinvasion (DCIS-M), and 646 patients with invasive breast cancer 2 cm or smaller in diameter were treated with BCT (wide local excision with radiotherapy) at The University of Texas M. D. Anderson Cancer Center. Survival was calculated by the Kaplan-Meier method. The median follow-up times were 11 years for patients with DCIS alone, 12 years for patients with DCIS-M, and 8 years for patients with invasive breast cancer.

RESULTS

Eleven (13%) of 87 patients with DCIS and 5 (23%) of 22 patients with DCIS-M had developed locoregional recurrences at follow-up. Two patients with DCIS with locoregional recurrence died of breast cancer. Of the 646 patients with invasive breast cancer, 56 (9%) had a locoregional recurrence, and 16 (2%) died of breast cancer. The median time to locoregional recurrence was significantly longer in patients with DCIS or DCIS-M (9-10 years) than patients with invasive tumors (5 years).

CONCLUSIONS

DCIS is a favorable disease with an excellent long-term survival. The locoregional recurrence rate in patients with DCIS treated with BCT is similar to that in patients with early-stage invasive breast cancer treated with BCT, but time to locoregional recurrence is significantly longer in patients with DCIS. In patients with DCIS treated with BCT, intense surveillance for locoregional recurrence needs to be maintained for the patient's lifetime.

Locoregional recurrence patterns after mastectomy and doxorubicin-based chemotherapy: implications for postoperative irradiation

PURPOSE

The objective of this study was to determine locoregional recurrence (LRR) patterns after mastectomy and doxorubicin-based chemotherapy to define subgroups of patients who might benefit from adjuvant irradiation.

PATIENTS AND METHODS

A total of 1,031 patients were treated with mastectomy and doxorubicin-based chemotherapy without irradiation on five prospective trials. Median follow-up time was 116 months. Rates of isolated and total LRR (+/- distant metastasis) were calculated by Kaplan-Meier analysis.

RESULTS

The 10-year actuarial rates of isolated LRR were 4%, 10%, 21%, and 22% for patients with zero, one to three, four to nine, or >/= 10 involved nodes, respectively (P <.0001). Chest wall (68%) and supraclavicular nodes (41%) were the most common sites of LRR. T stage (P <.001), tumor size (P <.001), and >/= 2-mm extranodal extension (P <.001) were also predictive of LRR. Separate analysis was performed for patients with T1 or T2 primary disease and one to three involved nodes (n = 404). Those with fewer than 10 nodes examined were at increased risk of LRR compared with those with >/= 10 nodes examined (24% v 11%; P =.02). Patients with tumor size greater than 4.0 cm or extranodal extension >/= 2 mm experienced rates of isolated LRR in excess of 20%. Each of these factors continued to significantly predict for LRR in multivariate analysis by Cox logistic regression.

CONCLUSION

Patients with tumors >/= 4 cm or at least four involved nodes experience LRR rates in excess of 20% and should be offered adjuvant irradiation. Additionally, patients with one to three involved nodes and large tumors, extranodal extension >/= 2 mm, or inadequate axillary dissections experience high rates of LRR and may benefit from postmastectomy irradiation.

Locoregional irradiation for inflammatory breast cancer: effectiveness of dose escalation in decreasing recurrence

PURPOSE

To evaluate the effect of radiation dose escalation on locoregional control, overall survival, and long-term complication in patients with inflammatory breast cancer.

PATIENTS AND METHODS

From September 1977 to December 1993, 115 patients with nonmetastatic inflammatory breast cancer were treated with curative intent at The University of Texas M. D. Anderson Cancer Center. The usual sequence of multimodal treatment consisted of induction FAC or FACVP chemotherapy, mastectomy (if the tumor was operable), further chemotherapy, and radiation therapy to the chest wall and draining lymphatics. Sixty-one patients treated from September 1977 to September 1985 received a maximal radiation dose of 60 Gy to the chest wall and 45-50 Gy to the regional lymph nodes, 22 treated once a day at 2 Gy per fraction, and 35 were treated b.i.d. (32 after mastectomy and all chemotherapy was completed, and 2 immediately after mastectomy; one patient had distant metastases discovered during b.i.d. irradiation, and treatment was stopped). Four additional patients received preoperative radiation with standard fractionation. Based on the analysis of the failure patterns of the patients, the dose was increased for the b.i.d. patients in the new series, with 51 Gy delivered to the chest wall and regional nodes, followed by a 15-Gy boost to the chest wall with electrons. From January 1986 to December 1993, 39 patients were treated b.i.d. to this higher dose after mastectomy and all the chemotherapy was completed; and 8 additional patients received preoperative irradiation with b.i.d. fractionation to 51 Gy. During this period, another 7 patients were treated using standard daily doses of 2 Gy per fraction to a total of 60 Gy, either because they had a complete response or minimal residual disease at mastectomy or because their work schedule did not permit the b.i.d. regimen. Comparison was made between the groups for locoregional control, disease-free and overall survival, and complication rates.

RESULTS

The median follow-up time was 5.7 years (range, 1.8-17.6 years). For the entire patient group, the 5- and 10-year local control rates were 73.2% and 67.1%, respectively. The 5- and 10-year disease-free survival rates were 32.0% and 28.8%, respectively, and the overall survival rates for the entire group were 40.5% and 31.3%, respectively. To evaluate the effectiveness of dose escalation, a specific comparison of patients who received b.i.d. radiation after mastectomy and completion of adjuvant chemotherapy was performed. There were 32 patients treated b.i.d. to 60 Gy in the old series versus 39 patients treated b.i.d. to 66 Gy in the new series. There was an significant improvement in the rate of locoregional control for the b.i.d. patients for the old vs. new series, from 57.8% to 84.3% and from 57.8% to 77.0% (p = 0.028) at 5 and 10 years, respectively. Chemotherapy regimens did not change significantly during this time period.Long-term complications of radiation, such as arm edema more than 3 cm (7 patients), rib fracture (10 patients), severe chest wall fibrosis (4 patients), and symptomatic pneumonitis (5 patients), were comparable in the two groups, indicating that the dose escalation did not result in increased morbidity. Significant differences in the rates of locoregional control (p = 0.03) and overall survival (p = 0.03), and a trend of better disease-free survival (p = 0.06) were also observed that favored the recently treated patients receiving the higher doses of irradiation.

CONCLUSION

Twice-daily postmastectomy radiation to a total of 66 Gy for patients with inflammatory breast cancer resulted in improved locoregional control, disease free survival, and overall survival, and was well tolerated.

Prognostic implications of pathological lymph node status after preoperative chemotherapy for operable T3N0M0 breast cancer

BACKGROUND

Although preoperative chemotherapy has become the standard of care for inoperable locally advanced breast cancer, its role for downstaging resectable primary tumors is still evolving. The purpose of this study was to determine whether the prognostic information from an axillary node dissection in patients with clinical T3N0 breast cancer was altered by preoperative chemotherapy compared with surgery de novo.

METHODS

Between 1976 and 1994, 91 patients with clinically node-negative operable T3 breast cancer received doxorubicin-based combination chemotherapy on protocol at one institution. Fifty-three patients received both preoperative and postoperative chemotherapy (PreopCT), and 38 received postoperative chemotherapy only (PostopCT). All patients underwent axillary lymph node dissection as part of their definitive surgical treatment. There were no differences between the PreopCT and PostopCT groups in median age (51 vs. 49 years), median tumor size at presentation (6 cm vs. 6 cm), tumor grade, or estrogen receptor status (estrogen receptor negative 38% vs. 32%). The median follow-up time was 7 years.

RESULTS

Patients in the PreopCT group had fewer histologically positive lymph nodes (median, 0 vs. 3, P < .01), and a lower incidence of extranodal extension (19% vs. 42%, P = .02). By univariate analysis, the number of pathologically positive lymph nodes (P < .01) and extranodal extension (P < .01) were predictors of disease-specific survival in PreopCT patients. Multivariate analysis showed that extranodal extension was the only independent prognostic factor in PreopCT patients (P < .01). Overall, PreopCT and PostopCT patients had similar 5-year disease-free survival rates (66% vs. 57%); however, PreopCT patients had worse disease-free (P = .01) and disease-specific survival (P = .04) when survival was compared after adjustment for the number of positive lymph nodes. Furthermore, PreopCT patients with 4-9 positive lymph nodes had a lower 5-year disease-free survival rate than PostopCT patients with 4-9 positive nodes (17 vs. 48%, P = .04).

CONCLUSIONS

Axillary lymph node status remains prognostic after chemotherapy. Pathologically positive lymph nodes after preoperative chemotherapy are associated with a worse prognosis than the same nodal status before chemotherapy.

Randomized trial of high-dose chemotherapy and blood cell autografts for high-risk primary breast carcinoma

BACKGROUND

Uncontrolled studies have reported encouraging outcomes for patients with high-risk primary breast cancer treated with high-dose chemotherapy and autologous hematopoietic stem cell support. We conducted a prospective randomized trial to compare standard-dose chemotherapy with the same therapy followed by high-dose chemotherapy.

PATIENTS AND METHODS

Patients with 10 or more positive axillary lymph nodes after primary breast surgery or patients with four or more positive lymph nodes after four cycles of primary (neoadjuvant) chemotherapy were eligible. All patients were to receive eight cycles of 5-fluorouracil, doxorubicin (Adriamycin), and cyclophosphamide (FAC). Patients were stratified by stage and randomly assigned to receive two cycles of high-dose cyclophosphamide, etoposide, and cisplatin with autologous hematopoietic stem cell support or no additional chemotherapy. Tamoxifen was planned for postmenopausal patients with estrogen receptor-positive tumors and chest wall radiotherapy was planned for all. All P values are from two-sided tests.

RESULTS

Seventy-eight patients (48 after primary surgery and 30 after primary chemotherapy) were registered. Thirty-nine patients were randomly assigned to FAC and 39 to FAC followed by high-dose chemotherapy. After a median follow-up of 6.5 years, there have been 41 relapses. In intention-to-treat analyses, estimated 3-year relapse-free survival rates were 62% and 48% for FAC and FAC/high-dose chemotherapy, respectively (P =.35), and 3-year survival rates were 77% and 58%, respectively (P =.23). Overall, there was greater and more frequent morbidity associated with high-dose chemotherapy than with FAC; there was one septic death associated with high-dose chemotherapy.

CONCLUSIONS

No relapse-free or overall survival advantage was associated with the use of high-dose chemotherapy, and morbidity was increased with its use. Thus, high-dose chemotherapy is not indicated outside a clinical trial.

Synchronous primary cancers of the breast and cervix: planning multidisciplinary primary treatment [clinico-pathological conference]

Multiple metachronous primary malignancies are becoming increasingly frequent; however, multiple synchronous primary malignancies are still unusual. We report the case of a 61-year-old woman with synchronous stage IIIB ductal carcinoma of the left breast and FIGO stage IB2 squamous cell carcinoma of the cervix. The patient was treated initially every 4 weeks with a 24-h intravenous infusion of paclitaxel (175 mg/m2) followed by a 1-h infusion of carboplatin (area under the curve of 5 mg/ml x min) with concurrent irradiation of the pelvis. Significant toxic reactions including nausea, vomiting, and diarrhea required hospitalization or outpatient intravenous fluids and antiemetics. After four cycles of chemotherapy, the breast cancer was in complete clinical remission, and the patient underwent a modified radical mastectomy with axillary lymph node dissection. Pathologic findings revealed a few microscopic foci of residual infiltrating ductal carcinoma exhibiting a marked treatment effect; none of the 14 axillary lymph nodes removed showed evidence of metastatic tumor. A near-complete pathologic response of the breast cancer and a complete clinical response of the cervical cancer were obtained. Adjuvant chemotherapy for the breast cancer was then initiated, followed by radiation and hormonal therapy.

Importance of radiation therapy for breast cancer patients treated with high-dose chemotherapy and stem cell transplant

PURPOSE

To determine local-regional failure rates in breast cancer patients treated with surgery and high-dose chemotherapy with stem cell transplant and to relate local-regional failure to the use and timing of radiation treatment.

METHODS AND MATERIALS

We retrospectively reviewed the records of 165 breast cancer patients treated on institutional protocols with surgery and high-dose chemotherapy with stem cell transplant. All patients had either Stage III disease, 10 or more positive axillary lymph nodes, or 4 or more positive axillary lymph nodes following neoadjuvant chemotherapy. Twelve patients had inflammatory breast cancer. Thirteen patients treated with breast preservation and 5 patients who died from toxicity within 30 days of transplant were excluded from the analyses of local-regional recurrences. In the remaining 147 patients, 108 were treated with adjuvant radiation and 39 were not. The disease stage distribution for these two groups was comparable. The median follow-up for surviving patients was 35 months.

RESULTS

The 3- and 5-year actuarial disease-free survival (DFS) for the entire group was 60% and 51%, respectively. The 5-year rates of freedom from isolated local-regional recurrence were 95% in the patients treated with adjuvant radiation and 86% in the patients who did not receive radiation (p = 0.014, log rank comparison). The 5-year rates of any local-regional recurrence as a first event (isolated recurrences plus those with simultaneous local-regional and distant recurrences) were 92% versus 82%, respectively for patients whose treatment did and did not include radiation (p = 0.038). We could not demonstrate a correlation of the timing of radiation with the risk of local-regional recurrence.

CONCLUSIONS

These data indicate that high-dose chemotherapy does not negate the importance of radiation in optimizing local-regional control in patients with high-risk breast cancer. Given the results of recent randomized trials studying postmastectomy radiation, which show that improving local-regional control improves overall survival (OS), we believe that all breast cancer patients with high-risk primary breast cancer who are treated with high-dose chemotherapy with stem cell transplant should receive radiation as a component of their treatment.

US-guided implantation of metallic markers for permanent localization of the tumor bed in patients with breast cancer who undergo preoperative chemotherapy

Metallic markers were implanted with ultrasonographic guidance in 51 malignant breast tumors in 49 patients to tag the tumor bed in anticipation of complete or almost complete response to preoperative neoadjuvant induction chemotherapy before breast-conservation surgery. The markers were the only remaining evidence of the original tumor site in 47% (23 of 49) of the patients preoperatively. This technique effectively addresses the problem of preoperative localization of the tumor bed in complete or nearly complete response of breast cancer to neoadjuvant chemotherapy.

Nickel release from orthodontic arch wires and cellular immune response to various nickel concentrations

AIMS

Results from two previous clinical studies suggested that exposure to high nickel-containing orthodontic arch wires may induce hypersensitivity in certain individuals. The purpose of this study was to measure the amount of nickel released from three types of nickel-containing arch wires into a synthetic saliva in vitro, and determine if the concentrations were sufficient to elicit either cytotoxic (trypan blue exclusion test) or stimulatory (MTT test) responses in human peripheral blood mononuclear cells (PBMCs) derived from nickel-sensitive and nickel-nonsensitive individuals. PBMCs were exposed to five concentrations of nickel sulfate solutions ranging from 0-29 ppm, and results were compared, particularly at concentrations obtained from nickel release experiments.

FINDINGS

The amount of nickel released into synthetic saliva ranged from 0.4-4.1 ppb. Wires subjected to a combination of soaking and cyclic straining released significantly more nickel than those that were soaked only (p </= 0.05), and NiTi wires released significantly more nickel than did stainless steel or nitrogen-implanted NiTi wires (p </= 0.05). For PBMCs, significant increased cell proliferation was not observed for any nickel concentration. PBMC cell death rates were highest at nickel concentrations of 29 ppm when the cells were cultured without a cell growth promoter (p </= 0.05), and MTT test values were significantly reduced at both 2.9 and 29 ppm when a growth promoter was included (p </= 0.05).

CONCLUSION

The maximum amount of nickel released from all tested arch wires was 700 times lower than the concentrations necessary to elicit cytotoxic reactions in human PBMCs.

Postmastectomy irradiation: rationale for treatment field selection

The goal of postmastectomy irradiation is to eliminate residual viable tumor in tissue remaining after standard mastectomy. Because this subclinical disease is, by definition, not detectable by current technology, the choice of patients and treatment volumes for postmastectomy irradiation must be inferred from a variety of data sources. The absolute risk of locoregional recurrence is related to the stage of disease, the extent of lymphatic involvement, and other treatment received. Patterns of failure analyses consistently identify the chest wall as the most important target for treatment with radiation therapy in high-risk patients. When patients with multiple locoregional sites of recurrence are included, the chest wall may be involved in as many as 60% to 80% of patients. The second most common place for locoregional failure is the undissected lymphatics of the paraclavicular region. The cumulative probability of failure in this region ranges from 10% to 35% of the patients treated for locoregional recurrence. Microscopic tumor metastases in the internal mammary chain are theorized to represent a potential source for distant metastases. Each of the prospective trials of postmastectomy irradiation that have shown survival benefit included the internal mammary chain within their target volume. Nonetheless, local failure in the internal mammary nodes is an uncommon finding. Similarly, after a level I and II axillary dissection, axillary failure is a minor component of local recurrence risk, and it is probable that only a subset of patients may benefit from axillary irradiation.

Tumor suppressor genes and breast cancer

The genetic determinants for most breast cancer cases remain elusive. However, a mutation in a tumor suppressor gene, such as p53, BRCA1, BRCA2, or ATM, has been determined to be one mechanism of breast carcinogenesis. It has been established that inherited mutations in p53, BRCA1, and BRCA2 significantly contribute to breast cancer risk, although the importance of an inherited ATM mutation is controversial. Sporadic mutations in p53 are also common in breast cancer cells. The precise deficiencies that result from these genetic mutations have yet to be fully described. Although the functions of these genes are different, they are all involved in the maintenance of genomic stability after DNA damage. Mutations that impair the function of these four genes may adversely affect the manner in which DNA damage is processed. It is likely that the risk of breast cancer development is increased through this mechanism. In this article, we review the relevancy of p53, BRCA1, BRCA2, and ATM mutations to breast cancer development, and review the in vitro, in vivo, and clinical data exploring the mechanisms by which these mutations affect genomic integrity and DNA damage repair.

Sequencing of chemotherapy and radiation in lymph node-negative breast cancer

PURPOSE

To conduct a retrospective analysis of chemotherapy and radiation sequencing in lymph node-negative breast cancer patients treated with breast-conserving surgery.

PATIENTS AND METHODS

Between February 1982 and January 1996, 124 patients with lymph node-negative breast cancer underwent breast-conserving surgery with axillary dissection followed by chemotherapy and radiation therapy. The outcome of 68 patients who received chemotherapy first was compared with that of 56 patients who received radiation first. The two groups were balanced with respect to patient age, tumor stage, margin status, and estrogen and progesterone receptor status. Sixty-two percent of the patients had T1 primary disease. The median follow-up among surviving patients was 44 months for the chemotherapy-first group and 61 months for the radiation-first group.

RESULTS

There were no statistically significant differences in local control, disease-free survival, or overall survival between the two groups. Five-year actuarial rates for local control for the chemotherapy-first and the radiation-first groups were 100% and 94%, respectively. Five-year recurrence-free rates for the chemotherapy-first and radiation-first groups were 92% and 77%, respectively. The 5-year overall survival rate was 89% for both groups.

DISCUSSION

Giving chemotherapy before radiation in lymph node-negative breast cancer did not compromise local control. Given the concerns about increased distant metastases if radiation is given first, the chemotherapy-radiation sequence is recommended.

Local-regional control of recurrent breast carcinoma after mastectomy: does hyperfractionated accelerated radiotherapy improve local control?

PURPOSE

Hyperfractionated, accelerated radiotherapy (HART) has been advocated for patients with local-regionally recurrent breast cancer because it is believed to enhance treatment effects in rapidly proliferating or chemoresistant tumors. This report examines the value of HART in patients with local-regionally recurrent breast cancer treated with multimodality therapy.

METHODS AND MATERIALS

The study included 148 patients with local-regionally recurrent breast cancer after mastectomy, who were treated with definitive local irradiation and systemic therapy consisting of either tamoxifen, cytotoxic chemotherapy, or both, along with excision of the recurrent tumor when possible. Patients with distant metastases were excluded, except for two patients with ipsilateral supraclavicular nodal metastases. Patients received comprehensive irradiation to the chest wall and regional lymphatics to a median dose of 45 Gy, with a boost to 60 Gy to areas of recurrence. Sixty-eight patients (46%) were treated once daily at 2 Gy/fraction (fx), and 80 (54%) were treated twice daily at 1.5 Gy/fx. Forty-eight patients (32%), who had palpable gross disease that was unresponsive to systemic therapy and/or unresectable, were irradiated. The median follow-up time of surviving patients was 78 months.

RESULTS

Overall actuarial local-regional control (LRC) rates at 5 and 10 years were 68% and 55%, respectively. Five- and ten-year actuarial overall survival (OS) and disease-free survival (DFS) rates were 50% and 35%, 39% and 29%, respectively. Univariate analysis revealed that LRC was adversely affected by 1. advanced initial American Joint Committee on Cancer (AJCC) stage (p = 0.001), 2. clinically evident residual disease at time of treatment (p < 0.0001), 3. more than three positive nodes at initial mastectomy (p = 0.014), 4. short interval from mastectomy to recurrence (< 24 months, p = 0.0007), 5. nuclear grade (III vs. I or II, p = 0.045), and 6. number of recurrent nodules (1 vs. > 1, p = 0.02). Patient age at time of recurrence (< 40 vs. > or = 40 years), recurrence location on the chest wall, estrogen receptor status, progesterone receptor status or menopausal status did not adversely affect LRC. On multivariate analysis, only clinically evident residual disease at the time of treatment and short interval from mastectomy to recurrence remained significant. When once-a-day irradiation was compared to the twice-a-day schedule, no significant differences were seen in LRC (67% vs. 68%), OS (47% vs. 52%), or DFS (42% vs. 36%) for the entire group of patients at 5 years. Pairwise comparison of the two fractionation schedules in each of the adverse outcome subgroups identified above showed no clinically significant differences in LRC at 5 years. For the 48 patients who began radiotherapy with measurable gross local recurrence, the complete response rate to radiotherapy was 73%, with no difference seen between the two fractionation schedules. The incidence of acute and chronic radiation-related complications was similar in both treatment groups.

CONCLUSIONS

Hyperfractionated accelerated radiotherapy, although well tolerated by patients with local-regionally recurrent breast cancer, did not result in superior local-regional control rates when compared to daily fractionated regimens. Alternative strategies, such as dose escalation or chemoradiation, may be required to improve control.

Feasibility of breast conservation therapy in metachronous or synchronous bilateral breast cancer

BACKGROUND

The optimal management of contralateral breast cancer (CC) in patients previously treated with breast-conserving therapy (BCT) is unclear, as is whether these patients continue to choose BCT as the preferred treatment of their second breast cancer.

METHODS

Of 1328 patients treated with BCT at The University of Texas M. D. Anderson Cancer Center between 1958 and 1994, 63 developed a contralateral breast cancer. We reviewed the charts of these patients retrospectively, and standard demographic and treatment variables were evaluated. Survival was analyzed by the Kaplan-Meier method and subgroups by chi2 analysis.

RESULTS

Twenty-nine percent of the patients had a family history of breast cancer. First breast cancers were detected by patient or physician in 67% of cases and by mammogram in 17% of cases, compared to 59% and 36%, respectively, of CC (P = .04). Median time to development of CC was 61 months. Sixty percent of the initial tumors were AJCC stage 0 or I with a median size of 2 cm, whereas 74% of the CC were stage 0 or I (P = .02), with a median size of 1.5 cm. Eighty-seven percent of patients chose BCT for treatment of CC. There were few treatment-related complications. Recurrence rates were not significantly different from those of patients undergoing BCT for the initial cancer (P = .47), and 5- and 10-year actuarial survival rates after the first cancer were 93% and 76%, respectively. Median follow-up was 134 and 56 months from the time of diagnosis of the initial cancer and CC, respectively.

CONCLUSIONS

Because contralateral breast cancer often is detected at an early stage, there are few treatment-related complications, and the risk of recurrence is no different from that for the initial cancer, BCT is an acceptable and desirable option for appropriately selected patients with metachronous or synchronous bilateral breast cancers.

Fetal dose estimates for electron-beam treatment to the chest wall of a pregnant patient

The purpose of this report is to discuss dosimetry and shielding for electron-beam radiotherapy of pregnant patients. Specifically, we have determined fetal dose for a pregnant patient considering electron radiotherapy for a chest wall recurrence of breast cancer. The treatment was simulated using an anthropomorphic phantom, and the measured dose to the unshielded fetus for this plan was 5.3 cGy, a level at which risk to the fetus is uncertain. Therefore abdominal shielding, consisting of 6.6 cm of lead, was used to reduce the dose to the fetus to less than 1.5 cGy, a level considered to be of little risk. We further found that using the lower (instead of upper) variable trimmer bars to define the field edge closest to the fetus resulted in approximately 30% lower dose to the fetus. These results show that it is possible to reduce fetal dose to acceptable limits in electron-beam radiotherapy of the chest wall using the general principles recommended for photon-beam radiotherapy.

Isoseparation curves: a mechanism for optimizing off-axis dose homogeneity of intact breast irradiation

The purpose of this paper is to determine whether using off-axis isoseparation curves to optimize the collimator rotation angle improves dose homogeneity. Eleven intact breast irradiation patients underwent computerized tomography (CT) treatment planning with 1 cm abutting slices. Central plane treatment planning, using 6 MV photons, tissue inhomogeneity corrections, and isocentric opposed tangent treatment fields, was performed. Collimators were rotated to match chest wall slope through the use of a beam's-eye-view setting. Patient separations were measured from the apex of the breast to the posterior field border on each axial CT slice. Sagittal-plane isoseparation curves were constructed from these measurements. Using these curves, the collimator rotation that minimized off-axis separation differences was determined. A comparison of off-axis dose inhomogeneity was performed for patients with a > or =10 degrees difference between this optimized collimator angle and the angle determined by chest wall slope. These comparative treatment plans differed only with respect to collimator angle rotation. The mean optimal collimator rotation angle differed significantly from the mean rotation angle which matched the chest wall slope (5.4 degrees vs. 11 degrees, respectively, P < 0.001). Four of the 11 patients had rotation angle differences of 10 degrees. In these patients, the optimization of collimator angle reduced the percentage of breast volume to "that" received > or =110% of the prescribed dose. For the patient with the largest breast size to the patient with the smallest breast size the decreases were, respectively, 5% (15% to 10%), 3% (24% to 21%), 1% (4% to 3%), and 1% (0.9% to 0%). The mean reduction in dose inhomogeneity was greatest in the inferior breast quadrants. At 6 cm and 4 cm off axis, the mean reductions in the percentages of the breast tissue to "that" received 110% of the prescribed dose were respectively 15.1% and 5.3 %. Optimizing the collimator angle through the use of isoseparation curves decreases dose inhomogeneity. The greatest improvements are in the inferior quadrants of the intact breast. The improved dose homogeneity may have clinical relevance in the treatment of patients with large breast sizes.

Pathologic tumor response in the breast following neoadjuvant chemotherapy predicts axillary lymph node status

PURPOSE

Neoadjuvant chemotherapy is becoming the standard of care for locally advanced breast cancer. This study was performed to determine whether pathologic primary tumor response to neoadjuvant chemotherapy might predict axillary lymph node status and so be used to identify patients in whom surgery could be effectively limited to biopsy of the previous primary tumor site without axillary dissection.

PATIENTS AND METHODS

Between 1992 and 1996, 170 consecutive patients with locally advanced breast cancer were treated in a prospective trial with four preoperative cycles of 5-fluorouracil, doxorubicin, and cyclophosphamide. Disease was staged before initiation of preoperative chemotherapy and before surgery. Segmental resection with axillary lymph node dissection or modified radical mastectomy was performed first, followed by postoperative chemotherapy and radiation therapy of the breast (or chest wall) and regional lymphatics. Patient and tumor characteristics associated with complete versus incomplete pathologic primary tumor response to neoadjuvant chemotherapy and correlation between primary breast tumor pathologic response and axillary lymph node status found at surgery were analyzed.

RESULTS

Of 156 evaluable patients, 30 patients (19%) had primary breast tumors that were completely eliminated after induction chemotherapy based on histologic assessment. Nineteen of those 30 patients (63%) had negative axillary lymph nodes at dissection, compared with 13 patients (33%) of the 40 who had a near-complete pathologic primary tumor response (< or = 1 cm3 remaining) and only 15 patients (17%) of the 86 who had > 1 cm3 tumor remaining in the pathology specimen of the breast primary. Of the 22 patients with a complete pathologic response in the breast and a clinically negative axilla after induction chemotherapy, axillary dissection revealed positive lymph nodes in four. These four patients had only one or two positive lymph nodes.

DISCUSSION

Because initial clinical regression of primary tumor with neoadjuvant chemotherapy is considered an excellent prognostic indicator and because patients with locally advanced breast cancer routinely receive local and regional radiation treatment followed by additional chemotherapy, the role of breast and axillary surgery has been questioned. In this study, a complete pathologic response of the primary tumor to induction chemotherapy is highly predictive of negative axillary lymph node status. Therefore, axillary lymph node dissection may be omitted in certain subsets of patients who have a biopsy-proven complete pathologic response in the primary tumor and a clinical negative axillary examination. Further prospective, randomized investigation is needed to confirm this finding.

Standards for diagnosis and management of ductal carcinoma in situ (DCIS) of the breast. American College of Radiology. American College of Surgeons. College of American Pathologists. Society of Surgical Oncology

A sufficient body of knowledge has developed about ductal carcinoma in situ of the breast to warrant a separate report on standards of care for women with this disease. This consensus report by these four organizations discusses evaluation of the patient, selection of treatment, technical aspects of diagnostic biopsy and definitive local excision, pathologic evaluation, radiation therapy considerations, follow-up care recommendations, and questions for future research.

Role of conservation therapy for invasive lobular carcinoma of the breast

BACKGROUND

Invasive lobular carcinoma (ILC) accounts for 5% to 10% of all invasive breast cancers. Although breast conservation therapy using local excision and postoperative irradiation is a standard therapy for early invasive ductal breast cancer, the result of this strategy in ILC is not well documented. We sought to determine the rate of locoregional recurrence after breast conservation therapy in patients with ILC.

METHODS

A retrospective review of 74 patients with ILC treated with breast conservation therapy at The University of Texas M. D. Anderson Cancer Center (n = 43) or The John Wayne Cancer Institute (n = 31) between 1977 and 1993 was performed.

RESULTS

The median age of patients was 60 years, and median follow-up was 56 months (range 1 to 207 months). Thirty-nine patients had American Joint Committee on Cancer stage I disease, 30 had stage IIa disease, and five had stage IIb disease. All patients underwent surgical resection and postoperative radiation therapy. Twelve patients received postoperative adjuvant chemotherapy, and 27 patients were treated with adjuvant hormonal therapy. The 5-year actuarial locoregional recurrence rate was 9.8%, and the median time to recurrence was 77 months (range 41 to 113 months). Patients with positive or close (< or = 1 mm) surgical margins were at increased risk for local recurrence on univariate analysis (p = 0.034). Of the nine patients with breast recurrence, six underwent salvage therapy with total mastectomy and are disease free at the time of this writing, two patients died of distant disease, and one is alive with local disease at the time of this report. The 5-year disease-specific survival rate was 93.7%.

CONCLUSIONS

Breast conservation therapy for ILC achieves locoregional control in the majority of patients. However, long-term follow-up of patients is important because many local recurrences following breast conservation therapy are late events.

Feasibility of postmastectomy radiation therapy after TRAM flap breast reconstruction

BACKGROUND

Postoperative radiotherapy (PORT) has been shown to decrease locoregional failure rates in high-risk breast cancer patients following modified radical mastectomy. However, there had not been a study evaluating the effect of PORT in patients after transverse rectus abdominis myocutaneous (TRAM) flap breast reconstruction. Therefore, we evaluated flap viability, cosmetic results, and locoregional recurrence in patients who underwent TRAM flap reconstruction and PORT.

METHODS

The charts of patients who had undergone modified radical mastectomy with TRAM flap reconstruction and PORT at our institution were reviewed. Patients were examined in the clinic and interviewed by telephone to evaluate their perceptions of the cosmetic result.

RESULTS

PORT was delivered to 19 patients with TRAM flaps (3 pedicled and 16 free flaps) between 1988 and 1994. There were no TRAM flap losses as a result of either surgical or radiotherapy complications. Two patients developed fat necrosis, one with a pedicled and one with a free TRAM flap. Patients with pedicled TRAM flaps noted more volume loss in the breast after radiation therapy. Eighty-four percent of patients felt their overall cosmetic result was excellent or good; only one patient reported a poor cosmetic result. Local control was achieved in three of the four patients who received PORT for local recurrence. There was only one local recurrence among the 14 patients who received PORT because they were at high risk of local recurrence.

CONCLUSIONS

These results suggest that PORT can be given safely to high-risk patients following TRAM flap breast reconstruction with excellent cosmetic results and good locoregional control.

Impact of extensive intraductal component on recurrence and survival in patients with stage I or II breast cancer treated with breast conservation therapy

BACKGROUND

The relationship between an extensive intraductal component (EIC) and recurrence and survival in patients with stage I or II breast cancer treated with breast conservation therapy has not been clearly defined.

METHODS

133 patients with stage I or II breast cancer who underwent breast conservation therapy between 1978 and 1990 at The University of Texas M. D. Anderson Cancer Center were retrospectively studied. All pathology slides were reviewed to determine tumor size, nuclear grade, extent of intraductal component, number of positive lymph nodes, and histologic margins. EIC was defined as ductal carcinoma in situ (DCIS) occupying 25% or more of the area encompassed by the infiltrating tumor and DCIS present in grossly normal adjacent breast tissue.

RESULTS

110 patients are alive, and 23 have died, with a median follow-up of 7 years; 85 of 133 patients had an intraductal component, but only 18 had an EIC. Locoregional control and disease-free and overall survival were not adversely affected by the presence of an EIC. Five of 133 patients had a locoregional recurrence, but only one had an EIC.

CONCLUSIONS

EIC, if negative margins can be achieved, does not adversely affect disease-free or overall survival or local control rates.

Combined-modality treatment of inflammatory breast carcinoma: twenty years of experience at M. D. Anderson Cancer Center

PURPOSE

To review the 20 years of experience at M. D. Anderson Cancer Center with a combined-modality approach against inflammatory breast carcinoma.

PATIENTS AND METHODS

A total of 178 patients with inflammatory breast carcinoma were treated in the past 20 years at M. D. Anderson Cancer Center by a combined-modality approach under four different protocols. Each protocol included induction chemotherapy, then local therapy (radiotherapy or mastectomy), then adjuvant chemotherapy, and, if mastectomy was performed, adjuvant radiotherapy. Chemotherapy consisted of 5-fluorouracil, doxorubicin, and cyclophosphamide (FAC) with or without vincristine and prednisone (VP). In protocol D, patients received an alternate adjuvant chemotherapy regimen, methotrexate and vinblastine (MV), if they did not have a complete response (CR) to induction chemotherapy.

RESULTS

The median follow-up of live patients in group A was 215 months, in group B 186 months, in group C 116 months, and in group D 45 months. An estimated 28% of patients were currently free of disease beyond 15 years. At the time of analysis, 50 patients were alive without any evidence of disease. A further 12 patients died of intercurrent illness, and 15 patients were followed beyond 10 years without recurrence of disease. Among initial recurrence, 20% of patients had local failure, 39% systemic failure, and 9% CNS recurrence. Initial response to induction chemotherapy was an important prognostic factor. Disease-free survival (DFS) at 15 years was 44% in patients who had a CR to induction chemotherapy, 31% in those who had a partial response (PR), and 7% in those who had less than a PR. There was no improvement in overall survival (OS) or DFS among patients who underwent alternate chemotherapy (MV) compared with those who did not. Using surgery and radiotherapy as opposed to radiotherapy alone as local therapy did not have an impact on the DFS or OS rate.

CONCLUSION

These long-term follow-up data show that with a combined-modality approach a significant fraction of patients (28%) remained free of disease beyond 15 years. In contrast, single-modality treatments yielded a DFS of less than 5%. Thus, using combined-modality treatment (chemotherapy, then mastectomy, then chemotherapy and radiotherapy) is recommended as a standard of care for inflammatory breast carcinoma.

Adjuvant radiation therapy after axillary lymphadenectomy for metastatic melanoma: toxicity and local control

BACKGROUND

Certain patients with locally advanced melanoma have a high risk of regional recurrence after surgical excision and lymphadenectomy alone. Growing evidence suggests that radiation therapy may improve local control with acceptable morbidity for patients with melanoma in some sites. There is no information regarding the safety or efficacy of this treatment when applied to the axilla for regional metastasis of cutaneous melanoma.

METHODS

We conducted a retrospective evaluation of patients who received postoperative radiation therapy to the axillary lymphatics for malignant melanoma at the M. D. Anderson Cancer Center between 1980 and 1992. Twenty-eight patients were identified who had undergone a formal axillary lymph node dissection followed by postoperative irradiation to the full axilla and supraclavicular fossa. Twenty-two patients were irradiated using a hypofractionated treatment regimen (4-7 Gy/fraction), generally to 30 Gy in five fractions.

RESULTS

Sixteen patients are currently alive. Actuarial survival at 5 years is 50.1%. Local tumor recurred or persisted in five patients, four of whom had clinically palpable tumor when they were irradiated.

CONCLUSIONS

Postoperative irradiation of the axilla for malignant melanoma has acceptable toxicity, even in those with extensive axillary dissection. In this group, patients treated for subclinical disease had a low rate of recurrence (1 of 21, [5%]).

Primary chemotherapy for early and advanced breast cancer

While locally advanced breast cancer (LABC) represents a small fraction of patients with breast cancer in industrialized nations, in developing countries it might constitute up to 50% of incident cases. The definition includes patients with stage IIB, III, and some with limited stage IV breast cancer. Inflammatory breast cancer (IBC) is part of LABC, but it is often reported separately, because of its dismal prognosis. LABC can be considered technically operable (stage II and IIIA), or inoperable (stage IIIB, IV and IBC). For the last two decades, patients with inoperable LABC and IBC have been treated with increasing frequency with systemic therapy first, followed by regional therapy, either surgical resection or radiotherapy. Most treatment programs also included adjuvant systemic therapy. The majority of patients with LABC and IBC respond to primary chemotherapy, and most can be rendered disease-free initially. Local control rates exceed 80% with modern combined-modality treatment strategies. Since most tumors are downstaged, some patients can be treated with breast-conserving treatments. The optimal sequence of local and systemic treatments has not been defined. Combined-modality therapies improve the treatment and the outcome for patients with LABC. Whether the sequence of utilization of various treatments influences outcome remains to be established. The administration of systemic therapies first also provides a useful biological model to assess the effects of systemic treatments on the primary tumor and regional metastases, since these are available for serial non-invasive evaluation and sampling of tumor tissue.

Serum antibody responses in human periodontitis to cellular components of Capnocytophaga

Serum levels of IgM, IgG and IgG-antibody subclasses directed against cell envelopes, lipopolysaccharides and cytoplasmic fractions from Capnocytophaga sputigena, C. gingivalis and C. ochracea were examined in age-, race- and sex-matched periodontally healthy (n = 25) subjects and subjects with adult periodontitis (n = 25). The envelopes and cytoplasmic fractions were obtained by ballistic disintegration of the cells and ultracentrifugation. Cell envelopes were treated with DNase, RNase and lysozyme. Lipopolysaccharides were obtained by hot phenol-water extraction and treated with DNase and RNase. The relative levels of the antibodies in response to the cell fractions were measured by the streptavidinbiotin micro enzyme-linked immunosorbent assay. Both groups showed IgM and IgG antibodies to each fraction of the three Capnocytophaga species, but the frequency of positive IgG subclass responses varied. The IgG4 responses were lower than the other subclasses. There were no significant differences between the IgM antibody levels of the two groups. However, the adult periodontitis group had significantly lower IgG antibody titres to the cell envelopes and cytoplasmic fractions of C. gingivalis and C. ochracea, and lipopolysaccharide of C. gingivalis. These results were reflected in the depressed levels of IgG1 and/or IgG2 to these cellular fractions from the same bacterial species. The adult periodontitis group also showed a lower level of IgG1 to the cytoplasmic fractions of C. sputigena without any depression in the total IgG antibody level. There were no significant differences between the groups in IgG3 and IgG4 antibody levels to any of the cellular fractions.(ABSTRACT TRUNCATED AT 250 WORDS)

Results of mastectomy and postoperative irradiation in the management of locoregionally advanced carcinoma of the breast

Between 1955 and 1984, 376 patients with locoregionally advanced breast carcinoma were treated at The University of Texas M. D. Anderson Cancer Center with mastectomy and irradiation and without adjuvant chemotherapy. Patients with inflammatory carcinoma or synchronous bilateral primary tumors were excluded. There were 202 patients with Stage IIIA disease and 174 patients with Stage IIIB disease (AJC Staging--1983). In 124 patients the surgical management was confined to the breast only--total mastectomy (BR) and in 252 dissection of the axilla was performed--extended total, modified radical, or classic radical mastectomy (BR + AX). All patients had postoperative irradiation. The follow-up period ranged between 8 and 34 years. At 10 years, the actuarial disease-specific, relapse-free survival (DSRFS) rate for the entire group was 40%, and the actuarial locoregional control rate was 82%. For patients with Stage IIIA disease the DSRFS was 48% and locoregional control rate was 88%. For those with Stage IIIB disease, the figures were 30% and 74%, respectively. Most of the failures occurred within 5 years of the mastectomy and essentially all occurred within 10 years. When analyzed by type of surgery, both the locoregional control and DSRFS rates were improved by the axillary dissection, the difference being largely caused by fewer axillary node recurrences after dissection of both the breast and axilla than after removal of the breast alone. In the 252 patients in whom the axilla was assessed, the number of positive nodes was a powerful predictor of both locoregional control and survival. The DSRFS rates at 10 years for patients with 0, 1-3, and greater than or equal to 4 positive nodes were 63%, 48%, and 30%, respectively. The actuarial locoregional control rates at 10 years exceeded 95% for patients with 0-3 positive nodes and 75% for those with greater than or equal to 4 nodes. These results show that locoregionally advanced breast cancer is not a uniformly fatal disease when treated without chemotherapy and provide a baseline upon which to assess the value of adjuvant systemic therapy for this stage of disease.

Cimetidine versus intensive antacid therapy for duodenal ulcer: a multicenter trial

In a randomized double blind multicenter trial, patients treated with cimetidine (800 or 1200 mg daily) or an intensive regimen of Al-Mg antacid (210 ml daily) had similar rates of duodenal ulcer healing and pain relief. After 4 weeks of treatment, the proportion of patients with ulcer healing by endoscopy were: cimetidine (1200 mg), 21 of 33 (64 percent); cimetidine (800 mg), 19 of 32 (59 percent); and antacids, 15 of 29 (52 percent). These proportions did not differ significantly. Eighty per cent of cimetidine-treated patients became asymptomatic by week 4, as did 63 percent of antacid-treated patients (P greater than 0.1). No untoward effects were observed during cimetidine treatment. Twenty-seven per cent of antacid-treated patients reported diarrhea.